Hiatal Hernia Repair

The condition

The esophagus passes through an opening in the diaphragm (i.e. esophageal hiatus) as it courses through the chest to the abdomen eventually ending at the stomach. This opening is usually adequate for passage of the esophagus and nothing else. However, patients that have a hiatal hernia have an enlarged opening. There are four different types of hiatal hernias described. The sliding hernia is the most common of the four representing more than eighty-percent of all hiatal hernias. The lower esophageal sphincter- the high pressure zone near the junction of the stomach and esophagus- fails and allows stomach contents to reflux into the esophagus.

Symptoms:

The symptoms associated with hiatal hernia are variable but generally include:

• Heartburn - 30 - 60 minutes after eating
• Regurgitation - worsened with lying flat
• Excessive belching
• Aspiration - stomach contents refluxed into the airway
• Asthma - chronic result of aspiration
• Chest pain - burning mid-chest pain
• Difficulty swallowing
• Pain with swallowing
• Bleeding
• Stomach twisting and perforation
• Obstruction

The procedure

Hiatal hernia repair can be done open or laparoscopically.  Patients that have paraesophageal hernia which allows the fundus to be displaced into the chest above the GE junction or patients with other abdominal organs (e.g. spleen, colon, liver) displaced into the chest should be repaired urgently. In the past, open surgery was the only option for repair. This approach is associated with prolonged recovery time and a large painful incision. With the new minimally invasive approach, surgery is now a viable initial therapy even for patients who are asymptomatic. The laparoscopic hiatal hernia repair and fundoplication are performed utilizing five quarter-inch incisions through which, a camera and instruments are placed. The hernia is reduced from the chest into the abdomen. This may require separation of abdominal organs from middle chest structures. The hiatus is then re-approximated to the appropriate size. Some hernias are so large and tissues are so poor that prosthetic material (mesh) must be used to prevent recurrence. The mesh is anchored on the diaphragm with the use of sutures or staples.  After adequate repair of the hiatus, a new lower esophageal valve is constructed by wrapping a 2-3 centimeter portion of the stomach around the lower most portion of the esophagus. This “collar” is then anchored to the tough fibers of the diaphragm.  Patients are started on clear liquids the next morning and are discharged in the afternoon. The open surgical technique involves an 8-10 inch upper abdominal incision with a hospital stay of 5-7 days.

Risks

• Pneumothorax (air into the chest)
• Perforation of the esophagus/stomach
• Splenic injury
• Vagal nerve injury
• Aortic injury
• Cardiac tamponade (injury to the heart)
• Recurrence of hiatal hernia
• Mesh erosion into the esophagus

Medical negligence

The above mentioned risks and complications are known to happen with hiatal hernia repair and such complications do not necessarily constitute deviation from the medical standard of care.  The following examples however may be considered as medical negligence.

• Heart and aortic injury if not recognized fast can be fatal.  Cardiac tamponade (heart injury) has been described during the anchorage of mesh to the diaphragm with the use of metal (titanium) tacks (pro-tack).
• Perforation of the esophagus/stomach.  If not diagnosed and treated can lead to high morbidity and mortality.