Hiatal Hernia Repair

Indication

Surgical repair of a hiatal hernia is generally recommended when:

• Symptomatic Paraesophageal Hernias (Type II, III, IV):
  • These are more likely to require surgery due to the risk of complications.
  • Symptoms can include chest pain, epigastric pain, difficulty swallowing (dysphagia), early satiety (feeling full quickly), shortness of breath (especially after meals if the hernia is large and compresses the lungs), and anemia (due to chronic blood loss from Cameron’s erosions – ulcers in the herniated stomach).
  • Current guidelines often recommend repair for large paraesophageal hernias, even if asymptomatic, particularly in younger patients (e.g., <60 years) to prevent future complications.
• Complications of Paraesophageal Hernias:
  • Obstruction: The herniated stomach can become blocked.
  • Strangulation: The blood supply to the herniated stomach can be cut off, leading to tissue death (ischemia/infarction) and perforation. This is a surgical emergency.
  • Gastric Volvulus: Twisting of the stomach, which can lead to obstruction and strangulation. This is also a surgical emergency.
  • Recurrent Aspiration Pneumonia: Due to reflux of stomach contents into the lungs.
• Symptomatic Sliding Hiatal Hernias (Type I) with Severe or Refractory GERD:
  • When gastroesophageal reflux disease (GERD) symptoms (severe heartburn, regurgitation, chronic cough, asthma due to reflux) are persistent and not adequately controlled with lifestyle modifications and medications (like proton pump inhibitors – PPIs).
  • Development of complications of GERD, such as severe esophagitis (inflammation of the esophagus), esophageal stricture (narrowing), or Barrett’s esophagus (though surgery primarily addresses reflux, not necessarily reverses Barrett’s).
• Large Hernias: Surgery may be recommended if the hernia is very large (e.g., >7 cm or involving >50% of the stomach), even if symptoms are manageable, due to the increased risk of future complications.
• Patient Preference: In young, healthy patients with symptomatic hernias who wish to avoid lifelong medication.

Asymptomatic or mildly symptomatic sliding hiatal hernias (Type I) usually do not require surgery and are managed with lifestyle changes and medication. For asymptomatic paraesophageal hernias in older individuals (>60 years) or those with significant comorbidities, a “watchful waiting” approach may be considered.

Preparation

Thorough preoperative preparation is crucial for a successful hiatal hernia repair:

• Medical Evaluation:
  • Detailed medical history and physical examination.
  • Assessment of symptoms, their severity, and impact on quality of life.
  • Evaluation of comorbidities and fitness for general anesthesia.
• Diagnostic Studies:
  • Upper Endoscopy (Gastroscopy): To visualize the esophagus, stomach, and duodenum; assess the type and size of the hernia; evaluate for esophagitis, ulcers (including Cameron’s erosions), strictures, and Barrett’s esophagus; and rule out malignancy. Biopsies may be taken. The surgeon can also assess the level of the GEJ.
  • Barium Swallow/Esophagram (Upper GI X-ray): To define the anatomy of the hernia, assess esophageal motility, the position of the GEJ, and the amount of stomach herniated.
  • Esophageal Manometry: To measure esophageal muscle function and LES pressure. This is important for deciding if an anti-reflux procedure is needed and which type (e.g., full vs. partial fundoplication) might be most appropriate, especially if dysphagia is a concern.
  • 24-hour pH Monitoring (or pH-Impedance): To objectively quantify reflux if GERD is a prominent feature and the diagnosis is uncertain.
  • Computed Tomography (CT) Scan: May be used for large or complex hernias, especially Type IV, to identify all herniated contents and their relationship to surrounding structures.
  • Pulmonary Function Tests: May be needed for patients with respiratory symptoms or significant lung disease.
  • Cardiac Evaluation: Especially for patients with chest pain, to rule out cardiac causes.
• Lifestyle Modifications:
  • Smoking Cessation: Strongly recommended for at least 4 weeks before surgery to reduce respiratory complications and improve healing. Patients may be tested for smoking on the day of surgery.
  • Weight Management: If the patient is overweight, weight loss is encouraged.
  • Dietary Adjustments: Patients may be advised to avoid foods that cause gas (e.g., corn, beans, cabbage, cauliflower), carbonated drinks, alcohol, citrus, and tomato products leading up to surgery. A clear liquid diet is typically not required, but patients will need to fast from food and drink for at least 12 hours before the procedure (or after midnight the night before).
• Medication Management:
  • Discontinuation of blood-thinning medications (e.g., aspirin, clopidogrel (Plavix), NSAIDs, warfarin) for a specified period (usually 1 week) before surgery, as directed by the physician.
  • Review and instructions for managing other regular medications.
• Physical Preparation:
  • Some protocols recommend walking 2-3 miles daily and performing breathing exercises (e.g., with an incentive spirometer) several times a day to optimize physical condition.
• Preoperative Education: The surgical team will explain the planned procedure (laparoscopic or open), potential use of mesh, likelihood of an anti-reflux procedure (like fundoplication), risks, benefits, expected recovery, and dietary restrictions post-surgery.
• Bowel Preparation: Generally not necessary unless specifically indicated by the surgeon.
• Hospital Admission: Instructions on what to bring, medication policies, and arrival time.

