Hiatus Hernia & Anti Reflux Surgery

Explore various treatment choices available for managing hiatus hernia, including surgical and non-surgical approaches.

Dr Ahmed Hassn is recognised for his exceptional and major contribution to the surgery of GERD and hiatus hernia. He regularly receives referrals from other surgeons in the country for complex hiatus hernia and for previously failed surgery.

He has performed more than one thousand laparoscopic antireflux surgery with excellent outcomes.

He has published extensively on antireflux surgery, hiatus hernia repairs and on redo antireflux surgery for failed procedures.

What is gastroesophageal reflux (GERD)?

Acid is secreted in the stomach to help the digestion of food and to kill many harmful compounds. The stomach lining is adapted to this acid, but the lining of the gullet (esophagus) is not adapted to acid.

We all have a valve mechanism at the lower part of the gullet (LES) which allows food to go down to the stomach but prevents acid and other stomach contents from regurgitating to the gullet.

When this valve is weakened or in association with a hiatus hernia, acid and other contents of the stomach regurgitate back to the gullet and cause symptoms and if left untreated, it can cause permanent damage to the gullet.

I. What is Hiatus Hernia?

Hiatus Hernia is a condition that occurs when a part of the stomach protrudes through the diaphragm into the chest cavity. This can weaken the lower esophageal sphincter (LES), the muscle that normally prevents stomach acid from flowing back into the esophagus. Hiatus Hernia can lead to GERD, causing heartburn, regurgitation, chest pain, and other uncomfortable symptoms.

Symptoms of gastroesophageal reflux and hiatus hernia

 

  • A burning sensation in your chest (heartburn), usually after eating, which might be worse at night or while lying down
  • Backwash (regurgitation) of food or sour liquid
  • Upper abdominal or chest pain
  • Trouble swallowing (dysphagia)
  • Sensation of a lump in your throat          
         

Other symptoms may include:

  • An ongoing cough
  • Inflammation of the vocal cords (laryngitis) and change in voice.
  • New or worsening asthma or repeated attacks of chest infection

Hiatus hernia and GERD are not synonymous but there is a common association. Not every patient with reflux would have hiatus hernia and not every patient with hiatus hernia would have reflux.

 

Treatment of GERD and hiatus hernia

  • Small sliding hiatus hernia which is not causing symptoms does not require treatment.
  • Sliding hiatus hernia causing acid reflux should be treated by laparoscopic repair of the hernia and antireflux procedure.
  • Other types of hiatus hernia should be treated by laparoscopic repair to avoid complications of incarceration and strangulation.
  • Patients with mild acid reflux happening only once or twice per week should be treated by medical acid suppressant tablets.
  • Patients requiring acid suppressant medication every day should be counselled for antireflux surgery even if they have complete relief of symptoms. This is to avoid the long-term side effects of acid suppressants.
  • Endoscopic procedures are advocated to treat GERD. None of these procedures proved to be effective on the long-term or equivalent to the gold standard Nissen fundoplication.

Why Anti Reflux Surgery?

Anti Reflux Surgery remain to be the only definitive treatment to cure GERD. During surgery, the LES is reinforced to prevent acid reflux and alleviate the symptoms associated with GERD. The surgery can significantly improve the patient’s quality of life by reducing the need for long-term medication use and minimizing GERD-related complications.

Preoperative Evaluation:

Before considering surgery, thorough evaluation is necessary to determine the patient’s candidacy and to tailor the treatment plan to their specific needs. The preoperative evaluation may include:

  • Medical history review: Understanding the patient’s medical background, previous treatments, and symptoms.
  • Physical examination: A comprehensive assessment of the patient’s overall health.
  • Upper endoscopy: Visual examination of the esophagus and stomach using a thin, flexible tube with a camera (endoscope).

 

In some cases, other tests might be required if the diagnosis was not established by the above tests.

 

  • Esophageal pH monitoring: A test to measure the acid level in the esophagus over 24 hours to assess reflux severity.
  • Esophageal manometry: A test to evaluate the strength and coordination of esophageal muscles.
  • Imaging studies: X-rays or CT scans to visualize the anatomy and detect any structural abnormalities.

The Procedure

Anti Reflux Surgery is commonly performed using a minimally invasive technique called laparoscopy. During the procedure, the surgeon creates a new and tighter valve mechanism around the lower esophagus to prevent reflux. This can be achieved through various surgical approaches. Nissen fundoplication is the gold standard treatment. Laparoscopy offers several benefits, including smaller incisions, reduced scarring, faster recovery, and a shorter hospital stay.

Reflux after bariatric surgery

This is a relatively new entity where a percentage of patients who had sleeve gastrectomy might develop GERD.

Those patients whom their symptoms are not controlled by medical treatment might require surgical treatment. The most used procedures include laparoscopic repair of the hiatus (diaphragm muscles) or laparoscopic modification of the previously sleeved stomach.