Not everyone who has a hiatal hernia will require surgery. Many people will be able to treat the condition with medication or lifestyle changes. However, for those who do need surgery, there is a range of procedures available, the most common being Nissen fundoplication.
This article discusses hiatal hernia surgery procedures, expected recovery times. complications, and risks.
When is surgery required?
Hiatal hernias can often be treated with medication or lifestyle changes, but some may require surgery.
Most hiatal hernias do not cause symptoms, and therefore treatment is not usually necessary. Those who have mild symptoms, such as heartburn, acid reflux, or gastroesophageal reflux disorder (GERD) may be able to treat their condition with medications or lifestyle changes.
However, surgery may be recommended if:
- symptoms are severe and interfere with quality of life
- symptoms do not respond to other treatments
- the hernia is at risk of becoming strangulated, which is where the blood supply to the herniated tissue is cut off — a situation that can be fatal
- symptoms include bleeding, ulcers, or narrowing of the food pipe (esophagus), which is known as an esophageal stricture
What types of surgery are there?
There are three types of surgery for a hiatal hernia: Nissen fundoplication (keyhole surgery), open repairs, and endoluminal fundoplication. All three procedures require a general anesthetic.
A Nissen fundoplication is the most commonly performed surgery for a hiatal hernia. This procedure uses laparoscopic repair or keyhole surgery. This surgery is minimally invasive and only requires the surgeon to make a few tiny incisions in the abdomen.
The surgeon inserts a laparoscope, which is a thin tube with a light and a camera, into the abdomen to repair the hernia. The surgeon may also tighten the stomach opening to prevent the hernia from coming back.
Laparoscopic repair has some advantages over other types of hiatal hernia surgery. These include:
- less risk of infection
- less painful
- reduced scarring
- less time in the hospital
- recovery is usually quicker
Open surgery involves making a larger incision in the abdomen so that the surgeon can fix the hernia. This procedure carries more risks than laparoscopic repair.
A surgeon will pull the stomach back up into the abdominal cavity and wrap the upper portion, called the fundus, around the lower part of the food pipe. This creates a tight sphincter which stops the stomach acid from leaking up into the food pipe (reflux).
Sometimes, the surgeon may need to insert a tube to keep the stomach in place. The doctor will remove the tube after several weeks.
This procedure is relatively new and is even less invasive than laparoscopic repair, though it is not commonly used. The surgeon does not need to make any incisions. Instead, they place an endoscope (a tube with a light and camera) down the throat and into the food pipe.
The surgeon tightens the area where the stomach and esophagus join to prevent reflux.
However, this treatment may have its limitations. According to an interview published in the journal Gastroenterology and Hepatology in 2015, the endoluminal devices developed to date are not entirely reliable, and many people experience their symptoms coming back.
After surgery, a person should drink clear liquids and then move onto soft foods, such as mashed potatoes.
After laparoscopic surgery, most people will not experience much pain, but they may feel discomfort in their abdomen and chest and have difficulty swallowing. This usually passes within 48 hours.
After a laparoscopy, a person may be able to go home the same day if they have recovered from the anesthetic. Otherwise, they may spend a night in the hospital and should be able to walk around the day after the surgery.
A person may soon feel well again but may find that they tire easily.
In the days after surgery, a person will usually be advised to:
- wash the incision area daily with plain soap and water
- shower instead of bathing, and avoid the use of pools and hot tubs
- walk about when possible to stop blood clots from forming in the leg
- avoid drinking through a straw
- practice specific breathing and coughing exercises to strengthen the diaphragm
In the weeks after surgery, the UK National Health Service (NHS) recommend the following:
- avoiding any heavy lifting for 2 to 3 weeks
- avoiding driving for 7 to 10 days
- returning to work within 2 to 3 weeks, or whenever a person is feeling well enough
- taking painkillers for several days after surgery to minimize discomfort
A person will need to follow a specific diet after surgery. It is advisable to drink clear liquids immediately after surgery and move onto soft or liquefied foods, including mashed potatoes, smoothies, and soups, the following day. A person should also avoid foods that cause gas and bloating.
During recovery, it might be a good idea for people to eat several smaller meals throughout the day instead of three large ones.
Most people can return to their regular diet between 3 to 6 weeks after surgery.
However, even after a person makes a full recovery, their doctor may recommend they continue to limit or avoid foods that contribute to gas, bloating, and acid reflux symptoms, such as:
- acidic foods, including citrus fruits and tomato products
- beans and lentils
- carbonated beverages
- cruciferous vegetables, including broccoli, cabbage, and cauliflower
Open surgery will usually require a lengthier stay in the hospital and an extended recovery time.
How effective is hiatal hernia surgery?
Nissen fundoplication is very effective for relieving symptoms of GERD. A 2009 study estimates that this surgery achieves a success rate of 90 to 95 percent.
The same study also suggests that even when the laparoscopic surgery has to be carried out again to control reflux symptoms further, the success rate is 86 percent.
The NHS in the UK estimate that 80 to 85 percent of people will continue to have relief from symptoms 10 years after surgery.
Complications and risks
All surgeries carry risks, including the risk of:
- injury to internal organs
However, the risk with laparoscopic procedures is lower than with open surgery. It is estimated that laparoscopic repair carries a mortality rate of just 0.57 percent, and open surgery carries a mortality rate of 1.0 to 2.7 percent.
Complications associated with hiatal hernia surgery include:
- abdominal bloating
- difficulty belching or vomiting
- difficulty swallowing
- recurrence of the hernia or reflux
Alternatives to hiatal hernia surgery
While surgery is an effective treatment for a hiatal hernia that causes severe symptoms, people with mild symptoms may find relief using medications or home treatments.
Heartburn and acid reflux may be treated with:
- Antacids. Antacid medication works by neutralizing stomach acid. Avoid overusing these as they can cause diarrhea or kidney problems. These medications are available over the counter, by prescription, or to buy online.
- H2 receptor blockers. This medication is designed to limit the production of stomach acid. Medications may contain cimetidine, famotidine, and ranitidine. Stronger H2 receptor blockers are available by prescription.
- Proton pump inhibitors (PPIs). These drugs block acid production for longer than H2 receptor blockers, giving the tissue of the esophagus more time to heal. PPIs may be bought at a pharmacy or may be prescribed by a doctor.
People may experience a reduction in their acid reflux when they quit smoking.
Some people can experience relief from reflux by making the following lifestyle changes:
- losing weight if overweight
- eating five to six small meals daily rather than three large ones
- avoiding foods that cause acid reflux, including fried foods, acidic foods, alcohol, and caffeine
- eating the last meal of the day at least 3 hours before bedtime
- quitting smoking
- raising the head of the bed by 6 inches to prevent acid rising during sleep
- wearing loose-fitting clothing to prevent pressure on the abdomen
Hiatal hernias usually do not cause symptoms. If they do, symptoms may be treated with medications or lifestyle changes, though if these do not work, surgery may give long-term relief from acid reflux and GERD.
Even when hiatal hernia surgery is necessary, the procedure is usually minimally invasive and has a high success rate. Most people make a full recovery in just a few weeks.