Hiatus Hernia Repair

Indications for Surgery

The oesophagus carries food from the mouth to the stomach. It passes through the muscle between the abdomen and chest (diaphragm) just before it meets the stomach, through an opening called the oesophageal hiatus. When the opening in the diaphragm is too large, some of the stomach can slip up into the chest cavity. This can cause heartburn (gastro-oesophageal reflux: GORD) as gastric acid backflows from the stomach into the oesophagus. Hiatal hernia repair is surgery to repair the bulging of stomach tissue through the muscle between the abdomen and chest (diaphragm) into the chest (hiatal hernia).

hernia

Hiatal hernia repair may be recommended when the patient has:

  • severe heartburn
  • severe inflammation of the oesophagus from the backflow of gastric fluid (reflux)
  • narrowing of the opening (hiatus) through the diaphragm (oesophageal stricture)
  • chronic inflammation of the lungs (pneumonia) from frequent breathing in (aspiration) of gastric fluids

Procedure

Using keyhole surgery the stomach and lower oesophagus are placed back into the abdominal cavity. The opening in the diaphragm (hiatus) is tightened and the stomach is stitched in position to prevent reflux. The upper part of the stomach (fundus) may be wrapped around the oesophagus (fundoplication) to reduce reflux.

procedure

Aftercare

Patients may need to spend 3 to 10 days in the hospital after surgery. Rarely, a tube may need to be placed into the stomach through the nose and throat (nasogastric tube) during surgery and may remain for a few days. Small, frequent meals are recommended.

aftercare

With Private Health Insurance

There is no waiting list. If you wish, your operation can usually be performed within a week or two or planned at a time of your choosing. For most patients with full private health insurance there will be some extra costs not covered by Medicare or your health fund. The cover provided by your health fund will vary according to which fund and which table you are on and in some cases you may have to pay an "excess". It is your responsibility to check with your health fund prior to surgery. Full financial details will be provided to you prior to surgery. Occasionally other tests, procedures or specialist consultations may be necessary and some other costs incurred.

Providing you have private health insurance you can expect to be out of pocket around between $1900 - $2000 depending on which health fund you are registered with. Hospitals used by LapSurgery Australia for this surgery are:

  • Mulgrave Private Hospital - Mulgrave
  • Knox Private Hospital - Wantirna.
  • Peninsular Private Hospital – Frankston.
  • St John of God Berwick Hospital – Berwick.

Without Private Health Insurance

If you do not have private health insurance, you can expect to be out of pocket between $8000.00 - $8500.00 depending on the hospital your surgery is performed at. Following your consultation with our surgeon our staff will be able to give you an informed financial consent prior to going ahead with surgery.

Public hospital waiting lists are very long and the surgery is usually carried out by trainee surgeons under the supervision of one of the specialist surgeons appointed by the hospital. There is no choice of surgeon in the Public Hospital and your LapSurgery Australia surgeon cannot not be involved in your operation.

Please contact our office if you have any other questions in regard to costings for this surgery: (03) 9760 2777

General risks as for all surgery

1. Risks of general anaesthetic
2. Infection
3. Bleeding
4. Deep vein thrombosis


Risk specific to this Surgery

1. Recurrence of the hernia up to 15-20%
2. Difficulty swallowing for 6 weeks occasionally requiring further treatment with stretching of oesophagus
3. Difficulty vomiting or belching with occasional increase in flatulence, all of which are mostly temporary
4. Rarely, injury to the internal organs

1. No need for long term medication

2. Relief of regurgitation and heart burn

3. Modest weight reduction

4. Decrease the risk of complication from reflux oesophagitis

5. Able to eat all food types

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The team at LAPSurgery Australia are recognised for their exceptional and major contribution to the Government sponsored Bariatric Safety Registry (BSR). The BSR tracks surgical complications and provides an unbiased safety record for weight loss surgery.

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FAQ

A hiatal hernia is an abnormality in which part of the stomach pushes through the diaphragm muscle which separates the abdomen from the chest cavities into the chest. Although hiatal hernias are present in approximately 10% of the population, they are associated with symptoms in only some of those afflicted.

Normally, the oesophagus passes down through the chest, crosses the diaphragm, and enters the abdomen through an opening in the diaphragm called the oesophageal hiatus. Just below the diaphragm, the oesophagus joins the stomach. In individuals with hiatal hernias, the opening of the oesophageal hiatus is larger than normal, and a portion of the upper stomach slips up (herniates) through the hiatus and into the chest. Although hiatal hernias are occasionally seen in infants where they probably have been present from birth, most hiatal hernias in adults are believed to have developed over many years.

It is thought that hiatal hernias are caused by a larger-than-normal oesophageal hiatus, the opening in the diaphragm through which the oesophagus passes from the chest into the abdomen; as a result of the large opening, part of the stomach "slips" into the chest. Other potentially contributing factors include:

1. A permanent shortening of the oesophagus (perhaps caused by inflammation and scarring from the reflux or regurgitation of stomach acid) which pulls the stomach up.

2. An abnormally loose attachment of the oesophagus to the diaphragm which allows the oesophagus and stomach to slip upwards.

Hiatal hernias are categorized as being either sliding or para-oesophageal.

