Background Information:

What are the other Names for the Procedure?

• Paraesophageal Hiatal Hernia Repair
• Repair of Hiatal Hernia
• Sliding Hiatal Hernia Repair

What is Hiatal Hernia Repair surgical procedure?

A hiatus hernia or hiatal hernia is the protrusion (or herniation) of the upper part of the stomach into the thorax, through a tear or weakness in the diaphragm.

• The most common type of hiatal hernia is the sliding hiatus hernia (type I, in 95% of the cases), where the gastroesophageal junction moves above the diaphragm, together with some of the stomach
• The less common types of hiatus hernia, such as types II, III, and IV, are all varieties of “paraesophageal hernias”
  • In type II hiatus hernia, a part of the stomach, herniates through the esophageal hiatus and lies beside the esophagus, without movement of the gastroesophageal junction
  • Type III hiatus hernia is a combination of type I and type II
  • Type IV hiatus hernia is associated with a large defect in the diaphragm, allowing other organs, such as colon, spleen, pancreas, and small intestine, to enter the hernia sac
• The symptoms can resemble many disorders, but in most cases however, a hiatal hernia does not cause any symptoms
• The pain and discomfort that a patient experiences, is due to the reflux of gastric acid, air, or bile

Hiatal Hernia Repair is a procedure indicated for the treatment of objectively documented, relatively severe, gastroesophageal reflux disease (GERD). This surgical procedure, also known as Anti-Reflux Surgery, is a consideration in chronic, long-term management of GERD.

What part of the Body does the Procedure involve?

A Hiatal Hernia Repair procedure commonly involves the:

• Esophagus
• Stomach
• Diaphragm

Why is the Hiatal Hernia Repair surgical procedure Performed?

• Gastroesophageal reflux disease (GERD) is initially treated with lifestyle changes, including a weight loss plan, reducing or eliminating smoking and alcohol consumption, altering one’s eating and sleeping patterns, etc.
• If symptoms persist after these lifestyle changes are commenced, then drug therapy (to help in neutralizing or decreasing the gastric acid production) is initiated
• Surgical therapy should be considered, when a diagnosis of reflux, acid or non-acid (or bile reflux), is objectively confirmed and when the patients:
  • Have failed medical management (inadequate symptom control, severe regurgitation not controlled with acid suppression, or have medication side effects)
  • Opt for a surgery, despite successful medical management
  • Have complications of GERD, including erosive esophagitis, stricture, and/or Barrett's esophagus (condition where the inner lining of the esophagus changes to that of the stomach lining, due to acid irritation)        
  • Have extra-esophageal manifestations, such as asthma, hoarseness, cough, chest pain, and/or aspiration

What are some Alternative Choices for the Procedure?

Surgical treatment should be considered in those individuals, who have failed medical management or developed complications of GERD.

• Open approach for Hiatal Hernia Repair is an alternative to laparoscopic approach, but due to the advantages of laparoscopic surgery (tiny incisions, less post-operative pain, faster recovery, earlier return to routine activity), nowadays, majority of the cases are performed laparoscopically
• Trans-oral intra-luminal endoscopic therapies are currently performed in some centers as alternatives to surgical approach; but, more evidence is needed in order for these procedures to be standardized

What are the Recent Advances in the Procedure?

• Trans-oral intra-luminal endoscopic therapies, like endoscopic fundoplication, radiofrequency ablation using STRETTA, implants, and injections are being performed in some health centers
• Robotic Hiatal Hernia Repair and Fundoplication is currently performed by some surgeons, who are gaining experience with using robots

What is the Cost of performing the Hiatal Hernia Repair surgical procedure?

The cost of Hiatal Hernia Repair surgical procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding Hiatal Hernia Repair surgical procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

http://www.sageswiki.org/index.php?title=Laparoscopic_Antireflux_Surgery

http://www.sages.org/publication/id/PI01/

http://www.nlm.nih.gov/medlineplus/ency/article/002925.htm

Prior to Hiatal Hernia Repair surgical procedure:

How is the Hiatal Hernia Repair surgical procedure Performed?

The surgical procedure used is called Hiatal Hernia Repair with Fundoplication. Generally, Nissen Fundoplication is the most common type of fundoplication performed.

