Surgical treatment of hiatal hernia

The loyalty program applies to surgical interventions in the inpatient department, making treatment even more affordable.

Esophageal hernia, or hiatal hernia, is the displacement of part of the stomach, and sometimes other abdominal organs, through an enlarged esophageal opening of the diaphragm into the chest cavity. Such a hiatal hernia may cause almost no discomfort for a long time or may manifest as heartburn, belching, pain behind the breastbone, difficulty swallowing, and other symptoms of reflux.

The diaphragm separates the chest cavity from the abdominal cavity, and the esophagus passes through its natural opening. When this opening widens and the tissues around it weaken, a hiatal hernia may gradually increase in size and cause more pronounced complaints.

A hernia forms when the tissues supporting the esophageal opening of the diaphragm weaken and the opening itself gradually widens. According to NCBI Bookshelf, the development of the pathology may be promoted by age-related tissue changes and prolonged increases in intra-abdominal pressure, as a result of which part of the stomach shifts into the chest cavity.

Factors that may contribute to the development of a hernia include:

• age-related changes in the muscle and connective tissue of the diaphragm;
• excess body weight and obesity;
• pregnancy, especially repeated pregnancy;
• chronic cough;
• prolonged constipation and regular severe straining;
• systematic lifting of significant weight;
• previous operations in the abdominal area;
• congenital weakness of the structures surrounding the esophageal opening.

In most cases, the pathology develops gradually under the influence of several factors at the same time. What matters is not only the presence of an individual risk factor, but also the duration of its effect on the structures of the diaphragm.

Doctors at Oxford Medical explain: with a sliding hernia, the upper part of the stomach together with the junction of the esophagus and stomach shifts above the diaphragm. Because of this, manifestations of GERD — heartburn and acid belching — occur more often. With a paraesophageal hiatal hernia, part of the stomach shifts into the chest cavity next to the esophagus, so a feeling of stomach fullness after eating, pressure behind the breastbone, and difficulty swallowing are more bothersome.

The risk of complications depends on the type and size of the hernia. With a sliding form, they are more often associated with prolonged reflux of acidic stomach contents into the esophagus, while large paraesophageal hernias may cause mechanical compression, impaired passage of food, or impaired blood supply to the displaced part of the stomach.

Possible complications include:

• esophagitis — inflammation of the esophageal mucosa due to prolonged exposure to stomach contents;
• erosions and ulcers of the esophagus;
• bleeding and the development of iron deficiency anemia;
• cicatricial narrowing of the esophagus;
• Barrett's esophagus with prolonged reflux;
• incarceration of a paraesophageal hernia;
• gastric volvulus with impaired passage of its contents;
• impaired blood supply to the stomach wall, up to ischemia and necrosis.

According to Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), one of the indisputable complicated gaming infections of the stomach. It may lead to obstruction and impaired blood supply, so sudden severe pain in the upper abdomen or behind the breastbone, repeated vomiting, or inability to swallow require urgent medical attention.

At the same time, pain behind the breastbone should not automatically be associated with a hernia. A similar symptom may also occur with cardiovascular diseases, in particular with myocardial infarction, therefore sudden intense

The management approach depends on the type of hernia and the severity of the symptoms. If a small hiatal hernia does not cause significant complaints or is manifested mainly by reflux, conservative treatment may be used initially. It helps control the symptoms but does not narrow the enlarged opening of the diaphragm or return the stomach to its normal position.

Conservative therapy may include:

• medications that reduce the acidity of the stomach contents;
• adjustment of diet and portion size;
• avoiding food 2–3 hours before sleep;
• weight reduction if there is excess body weight;
• limiting foods and drinks that provoke heartburn.

If a hiatal hernia causes pronounced symptoms or conservative therapy does not provide sufficient control, the doctor may recommend surgery. Surgical intervention makes it possible to return the displaced organs to the abdominal cavity and restore the normal size of the esophageal opening.

Indications for hernia removal may include:

• a large or symptomatic paraesophageal hernia;
• severe heartburn and regurgitation that persist despite properly selected therapy;
• difficulty with the passage of food and impaired swallowing;
• recurrent bleeding or anemia associated with the hernia;
• incarceration, gastric volvulus, or other complications;
• significant displacement of the stomach into the chest cavity;
• the need for surgical correction of severe reflux.

Doctors at Oxford Medical recommend not postponing a consultation with a surgeon if the symptoms worsen, interfere with normal eating, or are not controlled by medications. Timely examination helps determine further management and, if necessary, plan surgery before serious complications develop.

Most often, removal of the esophageal hernia is performed laparoscopically. Open surgery may be recommended in severe cases or in the presence of complications.

The laparoscopic surgery is performed as follows:

• The anesthesiologist administers general anesthesia.

• The surgeon makes several punctures up to 1 cm in diameter in the abdominal wall.

• Through one puncture, a laparoscope with a miniature video camera is inserted. The image is transmitted to a monitor with 40–60x magnification.

• Through another puncture, carbon dioxide is introduced into the abdominal cavity to enlarge the surgical field and improve visibility.

• After this, endoscopic surgical instruments are inserted, with which the surgeon performs the necessary manipulations.

• At the end, all instruments are removed, the carbon dioxide is carefully evacuated, and small sutures and sterile dressings are applied to the puncture sites.

After this, the patient is brought out of anesthesia and transferred to the intensive care unit, where they remain under monitoring for several hours.

The goal of surgical treatment is to eliminate the hernia and restore the anatomically correct position of the gastroesophageal junction. During the operation, the surgeon may perform:

• suturing of the esophageal opening of the diaphragm;

• strengthening of the diaphragm ligaments;

• restoration of the natural position of the stomach and its fixation (gastropexy);

• wrapping the upper part of the stomach around the lower end of the esophagus to prevent reflux of gastric juice into the esophagus (fundoplication).

The surgery allows for complete elimination of the pathology and its accompanying symptoms and complications. Statistics show absence of reflux in 94% of patients and absence of hernia recurrence in 85% of patients within 5 years after laparoscopic intervention.

The complexity and duration of rehabilitation depends on the type of surgery — open or laparoscopic.

After laparoscopy, usually the next day the patient is allowed to get up and walk in the ward, drink water and broth, and then gradually add soft foods to the diet.

The length of hospitalization is usually 1–3 days, and full recovery takes 3–4 weeks. During this period, the patient is advised to:

• take medications prescribed by the doctor;

• follow the recommended diet;

• limit physical activity and avoid lifting heavy weights.

Each patient receives detailed recommendations from the doctor. Successful recovery and absence of complications depend on following them.

The cost of the operation depends on the severity of the disease and the method of surgical intervention — laparoscopic or open access. The price of laparoscopic surgery may be slightly higher due to the use of expensive equipment. However, it is less traumatic, requires shorter hospitalization and rehabilitation, which also reduces additional costs.

Get to know the cost of surgical treatment at «Oxford Medical» you can here. To find out a more accurate price taking into account the diagnosis, make an appointment with a doctor at a time convenient for you.

This information is for educational purposes only and does not replace a doctor's consultation.

Sources:

Society of American Gastrointestinal and Endoscopic Surgeons

National Center for Biotechnology Information

US National Library of Medicine