Laparoscopic Hiatal Hernia Repair & Nissen Fundoplication in India
Hiatal Hernia
The esophagus passes through an opening in the diaphragm (i.e. esophageal hiatus) as it courses through the chest to the abdomen eventually ending at the stomach. This opening is usually adequate for passage of the esophagus and nothing else. However, patients that have a hiatal hernia have an enlarged opening. There are four different types of hiatal hernias described. The sliding hernia is the most common of the four representing more than eighty-percent of all hiatal hernias. The lower esophageal sphincter - the high pressure zone near the junction of the stomach and esophagus - fails and allows stomach contents to reflux into the esophagus.
Symptoms
The symptoms associated with the hiatal hernia are variable but generally include : -
Heartburn - 30-60 minutes after eating
Regurgitation - worsened with lying flat
Excessive belching
Aspiration - stomach contents refluxed into the airway
Asthma - chronic result of aspiration
Chest Pain - burning mid-chest pain
Difficulty swallowing
Pain with swallowing
Bleeding
Stomach twisting and perforation
Obstruction
Diagnosis
Several studies are helpful to your doctor in making the diagnosis of hiatal hernia including : -
Chest X-ray : -
Air fluid level in the chest
Esophagram (Barium UGI): -
Assess the function of the esophagus
Identifying structural abnormalities (twisting of the stomach)
Identify damage caused by reflux (e.g. esophagitis, Barrett's esophagus, malignancy)
Biopsy esophagus for evaluation of malignancy
Esophageal Manometry : -
Assess the function of the LES
Assess the wave-like motion (propulsive function) of the esophagus
Surgery
Laparoscopic Hiatal Hernia Repair and Nissen fundoplication is the procedure of choice for repair of a hiatal hernia. Patients that have paraesophageal hernia which allows the fundus to be displaced into the chest above the GE junction or patients with other abdominal organs
(e.g. spleen, colon, liver) displaced into the chest should be repaired urgently. Repair will help prevent complications such as bleeding, intestinal disruption, strangulation and the like. Elective repair is recommended only for patients that are asymptomatic and have a sliding hernia. This group of asymptomatic patients may also be followed clinically seeking surgery only when symptoms arise.
In the past, open surgery was the only option for repair. This approach is associated with prolonged recovery time and a large painful incision. With the new minimally invasive approach, surgery is now a viable initial therapy even for patients who are asymptomatic.
The laparoscopic hiatal hernia repair and Nissen fundoplication is performed through five quarter-inch incisions through which, a camera and instruments are placed. The hernia is reduced from the chest into the abdomen. This may require separation of abdominal organs from the lung and middle chest structures. The hiatus is then re-approximated to the appropriate size. Some hernias are so large and tissues are so poor that prosthetic material must be used to prevent recurrence. Hernia defects greater than 5 cm. are buttressed with mesh.
This significantly decreases the recurrence rate. After adequate repair of the hiatus, a new lower esophageal valve is constructed by wrapping a two-centimeter portion of the stomach around the lower most portion of the esophagus. This collar is then anchored to the tough fibers of the diaphragm. The procedure typically lasts for two to four hours depending on the size and contents of the hernia. Patients are started on clear liquids the next morning and are discharged in the afternoon. The open surgical technique involves an 8-10 inch upper abdominal incision with a hospital stay of 5-7 days.
Recovery
Patients recover sooner after laparoscopic hiatal hernia repair and Nissen fundoplication. Return to activities can occur within 2-7 days compared to 4-6 weeks with an open approach. Wound infections occur less frequently with the laparoscopic technique. Also, less pain has been reported with laparoscopy. Most importantly, greater than ninety-percent of patients are symptom free ten years after the procedure.
Laparoscopic Hiatal Hernia Repair FAQ's
1. What is a hiatal hernia?
A hiatal hernia occurs when part of the stomach protrudes through the diaphragm and up into the chest. Although hiatal hernias are present in approximately 15%-20% of the population, only a minority of those patients are afflicted with symptoms. Most patients require a repair of the herniated tissue.
Normally the esophagus or food tube joins the stomach through an opening in the diaphragm called the esophageal hiatus. In individuals with hiatal hernias, the opening of the esophageal hiatus is larger than normal, and a portion of the upper stomach passes through the hiatus and into the chest. This usually takes years to develop. The sliding hernia is the most common, where stomach contents passes back to the esophagus. This is also known as reflux.
2. What causes a hiatal hernia?
The exact cause is unknown, but some experts suspect that increased pressure in the abdomen from coughing, straining during bowel movements, pregnancy and delivery, or substantial weight gain may contribute to the development of a hiatal hernia. It is also thought that hiatal hernias are caused by a larger-than-normal esophageal hiatus, or can occur when the muscle tissue surrounding this opening becomes weak.
3. What are the symptoms of a hiatal hernia?
Symptoms include heartburn (30-60 minutes after eating), regurgitation (worsened with lying flat), regurgitation, nausea, excessive belching, chest pain, difficulty or pain with swallowing, and acid reflux. Hiatal hernias may also produce gastroesophageal reflux disease or GERD.
4. How is a hiatal hernia diagnosed?
Hiatal hernias are typically diagnosed when testing is performed to determine the cause of upper gastrointestinal symptoms such as upper abdominal pain. Diagnostic tests are done to assess the function of the esophagus and identify any structural abnormalities or damage caused by reflex. Tests include chest x-ray, upper GI series and endoscopy.
5. How is a hiatal hernia repaired?
In many cases, when symptoms are mild, medications can be prescribed to reduce acid secretion. Stress reduction techniques may be prescribed, or if overweight, weight loss may be indicated.
When hernia symptoms are severe and chronic acid reflux is involved, surgery is sometimes recommended. Cruroplasty and Nissen fundoplication is the procedure of choice for repair of a hiatal hernia and can be done laparoscopically. The procedure is performed through five quarter-inch incisions through which a camera and instruments are placed. In fundoplication, the upper part of the stomach is wrapped around the inferior part of the esophagus, preventing herniation of the stomach through the hiatus in the diaphragm and the reflux of gastric acid. The laparoscopic procedure typically lasts for two to four hours depending on the size and contents of the hernia. Patients are started on clear liquids the next morning and are discharged in the afternoon.
6. What is the recovery period after hiatal hernia?
Patients recover sooner after laparoscopic cruroplasty and Nissen fundoplication. Return to activities can occur within 2-7 days compared to 4-6 weeks with an open approach. Wound infections occur less frequently with the laparoscopic technique. Also, less pain has been reported with laparoscopy. Most importantly, greater than ninety-percent of patients are symptom free ten years after the procedure.
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