• In this procedure, the lower end of the esophagus and the upper part of the stomach is freed completely
• The hernia is reduced, thus bringing the gastroesophageal junction below the diaphragm
• Then, the opening on the diaphragm is narrowed, allowing a free passage of esophagus without any external compression on the wall of the esophagus. This narrowing is performed with sutures, and is called a diaphragmatic crural repair or cruroplasty
• To prevent recurrence of the hiatal hernia and reflux of gastric acid, the gastric fundus (upper part of the stomach) is wrapped around the lower part of the esophagus
• The wrap could either be a complete 360 degree wrap, or a partial 270 degree or 180 degree wrap
  • Complete 360 degree wrap is called Nissen Fundoplication
  • Partial posterior 270 degree wrap is called Toupet Fundoplication
  • Partial anterior 180 degree wrap is called Dor Fundoplication      
• The procedure can be performed via open or laparoscopic approach, through the abdomen or through the chest

Laparoscopic approach: Laparoscopic approach is now, the commonly performed surgical treatment for this condition.

• With proper patient selection, laparoscopic fundoplication has low complication rates and a quick recovery
• Outcomes of the laparoscopic technique are best, when surgery is performed by a surgeon with experience using this procedure
• Using a narrow tube-like instrument (cannula), the surgeon enters the abdomen in the area of the belly button
• A laparoscope (a tiny telescope) connected to a special camera is inserted through the cannula, giving the surgeon a magnified view of the patient's internal organs on a television screen
• Other cannulas are inserted, which allow the surgeon to perform the surgical procedure
• After completion of the repair and fundoplication, the small incisions are closed with stitches, or using surgical tapes

Where is the Procedure Performed?

The Hiatal Hernia Repair procedure is performed in a hospital. The patient is admitted, undergoes the procedure and is discharged, as per the instruction of the physician.

Who Performs the Procedure?

The Hiatal Hernia Repair procedure is performed by a surgeon trained in general surgery, with assistance from an anesthesiologist.

How long will the Procedure take?

The time for Repair of Hiatal Hernia procedure may take anywhere between 2-4 hours.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the surgical procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are being currently taken
• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Blood tests may be performed to determine, if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Normally local anesthesia is not used; however, do inform the physician, if you are allergic to any local anesthetics, lidocaine, etc.
• Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
• For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

What is the Consent Process before the Procedure?

A physician will request your consent for Hiatal Hernia Repair procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Hiatal Hernia Repair surgical procedure?

In establishing the diagnosis, there are several goals that should be met:

• Establishing that gastroesophageal reflux disease (GERD) is the etiology (cause) behind the patient's symptoms
• Estimating the risk of a progressive GERD disease
• Evaluating esophageal body function
• Evaluating gastric emptying function in patients suspected of having delayed gastric emptying. These include select patients with complaints of epigastric pain, persistent nausea and vomiting, frequent bloating, loss of appetite, and persistent upper abdominal discomfort

In order to meet these goals, the following tests (either all or most of them) are performed:

• Upper gastrointestinal series with gastrograffin or barium dye (commonly referred to as upper GI): It allows for preoperative delineation of the anatomy and helps in identifying the presence and size of a hiatal hernia
• EGD (esophago-gastro duodenoscopy, commonly referred to as upper GI endoscopy): It allows for a visualization of the esophageal mucosa for GERD-related pathological changes
• Esophageal manometry: This method allows for an evaluation of esophageal body function. It is also helpful in identifying conditions that might contraindicate Anti-Reflux Surgery (such as achalasia)
• 24-hour pH monitoring (with catheter, or placement of a capsule in the lower esophagus): This helps in identifying the intensity of the acid reflux. This test should be performed, when patients are “off” their medications that neutralize or suppress acid production
• Impedance study will determine, if there is any bile reflux (non-acid reflux disease). This is performed, if patients have symptoms of reflux disease, but there is no acid reflux on 24-hour pH monitoring
• Gastric emptying study

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is a Hiatal Hernia Repair procedure?
• Why is this procedure necessary? How will this procedure help?
• What does the procedure involve?
• How soon should I get it done? Is there an emergency?
• Who are the medical personnel involved in this procedure?
• What are the risks while performing the procedure?
• What are the possible complications that might take place, during recovery?
• When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any lifestyle restrictions or modifications required, after the procedure is performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• Is there any medication that needs to be taken for life, after the procedure?
• What are the costs involved?

During the Hiatal Hernia Repair surgical procedure:

What kind of Anesthesia is given, during the Procedure?

General anesthesia is administered during the Hiatal Hernia Repair procedure.

How much Blood will you lose, during the Procedure?

The amount of blood loss is generally minimal (especially when the procedure is performed laparoscopically), but if complications arise during the Hiatal Hernia Repair procedure, it could lead to a further loss of blood.

What are the possible Risks and Complications during the Hiatal Hernia Repair surgical procedure?