Sliding hiatal hernias, the most common type of hernia, are those in which the junction of the oesophagus and stomach, referred to as the gastro-oesophageal junction, and part of the stomach protrude into the chest. The junction may reside permanently in the chest, but often it juts into the chest only during a swallow. This occurs because, with each swallow, the muscle of the oesophagus contracts causing the oesophagus to shorten and to pull up the stomach. When the swallow is finished, the herniated part of the stomach falls back into the abdomen.

Para-oesophageal hernias are hernias in which the gastro-oesophageal junction stays where it belongs (attached at the level of the diaphragm), but part of the stomach passes or bulges into the chest beside the oesophagus. The para- oesophageal hernias themselves remain in the chest at all times and are not affected by swallows. A para-oesophageal hiatal hernia that is large, particularly if it compresses the adjacent oesophagus, may impede the passage of food into the stomach and cause food to stick in the oesophagus after it is swallowed. Ulcers also may form in the herniated stomach due to the trauma caused by food that is stuck or acid from the stomach. Fortunately, large para-oesophageal hernias are uncommon.

The vast majority of hiatal hernias are of the sliding type, and may not be associated with symptoms. The larger the hernia, the more likely it is to cause symptoms. When sliding hiatal hernias produce symptoms, they almost always are those associated with gastric reflux (GORD) or its complications. This occurs because the formation of the hernia often interferes with the barrier (lower oesophageal sphincter) which prevents acid from refluxing from the stomach up into the oesophagus. Additionally, it is known that patients with GORD are much more likely to have a hiatal hernia than individuals not afflicted by GORD. Hiatal hernias contribute to GOR, however, it is not clear if hiatal hernias alone can result in GORD. Since GORD may occur in the absence of a hiatal hernia, factors other than the presence of a hernia can cause GORD.

Other Symptoms seen in patients with hiatus hernia:

1. Heartburn or GORD

2. Regurgitation

3. Difficulty swallowing

4. Intermittent Vomiting

5. Chronic cough

Normally, there are several mechanisms to prevent acid from flowing backwards (refluxing) up into the oesophagus. One mechanism involves a band of oesophageal muscle where the oesophagus joins the stomach, called the lower oesophageal sphincter, which prevents acid from refluxing or regurgitating. The sphincter only relaxes when food is swallowed, allowing food to pass from the oesophagus and into the stomach. The sphincter normally is attached firmly to the diaphragm in the hiatus, and the muscle of the diaphragm wraps around the sphincter. The muscle that wraps around the sphincter adds to the pressure of the contracted sphincter to further prevent reflux of acid.

Another mechanism that prevents reflux is the valve-like tissue at the junction of the oesophagus and stomach just below the sphincter. The oesophagus normally enters the stomach so that there is a sharp angle between the oesophagus and stomach. The thin piece of tissue in this angle, composed of oesophageal and stomach wall, forms a valve that can close off the opening to the oesophagus when pressure increases in the stomach.

When a hiatal hernia is present, two changes occur. First, the sphincter slides up into the chest while the diaphragm remains in its normal location. As a result, the pressure normally generated by the diaphragm overlying the sphincter and the pressure generated by the sphincter no longer overlap, and as a result, the total pressure at the gastro-oesophageal junction decreases. Second, when the gastro-oesophageal junction and stomach are pulled up into the chest with each swallow, the sharp angle where the oesophagus joins the stomach becomes less sharp and the valve-like effect is lost. Both changes promote reflux of acid.

Hiatal hernias are often diagnosed incidentally when an upper gastrointestinal x-ray or Gastroscopy is done during testing to determine the cause of upper gastrointestinal symptoms such upper abdominal or chest pain.

CT scans and Barium X-rays can also help with further information important to the treating doctor.

At LSA we have the latest Oesophageal testing method currently available. The Manoscan is a machine using computer assessment that involves the passage of a fine catheter into the Oesophagus to study the acids reflux profile and function of the oesophagus. It provides us with information which is key to assessing the suitability of the person for surgery (see our Manometry page for more).

Treatment of large para-oesophageal hernias causing symptoms require surgery in selected cases. There is no other effective treatment other than drugs that can sometime control symptoms of reflux such as anti-acid medication.

During surgery, the stomach is pulled down into the abdomen, the oesophageal hiatus is made smaller, and the oesophagus is attached firmly to the diaphragm. This procedure restores the normal anatomy. A major development, and one that improves the outcome and prevents recurrence, is the use of absorbable mesh to reinforce the opening through which the oesophagus comes into the abdomen.

Surgeons at LSA have extensive experience and now perform this surgery using keyhole techniques with quick recovery, less pain and quicker return to work in comparison to the old open method. In addition, part of the upper stomach is wrapped around the lower sphincter to augment the pressure at the sphincter and further prevent acid reflux.

Hiatal Hernia - give me the most important points!

1. A hiatal hernia is an anatomical abnormality of the oesophagus.

2. Hiatal hernias contribute to gastro-oesophageal reflux disease (GORD).

3. The symptoms in individuals with hiatal hernias parallel the symptoms of the associated GORD.

4. The treatment of most hiatal hernias is the same as for the associated GORD and in some cases require Surgery.

5. At LSA we have the latest oesophageal testing method currently available called a Manoscan machine which is a computer testing procedure that involves the passage of a fine catheter into the oesophagus to study the acid reflux of the person prior to surgery.

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