Esophageal (Hiatal) Hernia
What is a hiatal hernia?
A hiatal hernia is a gastrointestinal condition that results from a defect in the diaphragm, i.e., the muscle that separates the abdominal cavity from the chest cavity. Specifically, part of the stomach physically shifts upward into the chest through a defect in the anatomical opening in the diaphragm for the esophagus. The most common type of hiatal hernia is a sliding hernia, accounting for approximately 90% of cases. In sliding hernias, the upper part of the stomach regularly moves into the chest. Characteristic symptoms are upper abdominal and chest pain, regurgitation of food, heartburn, vomiting, cough, hoarseness, and difficulty swallowing. The second type of hiatal hernia is a paraoesophageal hernia, where not only the upper section of the stomach moves into the chest but sometimes nearly the entire stomach. Paraoesophageal hernias may be asymptomatic, but when they occur, patients most often experience shortness of breath and an increased heart rate as large portions of the lungs and blood vessels to the heart are compressed.
Hiatal Hernia – Causes
A hiatal hernia more commonly affects women simply due to the physiological changes that occur during pregnancy and childbirth, namely the increased intraabdominal pressure by the fetus. This favors the formation of hernias through weaknesses in the diaphragm. Other factors that increase the risk of developing a hiatal hernia include:
- Age-related changes with the elasticity of the diaphragm
- Obesity
- Chest injury that damages the diaphragm
- Certain types of surgeries
- Lifestyle and occupation, such as working in a seated or forward-leaning position, heavy weightlifting, or wearing tight-fitted clothing
- Smoking
- Recurrent vomiting, chronic cough, constipation, and any other medical conditions that lead to increased intraabdominal pressure
Hiatal Hernia – Symptoms
The most common symptoms of a hiatal hernia are:
- Heartburn, especially after a large meal
- Belching or coughing up of stomach contents
- Vomiting
- Burning sensation in the mouth
- Difficulty swallowing
- Epigastric and retrosternal chest pain, often confused with coronary artery disease
- Hoarseness and cough when waking up in the morning
- Difficulty breathing and wheezing
- Increased sweating
Hiatal Hernia – Diagnosis
The diagnosis of hiatal hernia is made by gastroscopy, a procedure performed under mild or general anesthesia where a small camera is inserted through the mouth to examine the esophagus and stomach for any signs of ulceration or inflammation. The benefit of gastroscopy is it allows surgeons to take samples for histopathological examination and also to test for the bacteria, Helicobacter Pylori, which has been linked to certain types of cancer and lymphoma. Other useful tests in the diagnosis of hiatal hernia include computed tomography, high-resolution esophagus manometry, 24-hr pH/impedance reflux monitoring, and an X-ray with contrast.
Hiatal Hernia – Treatment
Treatment of a hiatal hernia depends on its type and severity. Pharmacological treatment is first-line in most cases and focuses on reducing gastric acid secretion while regulating gastrointestinal motility. It primarily involves proton pump inhibitors (PPIs), with H2 histamine receptor blockers as second-line options. Diet modification is also indicated and involves avoiding spicy and acidic food, sweets, carbonated beverages, and limiting caffeine, tea, and alcohol intake. People with hiatal hernias are also advised to avoid exercise immediately after a meal as it increases the risk for regurgitation and burning sensation. Surgery is indicated for patients for whom pharmacological treatment does not provide adequate symptom relief. Surgery is also indicated in patients with more advanced disease with an increased risk of complications, as well as those with congenital defects. Hiatal hernia is the most common cause of gastroesophageal reflux. Reflux can lead to inflammation of the esophagus and eventually Barret’s Disease, where the esophageal lining thickens to cause an obstruction, that if untreated, can lead to cancer.
Hiatal Hernia – Robotic Surgery
Hiatal hernia repairs are performed using both classical and minimally invasive approaches utilizing laparoscopic or robotic surgery. The goal of surgical treatment is to alleviate the symptoms of the disease as well as to prevent complications such as esophageal ulcers or inflammation of the esophagus which, if left untreated, may become cancerous.
Robotic surgery is done under general anesthesia and utilizes a few one-centimeter incisions in the abdomen that heal with little to no visible scarring. These small incisions serve as doors for the camera and all specialized surgical tools. After precisely localizing the hernia, surgeons create a sort of cuff around the esophageal opening using the anterior and posterior walls of the stomach. This is a technique designed to strengthen the muscular integrity of the opening between the esophagus and stomach, called the lower esophageal sphincter, and prevent it from allowing regurgitation. Afterward, the defect in the diaphragm that caused the hernia to form is sutured closed. Unlike open or laparoscopic surgery, the surgeon is not directly at the patient’s table, but rather controls the robotic instruments through a dedicated console in a comfortable seated position to avoid fatigue. Robotic surgery enables surgeons to operate at high magnification, which facilitates the accurate detection of nerves and blood vessels. Additionally, the robotic arms are more dexterous than the human hand, enabling surgeons to place sutures or dissect tissues with extreme precision. Robotic surgery benefits patients in many ways. Namely, it is less invasive, produces less postoperative pain, and has a lower risk of complications such as infection and blood loss. Robotic surgery also shortens the total duration of a procedure, lowering the risk of anesthesia-related complications, and ultimately decreasing the length of stay in hospital. Additionally, it allows patients with obesity to undergo a minimally invasive bariatric surgery.
Hiatal hernia – Price
The price of a hiatal hernia repair depends on the stage of disease, the type of mesh used for reinforcement, and whether it is done classically, laparoscopically, or robotically. All details of the operation and possible treatment options are always discussed together with the attending physician during the initial consultation where you are qualified for the procedure.