Patient positioning

The patient positioning depends on the surgical approach (laparoscopic or open) and surgeon preference:

• Laparoscopic/Robotic Hiatal Hernia Repair:
  • The patient is typically placed in a supine position.
  • A split-leg or modified lithotomy position is common, allowing the surgeon to stand between the patient’s legs.
  • The arms are usually extended out (abducted to <90 degrees) or tucked at the sides, and well-padded.
  • Steep reverse Trendelenburg positioning (head up, feet down, often 30 degrees or more) is crucial. This uses gravity to displace the abdominal organs (bowel) inferiorly, providing better visualization and access to the esophageal hiatus in the upper abdomen.
  • A footboard or other securing mechanisms (e.g., beanbag, safety straps) are used to prevent the patient from sliding on the table during the steep tilt.
  • An indwelling urinary catheter is usually placed after anesthesia induction.
  • An orogastric or nasogastric tube may be placed to decompress the stomach.
• Open Hiatal Hernia Repair:
  • Transabdominal Approach: The patient is typically in a supine position.
  • Transthoracic Approach: If a chest incision is planned (less common for primary repairs now but may be used for complex or recurrent hernias), the patient is usually placed in a lateral decubitus position (lying on their side, often the right side down for a left thoracotomy).

Port Placement (Laparoscopic/Robotic) / Incision (Open)

• Laparoscopic/Robotic Hiatal Hernia Repair:
  • Generally, 4 to 6 ports are used. The placement aims to provide optimal triangulation for instruments and camera views of the esophageal hiatus.
  • Camera Port (usually 10mm or 12mm): Often placed in the midline, at the umbilicus, or slightly superior and to the left of the umbilicus (e.g., midpoint between xiphoid and umbilicus).
  • Liver Retractor Port (usually 5mm): Placed in the subxiphoid region or right lateral subcostal area to insert a retractor (e.g., Nathanson liver retractor) to elevate the left lobe of the liver.
  • Working Ports (5mm or 12mm for surgeon’s instruments, assistant):
    • A port in the right upper quadrant (e.g., mid-clavicular line, subcostal) for the surgeon’s left hand or assistant.
    • A port in the left upper quadrant (e.g., mid-clavicular line, subcostal) for the surgeon’s right hand (often the main operating port).
    • An additional port in the left anterior axillary line or more laterally may be used by the assistant for retraction or suction/irrigation.
  • Port sizes and exact locations can vary depending on the surgeon’s technique, robotic platform (if used), and patient anatomy. A minimum distance (e.g., 8-10 cm for robotic ports) is maintained between ports to avoid instrument collision.
  • Pneumoperitoneum (insufflation of CO2 into the abdomen to 12-15 mmHg) is established before or during port placement.
• Open Hiatal Hernia Repair:
  • Transabdominal Approach: Typically involves an upper midline incision (from the xiphoid process to the umbilicus) or a left subcostal (chevron-type) incision.
  • Transthoracic Approach: Usually performed through a left posterolateral thoracotomy incision, often in the 6th or 7th intercostal space.

