Hiatal and Para-esophageal Hernia Denver
What is a Hiatal Hernia?
A hiatal hernia occurs when the upper part of the stomach goes up through the opening in the diaphragm (the muscle that separates the chest and the abdomen) that is normally occupied by the esophagus. Physicians often use the phrases “hiatal hernia” and “esophageal reflux” interchangeably. Esophageal reflux is a clinical diagnosis which is based on symptoms, such as heartburn or acid reflux, and is confirmed by tests that evaluate the extent of reflux of gastric juice and acid into the esophagus. A hiatal hernia is a diagnosis of an anatomic change that can only be made by x-ray studies or upper endoscopy.
The drawings below illustrate how the development of a hiatal hernia leads to unfolding of the valve mechanism, resulting in a funnel-shaped valve that increases the ability of stomach contents to reflux back into the esophagus (large arrow on right).
Many patients are told that they have a hiatal hernia when they complain of gastroesophageal reflux (GERD) symptoms, or when the hernia causes pain in their upper abdomen like how groin hernias cause pain in the groin area. Most smaller hiatal hernias (less than roughly 6 cm or 2.5 inches in size, such as the one illustrated above) do not cause pain. Very large hiatal hernias and paraesophageal hernias can cause upper abdominal or chest pain. When pain occurs, surgical repair may be needed to prevent strangulation of the stomach. For the most part, hiatal hernias weaken the effectiveness of the antireflux barrier and increase the severity of gastroesophageal reflux disease.
Large or Giant Hiatal Hernias
Large or giant hiatal hernias often cause a portion of the stomach to be up in the chest and can result in reflux or other problems including chest pain, food sticking, painful upper abdominal bloating, and the feeling of getting full early or shortness of breath, especially after eating.
They can also cause chronic blood loss leading to anemia. In these instances, if evaluation indicates that these symptoms are likely due to the hiatal hernia, then surgery to repair the hiatal hernia is needed. Surgery can often be performed laparoscopically and consists of three parts: (1) Freeing up attachments that are keeping the stomach up in the chest to get the stomach back down into the abdomen; (2) Repairing the opening in the diaphragm with sutures and an onlay patch to reinforce the sutured closure; and (3) Folding the stomach around the lower esophagus to create a bumper which prevents the stomach from riding back up into the chest again, as the stomach no longer has membranes to hold it in the abdomen (these membranes were stretched out when the hernia developed). At SOFI, we have repaired over 150 large and/or paraesophageal hiatal hernias, the majority laparoscopically.
Paraesophageal hernias are one type of large hiatal hernia and occur when the stomach slides up beside the esophagus (see diagram below). In these situations, the stomach may twist and lose its blood supply or obstruct. Symptoms of paraesophageal hernias often include bloating and chest pain. Surgery may be necessary in these situations to prevent loss of the stomach, and occasionally this surgery needs to be done on an emergency basis. The surgical repair is similar to that described above for large hiatal hernias.
Improved Results with Hiatal Hernia Repair
Since 2007 we have been using a biologic patch to reinforce many hiatal hernia repairs. This patch allows for a patient’s own tissue to grow into the patch as the patch gradually reabsorbs, which increases the overall strength of the repair considerably. Studies have shown that the addition of this patch may reduce the risk of recurring hiatal hernias, or the hernia coming back, by over 60%. In addition, we may also employ small squares of a permanent, felt-like material with each suture, called pledgets, to help distribute the tension on each suture.
Hiatal Hernias Associated with GERD
When a hiatal hernia leads to deformation of the antireflux barrier, it is repaired by performing a laparoscopic fundoplication. We are now using an acellular human collagen matrix to reinforce the hiatal hernia repair.
GERD in Which There Is Minimal Hiatal Hernia
Although up to 90% of patients with GERD have a hiatal hernia, the degree of that hiatal hernia is variable, and in many patients the hiatal hernia is fairly minimal (less than 2cm in height). In this situation, there are other surgical techniques (Transoral Incisionless Fundoplication (TIF) and LINX Reflux Management System) that have lower side effects and are very effective in the improvement of symptoms.