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.
This leads to reflux ->
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 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 is usually performed laparoscopically and patients are usually able to be discharged the same day. At Institute of Esophageal and Reflux Surgery, we repair over 50 large and/or paraesophageal hiatal hernias a year, with almost all of them being performed laparoscopically.
Paraesophageal hernias are one type of large hiatal hernia and occur when the stomach slides up beside the esophagus (see diagram above). In these situations, the stomach may twist and lose its blood supply or obstruct. Symptoms of paraesophageal hernias often include bloating and chest pain. Paraesophageal hernia 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.
At Institute of Esophageal and Reflux Surgery, we are involved in a clinical trial to evaluate the effectiveness of the LINX Reflux Management System in patients with paraesophageal hernias. Short term data shows excellent durability with minimal side effects.
When a hiatal hernia leads to deformation of the antireflux barrier, it is repaired by performing a laparoscopic fundoplication. In some patients, we can repair the hernia and place the LINX Reflux Management System.
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.