Laparoscopic Fundoplication & Hiatal Hernia
The esophagus (Food Pipe) passes from the chest to the abdomen through an opening in the diaphragm (esophageal hiatus) and eventually ends at the stomach.
This opening is usually just adequate for passage of the esophagus. However, patients that have a hiatal hernia have an enlarged opening.
A hiatal, or diaphragmatic, hernia occurs when the lower part of the esophagus and a portion of the stomach slide up through this esophageal hiatus into chest cavity.
Other potentially contributing factors include:
A permanent shortening of the esophagus (perhaps caused by inflammation and scarring from the reflux or regurgitation of stomach acid) which pulls the stomach up.
An abnormally loose attachment of the esophagus to the diaphragm which allows the esophagus and stomach to slip upwards
There are four different types of hiatal hernias and sliding hernia is the most common of the four representing more than eighty-percent of all hiatal hernias. The lower esophageal sphincter at the junction of the stomach and esophagus – fails and allows stomach contents to reflux into the esophagus.
Sliding hiatal hernias,are those in which the junction of the esophagus and stomach, and part of the stomach protrude into the chest. The junction may reside permanently in the chest, but often it juts into the chest only during a swallow. When the swallow is finished, the herniated part of the stomach falls back into the abdomen.
Para-esophageal hernias are hernias in which the gastro-esophageal junction stays where it belongs (attached at the level of the diaphragm), but part of the stomach passes or bulges into the chest beside the esophagus. The para- esophageal hernias themselves remain in the chest at all times and are not affected by swallows.
The symptoms associated with the hiatal hernia are variable but generally include:
Heartburn – 30-60 minutes after eating
Regurgitation – more with lying flat
Aspiration – reflux of stomach contents into the airway
Chronic cough or Asthma – because of chronic aspiration
Mid Chest Pain – burning
Difficulty or pain with swallowing
Symptoms of obstruction
Hiatal hernias are diagnosed incidentally when an upper gastrointestinal x-ray or endoscopy is done during testing to determine the cause of upper gastrointestinal symptoms such as upper abdominal pain.
Air fluid level in the chest
Esophagogram (Barium UGI): Useful in-
Assessing the function of the esophagus
Identifying structural abnormalities (twisting of the stomach)
Associated problems (e.g. aspiration, poor gastric emptying)
Upper GI Endoscopy (EGD):
Identify damage caused by reflux (e.g. esophagitis, Barrett’s esophagus, malignancy)
Biopsy esophagus for evaluation of malignancy
Assess the function of the LES
Assess the propulsive function of the esophagus
Large para esophageal hernias causing symptoms requires surgery.
Since sliding hiatal hernias rarely cause problems themselves but rather contribute to acid reflux, the treatment for patients with hiatal hernias is usually the same as for the associated GERD.
Patients that have Para esophageal 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. Repair will help prevent complications such as bleeding, intestinal disruption, strangulation and the like.
Nissen Fundoplication is surgery to repair hiatal hernia and is surgical treatment for GERD. Upper part of the stomach is wrapped around the LES to strengthen the sphincter, prevent acid reflux, and repair a hiatal hernia.
The open surgical technique involves an 8-10 inch upper abdominal incision with a hospital stay of 5-7 days and is associated with prolonged recovery time. With the new minimally invasive approach, surgery is now a viable initial therapy and is safe and effective in people of all ages, including infants.
In a laparoscopic Fundoplication, small (1 cm) incisions are made in the abdomen, through which instruments and a fiber optic camera are passed.
The operation is performed using these small instruments while the surgeon watches the image on a video monitor.. Laparoscopic Fundoplication results in less pain and shorter hospitalization and early return to activities within 2-7 days compared to 4-6 weeks with an open approach.
The stomach and lower esophagus are placed back into the abdominal cavity. Operation may require separation of abdominal organs from the lung and middle chest structures.
Hernia defects greater than 5 cm. are buttressed with mesh which significantly decreases the recurrence rate.
The opening in the diaphragm (hiatus) is tightened and the stomach is stitched in position to prevent reflux.
The upper part of the stomach (fundus) may be wrapped around the esophagus (Fundoplication) to reduce reflux.
The procedure may last for two to four hours depending on the size and contents of the hernia.
Blood Work, Medical Evaluation, Chest X-Ray and an ECG .
Drink clear liquids, for 2-3 days prior to surgery.
After midnight the night before the operation, you should not eat or drink anything
Drugs such as aspirin, blood thinners, anti-inflammatory medications and Vitamin E are to be stopped a week prior to surgery.
Patients are started on clear liquids the next morning and are discharged in the afternoon.
Patients are encouraged for early ambulation and light activity after surgery.
Post operative pain is generally mild for which pain medication may be given.
Anti-reflux medication is usually not required after surgery.
Early return to normal activities like showering, driving, walking up stairs, lifting, and working
Studies have shown that the vast majority of patients undergoing the procedure are either symptom-free or have significant improvement in their GERD symptoms.