Introduction to Hiatal Hernia:

An estimated 10% of the adult population in the United States of America have a hiatal hernia.  Most of them are asymptomatic; however, an estimated 5% of patients with a hiatal hernia have symptoms that we will discuss later on this post.

Most patients don’t know they have a hiatal hernia, most are diagnosed incidentally during X-rays or endoscopies for other reasons.

This type of hernia happens when the diaphragmatic hiatus (natural orifice were the esophagus goes through and meets the stomach in the abdomen) enlarges and allows the stomach to herniate into the chest.

This usually happens because of the pressure difference between the chest and the abdomen.

Hiatal Hernia Classification:

Hiatal hernias are classified depending on the location of the gastroesophageal (GE) junction.  I’m going to try to make this easy for you. The classification is more important information for doctors than for patients.

What you really want to know is if your hiatal hernia needs to be fix or not. We will get there so keep reading.

• Type I or Sliding hiatal hernia: This one is the most common accounting for 95% of the cases. A Type I hiatal hernia means that the GE junction slides up and down through the hiatus into the chest and back into the abdomen.

• Type II or Paraesophageal hiatal hernia: This is where it gets more complicated. Here the gastroesophageal junction is in the abdomen but a portion of the stomach sneaks around the esophagus and up in the chest.

• Type III: Is a combination of Type I and II. The GE junction and a portion of the stomach are both in the chest.  Most patients with this defect have over 1/3 of the stomach in the chest.

• Type IV: This is the mother of Hiatal hernias but also the least common. Only 4-5 % of all Hiatal hernias are Type IV.  In this hernia not only the stomach is herniating but also other organs like small bowel, colon, spleen or liver.

What Causes Hiatal Hernias:

As I briefly mentioned above, Hiatal hernias happen when the hiatus enlarges and allows the stomach or other organs to herniate into the chest.

The diaphragm is a muscle that divides the chest from the abdomen and any condition or circumstances that weakens this area can predispose the patient to develop a hiatal hernia or paraesophageal hernia.

• Sex: Women are four times more likely to develop a hiatal hernia versus male patients.

• Age: The incidence increases with advancing age.

• Genetics: Familial cases have been documented, so if you have a family member with a hiatal hernia you have a good chance of getting one.

• Trauma or surgery: Any injury or surgery in this area can predispose hernia formation.

• Congenital: Diaphragmatic hernias in babies are rare but not unheard of. The presentation can vary depending on the size and location within the diaphragm.

• Weight: Morbid obesity is a big risk factor because of the increase in intra-adominal pressure.

• Smoking or chronic respiratory conditions: Coughing increases the intra-abdominal pressure significantly, so any condition that promotes chronic coughing can increase your chance of having a hiatal hernia. Similarly, chronic vomiting, constipation or heavy lifting can be associated with Hiatal hernias.

Symptoms:

Symptoms are usually associated with the size of the hernia. Most small hernias are asymptomatic, but this is also true for some larger paraesophageal hernias. Other patients can present with:

• Chest pain
• Abdominal pain
• Difficulty swallowing
• Early satiety
• Heartburn
• Belching or indigestion
• Regurgitation of undigested food
• Anemia from gastrointestinal bleeding
• Shortness of breath or asthma

Hiatal Hernia Diagnosis:

Because many patients are asymptomatic or many have nonspecific symptoms the diagnosis of Hiatal hernias usually requires other test modalities besides the good old history and physical.

• Plain X-rays: Usually negative unless the patient has a large paraesophageal hernia.
• Contrast X-ray or Upper GI series: My test of choice not only for diagnosis but also to evaluate the size of the hernia, esophageal motility and/or reflux.
• CT Scan: Can be very useful in patients with larger hernias or complex hernias.
• EGD (endoscopy): Good diagnostic modality for Hiatal hernias and to rule out any other pathology that can be causing the symptoms. It can be used to do biopsies and other minor therapeutic modalities.

Non-Surgical Therapy:

As you can expect, asymptomatic Type I or sliding Hiatal hernias require no treatment. Patients with a sliding hiatal hernia and reflux are usually treated with H2 blockers or Proton Pump Inhibitors (PPI) antiacids.

Patients who fail to obtained symptomatic relief with medical therapy or who developed long term complications from reflux should consider surgical intervention.

You can find out more information about long term complications of acid reflux on my blog post HERE.

Patients who do not experience reflux but have other symptoms associated with their hiatal hernia should consider hernia repair.