There are general factors that increase the risk of getting complications during surgery and they include:

• Obesity: Generally greater the degree of obesity, greater is the surgical risk
• Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
• Advancing age
• Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Longstanding illness, such as autoimmune disorders, chronic infections
• Poor immune system due to a variety of causes

The possible risks or complications that may arise during the Hiatal Hernia Repair surgery are:

• Infection
• Bleeding
• Injury to the neighboring structures
• Pain
• Discomfort
• Anesthetic complications
• Need for further procedures
• Pneumonia
• Blood clot formation
• Heart problems
• Difficulty swallowing because the stomach is wrapped too high on the esophagus, or is wrapped too tightly
• The esophagus sliding out of the wrapped portion of the stomach so that the valve (lower esophageal sphincter) is no longer supported
• Heartburn that recurs
• Bloating and discomfort from gas buildup, because the person is not able to burp

What Post-Operative Care is needed at the Healthcare Facility after the Hiatal Hernia Repair surgical procedure?

• At the healthcare facility, generally there is no significant post-procedure care required, unless any complications arise
• In a majority of the cases, the patient is closely monitored in a post-operative room

After the Hiatal Hernia Repair surgical procedure:

What are the possible Risks and Complications after the Hiatal Hernia Repair surgical procedure?

Post Hiatal Hernia Repair procedure, the following complications may arise:

• Wound infection of the surgical site
• Difficulty in swallowing (dysphagia)
• Bloating of the stomach
• Recurrence of the hiatal hernia

What is the Prognosis after the Surgery?

• Before a Hiatal Hernia Repair surgery, additional tests are usually performed to ensure that the surgery is likely to help cure gastroesophageal reflux disease symptoms and to diagnose problems that could be made worse by surgery
• The indication for operation is based on the patient’s subjective assessment of symptoms, as the results are largely subjective. Outcomes are therefore highly dependent on patient expectations
• When deciding between surgery and treatment with medicine, one should weigh the cost, risks, and potential complications of the surgery against the cost and inconvenience of taking medicine
• For some individuals, the side effects of surgery, like bloating caused by gas buildup, swallowing problems, upper abdominal discomfort, are as bothersome as GERD symptoms. The fundoplication procedure cannot be reversed, and in some cases it may not be possible to relieve the symptoms of these complications, even with a second surgery
• Second surgeries are harder to do, are less successful, and are more risky. So it is extremely important that the first procedure be considered carefully and be done by an experienced surgeon, who is more likely to be successful the first time
• Patients that fail the operation are those who require reoperation or develop severe symptoms, or those who are not satisfied with initial surgery
• Some patients have been identified as having a predisposition to postoperative dissatisfaction and they include patients with:
  • Atypical symptoms of GERD (cough, asthma, chest pain)
  • Active psychological disease, those with hypochondriacal tendencies or irritable bowel disorder
  • Obesity (BMI > 35): In obese patients with significant reflux, obesity surgery (especially gastric bypass surgery) should be the preferred method of treatment for reflux disease
  • No response to medication

  • In some of these patients, partial wrap (either Dor or Toupet fundoplication) may be considered

When do you need to call your Physician?

Do contact your physician if you notice any of the following symptoms:

• Worsening pain around the surgical wound
• Swelling and redness
• Bleeding or fluid drainage around the spot
• Fever
• Dizziness
• Signs of infection
• Difficulty swallowing food
• Persistent heart burn

What Post-Operative Care is needed at Home after the Hiatal Hernia Repair surgical procedure?

At home, the following post-operative care is recommended, after a Hiatal Hernia Repair procedure:

• For few days after the surgery, have a diet consisting only of liquids or semi-solids or puree diet
• Avoid strenuous physical activities before slowly getting back to your regular daily routine
• Keep incision wounds clean and dry
• Complete the prescribed course of medications
• Avoid pain killers, unless prescribed
• Avoid any possibilities of constipation; take medication if required to do so (under physician’s advice)
• The patient has to change the way of  eating
• Chew food thoroughly and eat more slowly to give the food time, to go down the esophagus
• Avoid carbonated beverages as it will increase the feeling of gas bloating and these patients cannot burp after surgery
• Do not eat while lying down

How long does it normally take to fully recover, from the Procedure?

It may take anywhere between 4 to 6 weeks, to recover completely from the Hiatal Hernia Repair procedure.

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

• Usually, the procedure does not involve the surgical removal of any tissue
• Sometimes, hernia sac tissue is removed, which is then disposed as per the standard medical procedure

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• In a majority of the cases, since no tissue is sent to the pathologist during the procedure, a pathologist does not get involved in the care of the patient
• Sometimes, hernia tissue is removed, which is sent to a pathologist. In such cases, it may take up to 72 hours for a pathology report

Who will you receive a Bill from, after the Hiatal Hernia Repair surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The hospital
• The surgeon
• An anesthesiologist
• A pathologist, if the tissue is sent to the laboratory for analysis

Individuals are advised to inquire and confirm the type of billing, before the Repair of Hiatal Hernia surgical procedure is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA