What is a hiatus hernia?

Your oesophagus passes from your chest into your abdominal cavity through a small gap (hiatus) in your diaphragm. Normally the hiatus is the right size to allow the oesophagus to pass into the abdomen while keeping your stomach in your abdominal cavity. If the gap is too big, the top of your stomach, and in severe cases the whole of your stomach and other organs, can pass through the gap into your chest.

What are the benefits of surgery?

Surgery should completely resolve or significantly relieve some or all of your symptoms. If acid reflux is a symptom your surgeon may be able to perform an additional procedure at the same time to improve this.

Are there any alternatives to surgery?

Large hiatus hernia will not get better without surgery. There are measures that you can take to limit the symptoms. These include eating smaller meals more often and, if your hiatus hernia is causing acid reflux, taking regular anti-acid medication. Medication that lowers the acid content in the stomach can control symptoms of acid reflux and heal the inflammation in the oesophagus for most people.

What will happen if I decide not to have the operation or the operation is delayed?

Surgery is not usually essential and you can continue on medication to control your symptoms.

If you have been previously admitted to hospital as an emergency with your stomach 'twisted' as a result of your hiatus hernia then you will need to discuss the risk of that happening again. It can be serious and in some cases it is life-threatening.

You can take medication to control other less serious symptoms.

It is important to follow the eating and drinking instructions that your doctor gives you and try to maintain a healthy weight. You should eat smaller meals more often. Try to eat at regular times and not in the 2 hours before you go to sleep. Sleeping with the head of your bed raised can help reduce acid reflux and vomiting.

The hernia may get larger with time. A larger hernia can be dangerous because your stomach can get trapped and have its blood supply cut off (strangulation) (risk: 2 in 100 over 1 year).

Symptoms that may be caused by strangulation include:

• severe chest pain
• vomiting
• inability to keep any food down

This needs an urgent life-saving operation and is associated with a higher risk of developing serious complications.

What does the operation involve?

The operation is performed under a general anaesthetic and usually takes 2 to 3 hours.

During surgery your liver will be held out of the way to give your surgeon a clear view of the hiatus hernia and hole in your diaphragm. Tissues around the hernia will be freed up and the lining of the hernia will be removed from the inside of your chest. Your surgeon will return your oesophagus, stomach and other affected organs to their normal place.They will stitch your diaphragm to reduce the size of the hiatus so it is big enough to only allow your oesophagus to pass through.

Your surgeon will usually wrap and stitch the top part of your stomach around your lower oesophagus. This strengthens the repair and, if acid reflux is a problem, it may reduce the symptoms.

How can I prepare myself for the operation?

If you smoke, stopping smoking now may reduce your risk of developing complications and will improve your long-term health.

Try to maintain a healthy weight. You have a higher risk of developing complications if you are overweight.

Regular exercise should help to prepare you for the operation, help you to recover and improve your long-term health. Before you start exercising, ask the healthcare team or your GP for advice.

Speak to the healthcare team about any vaccinations you might need to reduce your risk of serious illness while you recover. When you come into hospital, practise hand washing and wear a face covering when asked.

What complications can happen?

Some complications can be serious and can even cause death.

General complications of any operation

• bleeding
• infection of the surgical site
• developing a hernia in the scar
• allergic reaction to the equipment, materials or medication
• blood clot in your leg
• blood clot in your lung
• chest infection
• irregular heartbeat
• heart attack
• death

Specific complications of this operation

Keyhole surgery complications

• surgical emphysema (crackling sensation in your skin caused by trapped carbon dioxide gas)
• damage to structures such as your bowel, liver or blood vessels
• developing a hernia near one of the cuts used to insert the ports
• gas embolism

Hiatus hernia surgery complications

• difficulty swallowing for a few months
• pneumothorax, where air escapes into the space around your lung
• the stitches used for the wrap may tear if you retch or vomit in the first few weeks
• making a hole in your oesophagus or stomach
• damage to your liver when holding it out of the way
• wrap migration, where the wrap pushes up through the gap into your chest
• mesh erosion, where the mesh erodes through the oesophagus or stomach

Consequences of this procedure

• pain
• scarring of your skin

Long-term problems

• continued difficulty swallowing
• tissues can join together in an abnormal way
• weight loss during the first 2 months
• abdominal discomfort
• diarrhoea
• recurrence of a hiatus hernia

How soon will I recover?

You should be able to go home the next day.

You will need to eat slowly and chew your food thoroughly.

You should be able to return to work after 3 to 4 weeks, depending on how much surgery you need and your type of work.

Your doctor may tell you not to do any manual work for a while. Do not lift anything heavy for a few weeks.

Regular exercise should help you to return to normal activities as soon as possible. Before you start exercising, ask the healthcare team or your GP for advice.

You should make a full recovery, with the symptoms of acid reflux gone or much improved. You should be able to eat and drink normally without feeling sick.

Summary

A hiatus hernia can cause heartburn or acid in your mouth. Large hernias can cause pain and problems with eating and drinking.

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