Diaphragmatic Hernia (Hiatal Hernia): Symptoms, Reflux, Heartburn, and Diaphragmatic Hernia Surgery

Although the exact cause of a diaphragmatic hernia is unknown, its prevalence increases with age. It is believed that wear and tear of the connective tissue around the esophagus and at the junction with the stomach plays a role.

In addition to age, being overweight is also a risk factor, as increased pressure in the abdominal cavity promotes the development of a diaphragmatic hernia. Furthermore, general connective tissue weakness or a congenital abnormality can increase the risk.

If a diaphragmatic hernia causing symptoms or repeated organ displacement is left untreated, complications may arise. A paraesophageal hernia, in particular, can become dangerous if parts of the stomach or intestine move into the chest cavity and become trapped.

Surgery for a hiatal hernia is then necessary to prevent circulatory disorders, perforations, or peritonitis. In cases of large diaphragmatic hernias, heart and lung function may also be impaired.

Furthermore, in axial hernias, stomach acid can flow back into the esophagus (reflux disease). This causes inflammation of the mucous membrane (reflux esophagitis) and, in the long term, increases the risk of esophageal cancer (esophageal carcinoma). Here, too, hiatal hernia surgery is considered the treatment of choice.

Depending on where the hiatal hernia is located and how large it is, it may remain asymptomatic. In some cases, however, it can develop into life-threatening peritonitis.

First, the doctor must determine exactly what type of hiatal hernia is present and whether surgery is likely to be successful.

To this end, a physical examination is conducted prior to any potential diaphragmatic hernia surgery, during which doctors assess the gastrointestinal tract in particular.

During this examination, the doctor looks for:

• Resistance when pressing on the abdominal wall

• Unusual bowel sounds

If a diaphragmatic hernia is suspected, doctors typically order an X-ray with contrast dye. This diagnostic procedure is also known as a barium swallow.

Before the X-ray of the upper abdomen, patients drink a contrast agent that spreads through the stomach and intestines.

In addition, a gastroscopy is often performed before diaphragmatic hernia surgery to carefully assess the esophagus and stomach.

A computed tomography (CT) scan is also useful, as it clearly visualizes the hernia.

Furthermore, the doctor may measure esophageal function (manometry) and assess the acidity level in the esophagus (pH monitoring).

In cases of long-standing inflammation of the esophageal lining caused by the reflux of acidic stomach contents, tissue samples are necessary to rule out malignant changes.

Patients may also need to stop taking medications that inhibit blood clotting (e.g., warfarin or aspirin) in consultation with their doctor.

Diaphragmatic hernia surgery (hiatal hernia surgery) is typically performed using a minimally invasive, keyhole technique via laparoscopy.

There are several procedures available, with the so-called fundoplication (gastric sleeve surgery) being the most commonly performed. In this procedure, doctors form a sleeve from a portion of the stomach and place it around the lower section of the esophagus.

This prevents the backflow of acidic stomach contents into the esophagus, thereby alleviating symptoms such as difficulty swallowing or reflux.

This surgery is performed through several small incisions, through which a camera and instruments are inserted into the abdominal cavity.

There are several variations of the gastric sleeve surgery:

• Nissen and Rosetti fundoplication

• Toupet fundoplication

In the Nissen method, the sleeve is placed completely around the esophagus, whereas in the Toupet method, it is only partially wrapped around it. In both cases, the sleeve is secured to the diaphragm and the stomach wall using special sutures.

The resulting loop is sutured to the anterior wall of the stomach. Additionally, the sleeve is secured to the diaphragm with sutures.

In the Toupet fundoplication, doctors do not place the loop completely around the esophagus. The sutures are secured to both the diaphragm and the anterior wall of the esophagus.

This method is primarily used when there are motility disorders of the esophagus.

In over 90 percent of patients, gastric sleeve surgery leads to a permanent cure. This spares young people with reflux disease, in particular, from having to take medication for many years.

Another surgical option is gastropexy (fundopexy), in which the stomach is secured to the anterior abdominal wall. In a hiatal repair, the opening in the diaphragm that has become too wide is narrowed with sutures so that only the esophagus can pass through. If necessary, a synthetic mesh is also inserted to prevent the organs from slipping out of place again.

If surgery for a diaphragmatic hernia (hiatal hernia surgery) was necessary, symptoms usually resolve completely afterward.

Nevertheless, certain complications can occur in rare cases. However, these problems occur much less frequently in a specialized clinic where hernia treatment is performed regularly.

The most common complication is bloating after surgery. This harmless but uncomfortable side effect occurs because air from the stomach can no longer escape through the stomach opening into the esophagus and therefore enters the intestines in greater quantities.

Occasionally, difficulty swallowing may occur because the hiatal hernia surgery narrows the passage between the esophagus and the stomach.

During the procedure, injury to the vagus nerve (also known as the visceral nerve) may also occur. Under certain circumstances, this can contribute to delayed gastric emptying. Damage to the phrenic nerve is also possible, which can lead to breathing difficulties.

Furthermore, it cannot be completely ruled out that doctors may injure organs or surrounding tissue in the abdominal cavity during the surgical procedure. This can result in bleeding or postoperative hemorrhage.

For diaphragmatic hernia surgery, a hospital stay of about three to five days is expected. The success of the procedure can be confirmed by a follow-up X-ray with contrast dye.

During this exam, doctors pay particular attention to the junction between the esophagus and the stomach. In most cases, this junction remains swollen for the first few days following diaphragmatic hernia surgery. Therefore, the patient should consume liquid or soft foods.

It may take some time for the diaphragm to regain its normal stability. For six weeks, you should avoid strenuous activities, such as lifting heavy objects or engaging in intense exercise.