HIATAL HERNIA PROCEDURE

Laparoscopic Hiatal Hernia Repair.

“Heartburn is a common problem in the Western world. Approximately 7% of the population experience symptoms of heartburn daily. An abnormal esophageal exposure to gastric juice is probably present in 20-40% of this population, meaning these people have GERD”.

 

INTRODUCTION

A hiatal hernia is a condition in which the upper portion of the stomach protrudes into the chest cavity through an opening of the diaphragm called the esophageal hiatus. This opening usually is large enough to accommodate the esophagus alone. With progressive weakening and enlargement, this opening can allow upward passage or even entrapment of the upper stomach above the diaphragm.

The presence of a hiatal hernia increases the risk of having GERD (Gastroesophageal Reflux), and when GERD is treated surgically, patients who have accompanying hiatal hernias, need surgical repair for this also; That is the reason why some patients and doctors use the term hiatal hernia to mean GERD indistinctly, even though they are two separate problems. However, there are many patients with GERD who do not have a hiatal hernia and many patients with a hiatal hernia that do not have GERD at all. That is why we decided to add this section to complement the one for GERD.

A hiatal hernia is a common condition; by age 60, up to 60% of people have it at some degree.

Laparoscopic Antireflux Surgery

GASTROESOPHAGEAL REFLUX DISEASE/GERD

CLASSIFICATION OF HIATAL HERNIAS AND INCIDENCE
SIGNS AND SYMPTOMS
DIAGNOSIS & TREATMENT
INDICATIONS FOR HIATAL HERNIA SURGERY
LAPAROSCOPIC VS. OPEN ANTIREFLUX SURGERY (AND/OR HIATAL HERNIA REPAIR)
SURGICAL TECHNIQUE (SIMPLIFIED EXPLANATION)

CLASSIFICATION OF HIATAL HERNIAS AND INCIDENCE
Type I (90%): Classic sliding hiatal hernia in which gastroesophageal junction (GEJ) migrates into the thorax through the esophageal hiatus.

Type II (9%): True paraesophageal hernia, in which the fundus of the stomach herniates into the thorax and the GEJ is in a normal position.

Type III (1%): Combination of the two previous types.

SIGNS AND SYMPTOMS
Hernia deslizante: la mayoría de las personas no tienen síntomas. Cuando está presente en realidad es el ERGE dando sus manifestaciones habituales. Haz clic aquí para obtener más información sobre la ERGE y la cirugía antirreflujo laparoscópica.

 

Sliding hiatal hernia: most people have no symptoms, when present its GERD giving its usual manifestations. Click here to learn more about GERD and Laparoscopic Antireflux Surgery.

Paraesophageal and mixed hiatal hernia: they also often have no symptoms or only minimal symptoms. When present, can be the usual ones for GERD plus:

 

  • Vague abdominal discomfort
  • Fullness sensation after meals
  • Vomiting
  • Chest pain (because of the stomach entrapment in the esophageal hiatus)
  • Anemia (occasional)

 

 

DIAGNOSIS

It is usually done when you are visiting the doctor for GERD symptoms, and it is made using the same diagnostic tools for detecting GERD.

TREATMENT

Occasional or mild symptoms can generally be treated by nonsurgical means, including lifestyle changes and medications.

When symptoms are frequent or intense, surgery is needed, the stomach is returned to the abdominal cavity, and the hiatus is closed with sutures; nevertheless, Dr. Rosales uses a special mesh to reinforce the hiatus closure since the recurrence rates are very high when a mesh is not used.

INDICATIONS FOR HIATAL HERNIA SURGERY

Since the presence of this defect itself is not an indication to correct it, the two main reasons to contact us for surgical treatment are:

  • Sliding (Type I) a hernia associated with intense GERD symptoms or complications related to this reflux.

Paraesophageal or mixed (Type II or III) hernias, this type of hernias have high morbidity and mortality when symptomatic and are not surgically repaired. Because of this, it generally is recommended that all people with these type of hernias undergo surgery regardless of the intensity symptoms.

 

CONTRAINDICATIONS

Absolute

 

  • Inability to tolerate general anesthesia
  • Uncorrectable high bleeding risk

 

 

Relative

 

  • Previous abdominal surgery close to the hiatal region
  • Severe obesity
  • Esophageal shortening

 

 

 

ADVANTAGES OF LAPAROSCOPIC HIATAL HERNIA REPAIR

 

  • Very small incisions (5)
  • Fast recovery time (one or two night hospital stay, depends on the case)
  • Minimal postoperative pain
  • Lower morbidity rate
  • Lower hospital stay
  • Return to normal activity and to work in shorter period of time (complete recovery in 5 to 7 days)
  • Decreased risk of wound infection and hernia formation
  • Minimal scarring

 

 

 

OUTCOMES/COMPLICATIONS

Results of laparoscopic antireflux surgery are encouraging with low rates of perioperative morbidity and mortality. Conversion rate from laparoscopic to open procedure is higher in inexperienced hands; the conversion rate in Dr. Rosales’ experience is less than 3%. Perioperative complications requiring reoperation such as stomach migration or esophageal perforation occur in less than 1%.

The overall satisfaction rates regarding symptoms after the procedure range from 90 to 100% and a significant improvement in the quality of life a few weeks after having the procedure.

SURGICAL TECHNIQUE (SIMPLIFIED EXPLANATION)

Under general anesthesia, a 5 mm abdominal incision is made at the left subcostal region (below the ribcage), CO2 is introduced to the abdominal cavity, then 4 more incisions are made in the abdomen (one of 10mm and the rest of 5mm) to introduce the rest of the instruments; the herniated stomach is returned to the abdominal cavity, the hernia sac is dissected, and we proceed to close the hiatal defect using a biological mesh to reinforce the area, if GERD accompanies the hernia we perform an antireflux procedure also (See Laparoscopic Antireflux Surgery), incisions are closed with suture and the procedure is completed.

**The materials Dr. Rosales uses depend what is best for your case.

Incisions for Laparoscopic Hiatal Hernia Repair


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