Minor complaints may be alleviated with medication, but in the case of more severe complaints and the risk of organ injury, diaphragmatic hernia surgery should be performed. The operation is performed under general anesthesia and there are various methods. Nowadays, laparoscopy is usually used, in which instruments and a tiny video camera are inserted through small incisions. In some cases, however, an abdominal incision (laparotomy) may be necessary.
Although no exact cause for diaphragmatic hernia is known, it can be observed that its frequency increases with age. This leads to the conclusion that signs of wear and tear of the connective tissue in the area of the esophageal opening (at the transition to the stomach) play a role in the development of a hiatal hernia.
However, hiatal hernias do not only occur with age, but also with obesity. This is presumably because excess weight increases the pressure on the diaphragm, which can lead to a hiatal hernia. However, a general weakness of the connective tissue can also contribute to a diaphragmatic hernia.
In addition to these acquired forms, diaphragmatic hernias can also be congenital, which can make surgery necessary at an early age.
If a diaphragmatic hernia with symptoms or repeated (recurrent) organ displacement is not operated on, various difficulties can arise depending on the type, location and size of the hernia.
In the case of a paraesophageal hernia (located next to the oesophagus), parts of the stomach and intestine may be displaced into the chest cavity, even if the stomach has not completely detached. In this case, a hiatal hernia operation is particularly indicated if there is a risk of parts of the stomach or intestine becoming trapped in the gap, which can lead to circulatory disorders or even the death of parts of the intestine, perforation and peritonitis. These complications can be avoided if hiatal hernia surgery is performed in good time.
In the case of large hiatal hernias, even heart and lung function can be restricted because the stomach and intestinal parts in the chest cavity can lead to constriction of the heart and lungs. Hiatal hernia surgery should also be performed in this case. However, hiatal hernia surgery can also prevent further damage in other cases. In axial hernias, for example, acidic stomach contents can leak back into the oesophagus (reflux disease). In the long term, this can lead to inflammation of the mucous membrane (reflux esophagitis), which in turn increases the risk of esophageal cancer (esophageal carcinoma). Here too, hiatal hernia surgery is the treatment of choice.
Depending on where the hiatal hernia is located and how large it is, it can be symptom-free or develop into a life-threatening peritonitis. The first step is therefore to determine exactly what type of diaphragmatic hernia is present and whether an operation can achieve a cure. For this purpose, a physical examination is carried out before a possible diaphragmatic hernia operation, in which the gastrointestinal area in particular is examined. Here, attention is paid to resistance when pressing in the abdominal wall (resistance) as well as unusual bowel sounds.
As soon as a diaphragmatic hernia is suspected, an X-ray with contrast medium is taken. This examination is also known as an X-ray hiatal hernia. Before the upper abdomen is X-rayed, the patient drinks a contrast agent that is distributed in the stomach and intestines so that they can be better visualized in the X-ray image. In addition, an esophagogastroduodenoscopy is usually performed before a hiatal hernia operation. Sometimes a computer tomography (CT) scan is also performed before a hiatal hernia operation, in which the hernia can be clearly visualized.
In addition, a measurement of the esophageal function (manometry) and a measurement of the acid content in the esophagus (pH-metry) can be carried out. In the case of long-standing and pronounced inflammation of the esophageal mucosa due to reflux, tissue samples are required to rule out malignant changes (tumors). If necessary, medication that inhibits blood clotting (e.g. Marcumar or aspirin) must be discontinued in consultation with the doctor before the hiatal hernia operation.
Hiatal hernia surgery is usually performed using laparoscopy as the access route. There are several methods of hiatal hernia surgery, with fundoplication being the most common method. In a fundoplication, a sleeve is formed from parts of the stomach and placed around the lower part of the oesophagus. This reduces the backflow of acidic stomach contents into the oesophagus (reflux). The chyme, on the other hand, can be transported further from the oesophagus into the stomach. This operation is usually performed as a laparoscopy. Small skin incisions are made through which surgical tools and a small camera are inserted into the abdominal area.
There are two different procedures within fundoplication. When performing fundoplication according to Nissen and Rosetti, the sleeve is passed completely around the oesophagus, while the front wall of the gastric fundus is placed behind the oesophagus.
The resulting loop is sutured to the anterior wall of the stomach. The sleeve is also attached to the diaphragm with sutures.
In fundoplication according to Toupet, the loop is not passed completely around the oesophagus and is secured with sutures both to the diaphragm and to the anterior wall of the oesophagus.
This method is mainly used if there are movement disorders (motility disorders) of the esophagus. In over 90 percent of those affected, fundoplication leads to a permanent cure. Young people with reflux disease in particular are spared the need to take medication for many years.
Another method of hiatal hernia surgery is gastropexy, also known as fundopexy. In this procedure, the stomach is moved into its normal position and sutured to the anterior abdominal wall so that it can no longer move. In a hiatoplasty (also known as hiatal constriction), the gap in the diaphragm is sutured tighter.
The gap in the diaphragm, which has become too large, is reduced to such an extent that only the oesophagus can pass through it. The edges of the diaphragmatic hiatus are then rejoined using special sutures. If necessary, a plastic mesh is stapled onto these sutures to reduce the risk of another hernia.
If a hiatal hernia operation was necessary, the symptoms usually disappear completely afterwards. Nevertheless, certain complications can occur in rare cases, although it should be noted that complications are less common in centers where hiatal hernia surgery is frequently performed.
The most common complication is the occurrence of bloating after hiatal hernia surgery. This harmless, albeit unpleasant, complication is related to the fact that air from the stomach can no longer enter the oesophagus and therefore increasingly ends up in the intestine. Swallowing difficulties occur less frequently, as the hiatal hernia operation has caused a narrowing of the passage between the oesophagus and stomach.
Diaphragmatic hernia surgery can also result in injury to the vagus nerve (the so-called visceral nerve). Under certain circumstances, this can result in a gastric emptying disorder. The phrenic nerve (the so-called diaphragmatic nerve) can also be injured during diaphragmatic hernia surgery. If this is affected, this can result in breathing difficulties.
And as with any operation, it cannot be completely ruled out that organs and tissue in the vicinity of the operation site may be damaged during diaphragmatic hernia surgery, which can lead to bleeding or secondary bleeding.
A stay in hospital of around three to five days is to be expected for diaphragmatic hernia surgery. The success of the operation is ensured by a repeat X-ray examination with contrast medium. Here, the transition area from the oesophagus to the stomach is examined again in particular. As the transition from the oesophagus to the stomach is often still a little swollen immediately after the hiatal hernia operation, the diet for the first few days consists of liquid or mushy food.
It may take some time for the diaphragm to regain normal stability. For this reason, no strenuous activities, e.g. lifting heavy objects or too intensive sport, should be carried out for up to six weeks after the operation.
