Hiatus Hernia
Anatomy
The food tube or 'oesophagus' delivers food and drink into the stomach via the gastro-oesophageal junction (GOJ), which is normally below a sheet-like muscle called the diaphragm that seperates the thorax and abdomen. The oesophagus passes through an opening in the diaphragm called the oesophageal 'hiatus'.
What is a Hiatus Hernia
A hiatus hernia is where tissue from the abdomen bulges or herniates from the abdominal cavity, through the hiatus, into the thorax.
Typically the tissue that herniates first is part of the stomach. This may be the gastro-oesophageal junction itself resulting in a 'sliding hiatus hernia'. The predominant symptoms of a sliding hiatus hernia are heartburn and regurgitation. As the oesophagus shortens during swallowing, a small (<2cm) sliding hiatus hernia is not necessarily considered clinically significant.
When part of the stomach or other organ herniates through the hiatus alongside the oesophagus it is called a 'paraoesophageal hernia'. Typical symptoms include difficulty swallowing and chest pain during or soon after eating.
What are the risks?
Although less common, paraoeosphageal hernia is associated with increased risk if left untreated. This is because stomach that has herniated into the chest may be constricted at the level of the hiatus and lose part of its blood supply resulting in a major complication.
Patients with a large paraoesophageal hernia may be more prone to gastric volvulus or twisting of the stomach. This is an emergency as the stomach is unable to empty and may become pressurised and perforate.
How is Surgery Performed?
The surgery, laparoscopic hiatus hernia repair +/- fundoplication is performed using keyhole surgery under general anaesthesia.
The procedure takes typically 1.5-3 hours and involves carefully reducing the hernia contents back into the abdomen. Next, the lower oesophagus is freed from its surrounding attachments so that the GOJ returns to below the diaphragm.
Great care is taken to identify and protect the branches of the vagus nerve, The vagus nerve plays an important role in gastric emptying and if injured can result in delayed gastric emptying
Cruroplasty
Non-absorbable sutures are then placed around the hiatus to close the defect around the oesophagus and prevent reherniation.
A delicate balance has to be reached so that the defect is not so wide that it allows stomach to herniate back up into the chest. If the hiatus is closed too tightly around the oesophagus it will lead to longstanding issues with food getting stuck. A small gap has to be left next to the oesophagus to allow the oesophagus to expand slightly as food boluses are swallowed.
Mesh
In certain instances, a hiatus hernia is large and the diaphragmatic muscle is deemed not strong enough to result in a sound repair with cruroplasty alone. In these circumstances a prosthetic mesh will be sutured over the repair to reinforce the cruroplasty. Utmost care is taken to prevent encircling of the oesophagus to prevent post-op difficulty with swallowing. If a mesh is needed, an absorbable material is chosen due to concerns of permanent mesh causing erosion into the oesophagus.
Recovery
Just as you need to rest your ankle after ankle surgery, for example, it is important to rest your oesophagus after having a hiatus hernia repair.
This is because swelling around the hiatus can take weeks to go down. You will be advise to go on a 2 / 2 / 2 diet. That is, 2 weeks of clear fluids, 2 weeks of puree'd food and 2 weeks of soft food. Not everyone heals at the same rate so this rule of thumb does not suit everyone. If you have difficulty swallowing after progressing your diet, it is advisable to step-back down for a week and re-attempt the progression afterwards.
Maintenance
It is important to look after your hiatus lifelong after this surgery to achieve the best longterm results. This means taking small mouthfuls, chewing your food well and eating your meals slowly. Its also important to avoid eating your evening meals within two hours of going to bed.