Patients with Type II-IV Hiatal hernias should consider surgical repair, especially if they have symptoms. The hiatal hernia will not spontaneously resolve and they will usually get bigger with time. It’s also true that the smaller the hernia the easier it is to repair.

For patients that are not good candidates for surgery due to age or extensive medical history, lifestyle modifications are important to alleviate some of the symptoms. Some examples are:

• Smaller more frequent meals
• Avoid alcohol drinks, spicy foods, chocolate and other foods that trigger heartburn or reflux
• Elevate the head of the bed
• Don’t eat before laying down
• Lose weight and stop smoking

Laparoscopic Hiatal Hernia Repair:

If you remember only one thing about this post, make sure you remember what I’m about to say now “In the 21 st Century 99.9% of these surgeries can be done laparoscopically or minimally invasive”.

Laparoscopic surgery gives you many advantages over the open (large incision) approach. Including less pain, faster recovery, faster return to your activities, fewer chances of wound complications like hernias or infections.

Having said that, not every surgeon that can do laparoscopic cases can do a good hiatal hernia repair or anti-reflux surgery. For this surgeries experience and skills matter.  You want a surgeon that has done many of these cases, a surgeon that does a lot of complex laparoscopic surgeries with excellent outcomes.

Before you undergo surgery in my practice you will need several studies, some I mentioned above. At the minimum, you will undergo an Upper GI series and Endoscopy.  Depending on those results you might also need an esophageal manometry and pH study (see acid reflux post).

You will have 5 small incisions, the largest is 12 mm in size (only one), the others are 5 mm in size. The surgery takes on average 60 to 120 minutes depending on the size of the hernia and your prior surgical history. It is done under general anesthesia. Surgery usually has two parts.

The first part is the hernia repair were the stomach is pulled back down in the abdomen, the hernia sac is removed and the diaphragmatic hiatus is closed to its normal size with sutures and in some cases with an absorbable mesh (BARD Allomax Mesh).

The second part is the anti-reflux portion.  A 360-degree fundoplication or Nissen fundoplication is done to prevent postoperative reflux. A Nissen fundoplication is were the floppy part of the upper stomach is wrapped around the esophagus to recreated or strengthen the esophageal sphincter to prevent reflux.

For small Hiatal hernias a LINX device could be used instead of doing a fundoplication. The LINX is a magnetic ring that is placed around the esophageal sphincter to prevent reflux. I go over more detail in the acid reflux post HERE.

Postoperative you will be admitted to the hospital for 24-48 hours depending on your age and medical conditions.  The admission is mainly for pain control and close monitoring.

Diet After Hiatal Hernia:

You will be on a special diet after hiatal hernia surgery. For the first two weeks, you will be on a liquid diet. Yes I know, torture.  The reasoning behind it is that you want to eat things that are easy to swallow.  You will have some swelling in the area and swallowing solids can cause you to vomit and potentially undoing the repair and getting a recurrence.

In the second two weeks, you will graduate to soft food.  Things like mash potatoes, eggs, grits, and fish. This will be the best eggs you will ever eat.

After this terrible 4 weeks, you should be able to eat normal food… Amen.

If you undergo a LINX you will skip these diet steps. With the LINX you want to eat regular food immediately after surgery.  That is one point for the LINX.

Can I Stop My Anti-Acid Medications After Hiatal Hernia Surgery:

My patients will continue to take the PPI or H2 blockers for 3 months after surgery. After that period you will take it as needed.  For patients that have Barrett’s esophagus, the will need PPI for life or at least until new research say that you don’t need it. For now, it is recommended that you continue to take it if you have Barrett’s.

What About Complications:

I have outstanding outcomes but complications can always happen. Any surgery has risks. The chances that you will die from the surgery is less than 1%.  The overall short term complication rate for the laparoscopic approach is around 15-20% compared to 50-60% for the open approach.

• Pneumonia (4%)
• Pulmonary embolism (3.4%)
• Congestive heart failure (2.6%)
• Leak or esophageal injury (2.5%), etc…

Older patients with multiple comorbidities, smokers and obese patients have a higher risk of complications.

Long term the recurrence rate is around 15% and around 5% of the patients will need a re-operation.

Over 90 % of the patients are highly satisfied with the results and strongly recommend the surgery.

What’s Next:

If you have a hiatal hernia, paraesophageal hernia, acid reflux or anything in between give us a call, make an appointment and we can go over your options.

In the North Central Florida area, nobody has more experience doing these procedures than Dr. Angel M. Caban. We are the only practice in this area trained and certified to do the LINX procedure.

Call Us Today

(352) 291-0239