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Patient Care

Laparoscopic Paraesophageal Hernia


Laparoscopic Paraesophageal Hernia (Hiatal Hernia)

What is it?

A hiatal hernia occurs when part of the stomach and/or other intra-abdominal contents have abnormally protruded through the diaphragm into the chest. This may be classified into several different types depending on the position of the gastro-esophageal junction relative to the diaphragm and the degree to which organs have herniated into the chest.

What causes it?

The exact cause of hiatal hernias is typically not known, but they may result from and be exacerbated by any condition that results in increased abdominal pressure such as cough, straining from constipation, and obesity. The incidence increases with age.

What are the Symptoms?

The most common symptoms are reflux and chest pain. Reflux symptoms include the typical symptoms of heartburn and water brash, and atypical symptoms of chronic cough, hoarseness, or recurrent pneumonia from aspiration of refluxed material. The chest pain is typically substernal, may radiate to the back, occurs following meals, and may mimic the pain of a heart attack. Other symptoms that may occur include shortness of breath and difficulty swallowing.

How is it Diagnosed?

When a patient presents with symptoms consistent with hiatal hernia a variety of tests need to be performed to diagnose the problem and to plan appropriate operative management. The workup should begin with a chest x-ray, which may demonstrate the presence of abdominal contents within the chest. This is typically followed by an upper GI swallow exam, which will further delineate the anatomy and identify smaller hernias not seen on plain x-ray, and possibly a CT scan. An upper endoscopy should be performed in order to assess the lining of the esophagus and stomach. Esophageal manometry, which measures the contractions of the esophagus, may be obtained to assess swallowing.

Treatment Options

Small hiatal hernias may be managed nonoperatively with medical management of reflux using H2 blockers or proton pump inhibitors. Patients with larger hernias, specific types of hernias, evidence of injury to the esophageal lining from reflux, or who have failed to have symptoms resolve with medical management should have operative repair. Traditionally this repair was performed through a large incision in the abdomen or chest, but over the past decade this approach as been supplanted by a laparoscopic approach.

A laparoscopic hiatal hernia repair is a minimally invasive approach that involves specialized video equipment and instruments that allow a surgeon to repair the hiatal hernia through several tiny incisions, most of which are less than a half-centimeter in size. The concept of the repair remains the same as the open approach. The organs that have herniated into the chest are reduced back into the abdomen, the diaphragm is repaired using either sutures of a piece of mesh, and part of the stomach is wrapped partially or completely around the esophagus in order to prevent further reflux symptoms. The advantages of this method include a shorter hospitalization, less pain, fewer and smaller scars, and a shorter recovery.

Laparoscopic hernia repair is a safe and effective treatment for hiatal hernias. However, in the presence of infection, adhesions, or variations in anatomy, this method becomes dangerous and your surgeon may need to make the prudent decision to continue by making the traditional incision to safely complete the operation. This should not be seen as a failure, but as a wise decision by your surgeon to prevent dangerous complications.

Other complications, although rare, include bleeding and infection. It is uncommon to require a blood transfusion for this operation. There is a slight risk of injury to the esophagus, liver, stomach, bowel, lung, and spleen. Post-operatively, rare problems may occur. These include difficulty with swallowing or the repaired area slipping back into the chest.

In an otherwise healthy person, little is required to prepare for surgery. Depending on your age, gender, and health problems, some routine blood tests, an EKG and a chest x-ray may or may not be needed. Your surgeon or family doctor will order these tests as needed. You will be asked to refrain from eating 8 hours before surgery. Be sure to let your doctor know what medications you are taking, as some will need to be stopped before surgery. In general, all blood thinners need to be stopped for several days. These include aspirin, Ibuprofen or Motrin, Coumadin and Plavix.

This operation is generally performed with general anesthesia. An IV line will be placed in your arm for fluids and you will be brought into the operation room. The anesthesiologist and nurses will use monitors to check your heart rate and breathing during the procedure. These may include EKG leads, a blood pressure cuff, an oxygen mask and sleeves on your legs to prevent clots from forming.

Once you are asleep, the operating room team will work together to perform your operation. When your operation is complete, you will be awakened from anesthesia in the operating room but you may not remember this. After a few hours in the recovery room you will be transferred to the surgical ward. It is common to feel groggy and nauseated soon after surgery and medication is available to help with these discomforts. At the Ohio State University Medical Center most patients remain in the hospital for 2-3 days following the surgery. You will gradually be allowed to increase your intake by mouth, first liquids only followed by soft then regular solid food. Once your surgeon feels your recovery has been appropriate, meaning you are able to eat and drink adequate quantities and you pain is adequately controlled with pills, you will be discharged to home.

You may experience pain at the incision sites and in the chest, as well as mild difficulties swallowing. You will be provided with a prescription for narcotic pain medicine. You should take a stool softener in conjunction with this pain medicine in order to prevent constipation. Heavy lifting of greater than 10 lbs or any strenuous physical activity should be avoided until your follow-up appointment. Driving should be avoided particularly while taking narcotic pain medication. Symptoms that should prompt an immediate call the your surgeon include severe pain, fever of > 101 F, inability to swallow, vomiting, redness or drainage at the incision sites, or shortness of breath.

This information is not intended to replace a visit with your physician. If you have further questions, please call 614-293-3230.