Hiatus hernia repair

General measures

• Losing weight is strongly recommended and very helpful for obese patients and patients who have recently gained weight.
• Raising the head of the bed can be useful, especially for patients who have complaints at night or in case of coughing and/or hoarseness.
• The last meal should be consumed no later than two to three hours before going to bed.
• Some foods promote the production of stomach acid or relax the oesophageal sphincter. Greasy or spicy foods, caffeine, chocolate, fizzy drinks, peppermint etcetera are best avoided. Finally, tobacco, alcohol and smoking may also aggravate reflux complaints; it is therefore recommended that its use or intake is avoided.

Anti-reflux medication

• The majority of patients can be treated with medication that reduces the production of stomach acid or that neutralises the acid.
• Proton pomp inhibitors (PPI) are the most powerful medication to reduce the production of stomach acid and deliver faster improvement of reflux complaints. They are the first choice for severe erosive oesophagitis, severe or frequent reflux that impact on the quality of life or for Barrett's oesophagus.
• Histamine-2 receptor antagonists (H2RA) decrease in efficacy in the longer term, and long-term use is therefore not recommended.
• Antacids are medicines that neutralise the acidity of the stomach, leading to mild improvement of the complaints without actually avoiding reflux. They work in five minutes but only have a short-term effect of 30 to 60 minutes.

Surgical treatment

A procedure may be considered if medication to reduce stomach acid and lifestyle changes have an insufficient impact on the reflux (failure of medical therapy). A procedure may also be necessary if complications associated with reflux develop, such as chronic or recurrent inflammation of the oesophagus, Barret’s metaplasia, asthma, etcetera.

During anti-reflux surgery (Nissen fundoplication), the upper part of the stomach is wrapped around the lower part of the oesophagus, where the sphincter is located, like a kind of cuff or ring. This is done through laparoscopy (keyhole surgery). This stops the stomach from bulging through the diaphragmatic hernia and results in increased pressure in the lower part of the oesophagus, preventing reflux.

If a diaphragmatic hernia does not cause reflux but leads to other problems such as vomiting, difficulty swallowing or pain in the chest area, etcetera, the decision may be taken to repair the hiatus hernia through laparoscopy and to narrow the opening in the diaphragm, without performing anti-reflux surgery.

Studies have demonstrated that the majority of patients remains symptom free 10 to 20 years after the procedure, but the symptoms may always recur.

As with any operation, a number of general complications can occur such as bleeding, wound infection, thrombosis or lung infection, etcetera. Shoulder-tip pain is a typically occurring complaint after a laparoscopy and will disappear by itself in a few days. This is caused by the gas that is used in the procedure and leads to irritation of the diaphragm, which is registered by the nervous system at the tip of the shoulders.

During the operation, bleeding of the spleen (or liver) is the most important, but fortunately uncommon, complication. Detaching the stomach which has moved up in the chest may also lead to a pneumothorax (collapsed lung) because of a perforated lung, which causes air to leak into the chest leading to a partial collapse of the lung. This sometimes requires placement of a drain.
During the procedure, nerves that run along the oesophagus and stomach may be damaged too, resulting in (usually temporary) diarrhoea and gastrointestinal problems. Detaching the stomach from the spleen or from the chest wall may lead to a stomach perforation, causing stomach juices to run into the abdominal cavity.

Finally, in certain cases a laparoscopy cannot provide a good view of the stomach requiring conversion to a classic incision.

A contrast swallow is performed on the first post-operative day. This requires patients to drink a contrast fluid to confirm smooth passage from the oesophagus to the stomach, which is where the cuff has been fashioned. This also allows for ruling out any leaks (due to detachment of the stomach). If the contrast swallow results are reassuring, the patient may start on fluids and liquid, mixed foods.

While you are in hospital, a dietitian is consulted to explain your dietary advice for when you are home, and he or she will provide you with a diet plan. If fluids and liquid food are consumed without any problem, the IV line can be removed on the second post-operative day and the patient may potentially be discharged.

During the first three weeks after a Nissen fundoplication, only liquid, mixed foods may be consumed. Certain foodstuffs are best avoided in this period (such as cabbage, pulses, greasy food, spicy food, etcetera.) Since burping is difficult in the first weeks after the procedure, fizzy drinks must be absolutely avoided. After the procedure, anti-reflux medication is generally no longer necessary. Sutures may be removed by the GP on the tenth day after the procedure. Until then, make sure to protect the wound from contact with water. Bandages may be changed when they are soiled or loosened.

The Maria Middelares Hernia Centre in Ghent charges the official RIZIV prices. The invoice will be sent to you by post after a period of approximately three months. In addition to the surgeon's and anaesthesiologist's fee, this will display the general charges for hospital admission and the use of materials such as the mesh.

As is the case in almost any hospital, there is an additional charge for the use of a single room. At the Maria Middelares General Hospital in Ghent, this additional charge is a maximum of 150% of the official price. No additional charges are added to the fee if a multiple-occupancy room is chosen.

Latest publication date: 15/12/2023