Surgery for a hiatal hernia (synonym: hiatus oesophageus) is an invasive treatment method for an existing hernia (hernia) of the diaphragm. The esophageal hiatus represents the passage of the diaphragm through which the esophagus (food pipe) physiologically leads to the stomach. Hiatal hernia is defined as displacement of parts of the stomach, especially the cardia (upper part of the stomach) and possibly adjacent structures, through the esophageal hiatus. The cause for the development of the hernia is in most cases a congenital weakness of the connective tissue, which leads not only to a widening of the hiatus oesophageus but also to a loosening of the attachment of the gastric parts to the diaphragm. The classification of hiatal hernias is of great importance, since the distinction of the respective types of hiatal hernia is particularly important for therapy. While the axial sliding hernia, which follows the longitudinal axis of the esophagus in its course and is the most common hernia with 85%, is only typically seen in concomitant severe gastroesophageal reflux disease (synonyms: GERD, gastroesophageal reflux disease; gastroesophageal reflux disease (GERD); gastroesophageal reflux disease (reflux disease); gastroesophageal reflux; reflux esophagitis; reflux disease; reflux esophagitis; peptic esophagitis); inflammatory disease of the esophagus (esophagitis) caused by the abnormal reflux of acidic gastric juice and other gastric contents) and typically operated on for mixed-type hernia. In the setting of paraesophageal hernia, there is often a pathologic (pathological) hiatus communis, which is a joint passage of the esophagus and aorta through the diaphragm.
Indications (areas of application)
Regardless of hernia type
- Incarceration or high risk of incarceration – If incarceration (entrapment of hernia contents) is already imminent but especially present, hiatal hernia surgery must be performed as soon as possible to prevent or contain abdominal infection. In parallel with the operation, the administration of antibiotics is necessary.
- Hemorrhage – Hemorrhage is also an indication for surgery, regardless of the type of hernia.
- Cardiac insufficiency – Inadequate closure function between the esophagus and the entrance to the stomach may result in gastroesophageal reflux (reflux of food pulp from the stomach or gastric acid into the esophagus). The indication for surgery is made depending on the extent and personal burden.
Paraesophageal hernias
- Paraesophageal hiatal hernia is characterized by a high tendency to progression and risk of complications, so that the indication for surgery can be made when the diagnosis is confirmed. Examples of complications include venous congestion to strangulation (gagging; constriction) of the gastric fundus (gastric portion). These complications can lead to gastric wall necrosis (death of the gastric wall).
Mixed typhernia
- Mixed-type hernia usually arises from an axial sliding hernia with increasing displacement of gastric segments paraesophageally through the dilated oesophageal hiatus. Usually, mixed type hernia is an indication for surgery.
Contraindications
- Severely reduced general condition – Surgery for hiatal hernia is necessary in the presence of complications in reduced general condition, but the benefits should always be balanced with the risks.
- Malignant neoplasia – Tumor disease, as a consumptive disease (disease with disease-related involuntary weight loss), is a relative contraindication to surgery. In this case, too, the risk must be compared with the benefit.
Before surgery
First of all, it must be precisely determined what type of hernia is present and therefore whether there is an indication to perform the operation. X-ray diagnostics and endoscopy, among others, are used for diagnostics. By means of X-ray diagnostics it is possible to visualize the anatomy (physical features) of the upper gastric region. Endoscopy can also be used to diagnose axial hiatal hernia. However, differentiation from paraesophageal hernias and mixed hernias is difficult under endoscopic observation.
Surgical procedures
Surgery for axial sliding hernia
- If the indication for surgery is present, fundoplicatio according to Nissen-Rosetti or semifundoplicatio according to Toupet represent the procedures of choice. In fundoplicatio, the gastric fundus (upper portion of the stomach) is placed in the form of a sleeve around the entrance to the stomach and fixed with individual sutures. The procedure is typically performed laparoscopically (via laparoscopy). The 90-day mortality (death rate) for laparoscopic fundoplicatio was 0.08% in a Swedish nationwide study.Potential side effects of Nissen-Rosetti fundoplicatio:In a survey of patients who had undergone the procedure many years ago (between 8 and 15 years), flatulence was reported as the most common side effect (85% of patients); 54% of respondents rated the severity as the second highest or highest category. Given the frequency of this side effect, it should be educated before the procedure.
Paraesophageal hernia surgery.
- As a rule, for surgical treatment of paraesophageal hernia, the hernia sac is often left in place, and only the hernia gap must be completely closed. Because a hiatus communis is present in the majority of paraesophageal hernias, closing the hernial gap is complicated. It is possible to perform a fundopexy to cover the hernia gap closure, in which the upper portion of the stomach is sutured either to the diaphragm or to the esophagus.
Surgery for mixed hernias
- The basic principle of therapy for paraesophageal mixed hernia is considered to be permanent reduction (repositioning) of the prolapsed (prolapsed) stomach.
After surgery
With conventional surgical techniques, food abstinence (abstaining from food) must be observed for two to three days, so that a slow build-up of food can follow. When performed laparoscopically, immediate food buildup is possible.
Possible complications
- Meteorism (flatulence) – A common complication is the occurrence of postoperative flatulence (after surgery). This harmless but unpleasant complication is due to the inability of the air from the stomach to enter the esophagus, and therefore increased in the intestine.
- Dysphagia (difficulty swallowing) – Rarely, the feeling of difficulty swallowing occurs postoperatively in patients due to a narrowing of the junction between the esophagus and the entrance to the stomach.