Intraoperative Steps

The operative steps vary depending on the type of hiatal hernia, the surgical approach, and surgeon preference, but generally include:

1. Access and Exposure:
   • Laparoscopic/Robotic: After establishing pneumoperitoneum and port placement, the liver is retracted (usually the left lobe superiorly) to expose the esophageal hiatus.
   • Open Transabdominal: The abdomen is opened, and retractors are placed to expose the hiatus.
   • Open Transthoracic: The chest is entered, the lung is retracted, and the posterior mediastinum is exposed.
2. Reduction of Herniated Contents:
   • The herniated portion of the stomach and any other organs are gently dissected and reduced from the chest back into the abdominal cavity. This involves careful dissection of adhesions between the hernia sac and mediastinal structures.
3. Hernia Sac Management:
   • The hernia sac (a pouch of peritoneum that lines the herniated contents) is dissected away from the mediastinal structures (pleura, pericardium, aorta) and the esophageal hiatus.
   • The sac is typically excised completely or at least partially, or it may be inverted into the abdomen. Complete excision is often advocated for paraesophageal hernias to reduce recurrence.
4. Esophageal Mobilization:
   • The distal esophagus is circumferentially mobilized to ensure adequate intra-abdominal length (typically at least 2-3 cm, sometimes more, below the diaphragm without tension). This often requires dissection high into the mediastinum.
   • Care is taken to identify and preserve the vagus nerves (anterior and posterior trunks) during this dissection.
5. Crural Repair (Hiatorrhaphy):
   • The enlarged esophageal hiatus in the diaphragm is repaired by approximating the diaphragmatic crura (muscle pillars) with non-absorbable sutures, typically posterior to the esophagus. Some surgeons may also place anterior sutures.
   • The repair should be snug enough to prevent re-herniation but not so tight as to cause dysphagia. The size is often calibrated over an esophageal dilator (bougie) or endoscope.
6. Mesh Reinforcement (Optional but common for large defects):
   • For large hiatal defects or in cases of recurrent hernias, surgeons may reinforce the crural repair with a prosthetic or biologic mesh.
   • Mesh can be placed as an onlay, inlay, or in a U-shape or keyhole configuration around the esophagus.
   • The type of mesh (absorbable, non-absorbable synthetic, or biologic) and its use remain topics of debate due to potential complications like erosion, though it may reduce recurrence rates for large hernias.
7. Anti-Reflux Procedure (Fundoplication – Common, especially if GERD is present):
   • Since hiatal hernias often lead to GERD, an anti-reflux procedure is frequently performed in conjunction with the hernia repair.
   • Nissen Fundoplication (360-degree wrap): The most common type, where the fundus of the stomach is wrapped completely around the distal esophagus.
   • Partial Fundoplications (e.g., Toupet – posterior 270-degree, Dor – anterior 180-200 degree): May be chosen if there’s concern about esophageal motility or to reduce side effects like gas bloat and dysphagia.
   • The choice of fundoplication depends on preoperative manometry findings, surgeon preference, and patient factors. The short gastric vessels may need to be divided to mobilize the fundus adequately for the wrap.
8. Gastropexy (Alternative or Adjunct in some cases):
   • In some situations, particularly if a fundoplication is not performed or to further secure the stomach, a gastropexy (suturing the stomach to the diaphragm or anterior abdominal wall) might be done to prevent re-herniation.
9. Esophageal Lengthening Procedures (e.g., Collis Gastroplasty – for true short esophagus):
   • If, after extensive mobilization, the esophagus is still too short to allow for a tension-free intra-abdominal repair, an esophageal lengthening procedure like a Collis gastroplasty (creating a tube of stomach to extend the esophagus) may be necessary before the fundoplication.
10. Final Inspection and Closure:
    • The repair and any fundoplication are inspected. Intraoperative endoscopy may be performed to assess the wrap and rule out perforation.
    • Hemostasis is confirmed.
    • Laparoscopic/Robotic: Instruments are removed, CO2 is desufflated, and port sites are closed.
    • Open: The abdominal or thoracic incision is closed in layers.
    • Drainage tubes are usually not required unless there are specific concerns.

Possible Complications and Management

Hiatal hernia repair, while generally safe, can have potential complications:

General Surgical Complications (Applicable to both open and laparoscopic):

• Bleeding: Intraoperative or postoperative. Management: Observation, transfusion, or reoperation if severe.
• Infection: Surgical site infection (superficial or deep), intra-abdominal abscess, or pneumonia. Management: Antibiotics, wound care, drainage if needed.
• Thromboembolic Events: Deep vein thrombosis (DVT) or pulmonary embolism (PE). Management: Prophylaxis (e.g., compression stockings, anticoagulants in high-risk patients), anticoagulation if they occur.
• Anesthesia-related complications.
• Injury to Adjacent Organs:
  • Esophagus or Stomach Perforation: A serious complication requiring immediate repair. May lead to leak, infection, and sepsis.
  • Spleen Injury: More common with extensive fundus mobilization (division of short gastric vessels); may require splenectomy if bleeding is uncontrollable.
  • Liver Injury: Usually minor, from retraction.
  • Pleura/Lung Injury (Pneumothorax): Especially during mediastinal dissection. May require a chest tube if significant.
  • Vagus Nerve Injury: Can lead to gastroparesis (delayed gastric emptying), diarrhea, or dumping syndrome. Careful dissection is key.
  • Aorta/Major Vessel Injury: Rare but life-threatening.
• Cardiovascular Complications: Irregular heartbeat, heart attack (especially in patients with pre-existing cardiac conditions).

Laparoscopic/Robotic Specific Complications:

• Port-site Hernia: Herniation of abdominal contents through a trocar site.
• Surgical Emphysema: CO2 accumulation in subcutaneous tissues, usually resolves spontaneously.
• Gas Embolism: Rare but serious.

Hiatal Hernia Repair Specific Complications:

• Dysphagia (Difficulty Swallowing):
  • Early/Temporary: Common due to postoperative swelling around the esophagus and hiatus. Usually resolves within weeks to a few months with a modified diet (liquid to soft foods).
  • Persistent/Severe: May be due to a crural repair that is too tight, a fundoplication that is too constricting, or wrap migration/stenosis. Management: Dietary adjustments, endoscopic balloon dilation, or rarely, revisional surgery.
• Gas Bloat Syndrome: Difficulty belching or vomiting, leading to abdominal fullness, bloating, and increased flatulence. More common with Nissen fundoplication. Management: Dietary changes, medications (e.g., simethicone), and time; rarely requires intervention.
• Recurrence of Hiatal Hernia: Can occur in a percentage of patients, especially with large hernias or high-tension repairs. Symptoms may or may not return. Management: Observation if asymptomatic, medication for GERD symptoms, or revisional surgery for symptomatic or complicated recurrences. Use of mesh aims to reduce this but has its own potential issues.
• Wrap-Related Complications (if fundoplication is performed):
  • Wrap Slippage or Migration: The fundoplication can move from its intended position, leading to recurrent reflux or obstruction.
  • Wrap Too Tight or Too Loose: Leading to dysphagia/obstruction or recurrent reflux, respectively.
• Mesh-Related Complications (if mesh is used):
  • Erosion: Mesh can erode into the esophagus or stomach over time, a serious complication requiring mesh removal and complex reconstruction.
  • Infection: Mesh can become infected.
  • Stenosis/Stricture: Scarring around the mesh can lead to narrowing.
  • Chronic Pain: Some patients may experience persistent pain related to the mesh.
• Postoperative Pain: Usually well-controlled with analgesics. Shoulder tip pain is common after laparoscopy due to diaphragmatic irritation from CO2.
• Nausea and Vomiting: Can occur in the early postoperative period.
• Diarrhea or Dumping Syndrome: May occur, sometimes related to vagal nerve effects.
• Weight Loss: Common in the first few months due to dietary restrictions and early satiety.

Management of Complications:

• Conservative Management: For mild issues like transient dysphagia or mild gas bloat (dietary modifications, reassurance, symptomatic medication).
• Endoscopic Management: Balloon dilation for dysphagia due to stricture or tight wrap/hiatus. Endoscopic removal of eroded mesh in some cases.
• Medical Management: PPIs for recurrent GERD, antiemetics for nausea, pain medication.
• Radiological Imaging: Barium swallow, CT scan, or endoscopy to diagnose structural complications like recurrence, wrap issues, or mesh problems.
• Revisional Surgery: May be necessary for significant or persistent complications such as symptomatic recurrent hernia, severe dysphagia unresponsive to dilation, wrap failure, or mesh erosion. Revisional hiatal hernia surgery is often more complex and carries higher risks than primary repair.

Postoperative recovery involves a gradual return to normal activities and diet. Patients are typically discharged within 1-3 days after laparoscopic repair and may take several weeks to fully recover. Long-term outcomes are generally good, with significant improvement in symptoms for most patients, but recurrence and side effects can occur. Close follow-up with the surgical team is important.