Hiatal hernias, often called paraesophageal hernias, occur when the opening of the diaphragm (the muscle that separates the abdomen from the chest and helps you breath) becomes enlarged, allowing the stomach or other abdominal organs to protrude into the chest. There are several types of hiatal hernias, and the most common type usually does not need surgery. Hiatal hernias that cause significant symptoms are very large or are at risk of trapping a part of the stomach or other organs in the chest. This can cause such structures to die and are all reasons to have these hernias repaired.
Symptoms of hiatal hernias include abdominal pain and reflux most often. Reflux is the upward flow of stomach acid into the esophagus, in this case caused by the abnormal pressure of the muscles around the lower esophagus (the lower esophageal stricture, or LES). Common symptoms include central burning chest pain after eating (indigestion), bloating, belching, and regurgitation of bitter tasting fluid. Atypical symptoms include coughing, asthma, or other breathing difficulties. Most of the time, reflux can be treated effectively with medications. Very large hernias may cause difficulty breathing due to abdominal organs pressing into the chest and preventing the lungs from filling normally. Some patients continue to have symptoms that are not controlled with medications or have changes in the esophagus indicating a continued acid reflux problem. Patients with poorly controlled reflux symptoms, significant pain, entrapment of a portion of the stomach, or breathing difficulties would likely benefit from surgery to repair the hiatal hernia.
Hiatal hernia repair involves pulling the abdominal organs out of the chest and back into the abdominal cavity. The hole in the diaphragm is closed with sutures and covered with a piece of mesh to prevent recurrence. Most of the time, a portion of the stomach is wrapped around the lower part of the esophagus. This is called a fundoplication, and a Nissen is the most common type of fundoplication performed, though other similar operations may be done. This helps to prevent further reflux as well as decrease the risk of the stomach slipping back into the chest.
Most hiatal hernia surgery is done as an elective procedure and requires you to stay in the hospital 1-2 days. You will usually have an x-ray swallowing study done the morning after surgery and, if the study is OK, be advanced to an oral diet before being sent home. You will have specific diet restrictions after reflux surgery and will be seen by a nutritionist before your discharge.
Preoperative Information
Prior to hiatal hernia repair, you will be asked not to eat or drink anything after midnight prior to your surgery. You will be given specific instructions from your surgeon or anesthesiologist about which medications you should or should not take prior to your surgery. You should not take any blood thinning medications, such as aspirin, Ibuprofen, Coumadin or Plavix, at least 5 days prior to your operation. This should be discussed with your surgeon at your preop visit.
Your work up before having a hiatal hernia repair will include an upper endoscopy
to look directly at the esophagus and stomach and take any biopsies, if necessary.
You may have a pH study to evaluate the severity of your reflux. This study involves
a small sensor placed into your esophagus that takes measurements of the acid levels
over 24 hours. The number of episodes of reflux you have, the total time the acid
level is too high in your esophagus, and the level in the esophagus the acid reaches
are all recorded to determine the severity of your reflux and whether you might benefit
from surgery. This study is not always possible or reliable in large hiatal hernias
because it is difficult to place the sensors in the proper locations. The function
of your esophagus will also be measured with a swallowing study (x-ray study) or measuring
the actual muscle contractions of the esophagus (manometry). If the esophagus does
not function properly, your surgeon may not perform the anti-reflux portion of your
hiatal hernia repair or perform a variation of the Nissen that leaves the wrap around
the esophagus looser than normal.
You will also have a detailed discussion with your surgeon about the risks and benefits
of reflux surgery, including the possibility that your symptoms will not get better
or that you may need to continue taking medications to help control your symptoms.
If you have a large hernia, the upper endoscopy and pH study show a significant reflux
problem and you have adequately tried medical therapy, and you continue to have poorly
controlled symptoms, there is a good chance you will benefit from repair of your hiatal
hernia. A Nissen fundoplication may be offered as part of your surgery to control
any anticipated reflux.
Postoperative Information
Hiatal hernia repair can be performed laparoscopically. In this case, you will stay
in the hospital overnight and likely be discharged 1-2 days after surgery.
In the event that you require an open hiatal hernia repair, you may have to stay in the hospital a little longer for pain control, though not in all cases.
You will have a swallowing study done the morning after surgery. This is to make sure there is no leak from the esophagus from the surgery. If the swallow study is normal, you will be given a liquid diet and you will start preparing to go home.
Activity
You can resume most usual activities gradually beginning shortly after surgery. You
should begin walking the night of surgery or the following morning and continue to
increase as you are able. Increased activity reduces the risk of blood clots, and
improves breathing to prevent pneumonia.
While in the hospital, you will be asked to walk several times a day, beginning no later than the morning after surgery in most cases. You will usually need assistance to get out of bed, especially the first time, since you will likely have IV tubing and sometimes drains or catheters that need to be disconnected in order for you to get around. A Physical Therapist often helps you get out of bed and regain your strength after major surgery. Walkers, canes or crutches will be made available as needed. In some cases a short stay in a rehabilitation center or short-term nursing home may be needed. This is uncommon and usually only needed for people who had to have emergency operations or had some other complications and a long hospital stay.
After discharge from the hospital, avoid lifting more than 10 pounds for 2-4 weeks and excessive bending or twisting for 1-2 weeks following surgery. This is to allow healing of the incisions, specifically the fascia (the strongest layer of the abdomen wall) and decrease the risk of a hernia developing. For laparoscopic surgery there may be less risk for developing a hernia and it may be safe to return to unrestricted activity sooner.
Avoid driving until you no longer need narcotic pain medication and you feel you can make rapid movements unimpaired by pain. Driving while taking narcotics can impair your ability to drive safely.
You should be able to return to work in 1-3 weeks. If your job involves heavy lifting and light duty is not an option, you may need up to 4 weeks off work to recover
Wound Care, Drain Care, Ostomy Care
If your hiatal hernia repair was done laparoscopically, small gauze and clear tape
dressings or a small white dressing is typically placed over each incision. These
dressings may be removed 48 hours (2 days) after the operation. If you are in the
hospital more than one day, these may be removed before you leave the hospital. Below
this dressing are small brown or white pieces of tape (called Steri-Strips); these
will fall off on their own within 1-2 weeks or be removed at your follow-up visit
with your surgeon. If your surgeon gives you specific instructions other than this,
please follow those instructions.
If your hiatal hernia repair was done as an open procedure, you will probably have a long white dressing or gauze and tape dressing over your incision. This dressing may be removed 48 hours (2 days) after the operation and will probably be removed before you leave the hospital. Your incision will probably be closed with small metal staples. These will be removed at your postop visit, usually 10-14 days after your operation. If you are in the hospital more than a week, these may be removed before you go home.
Occasionally, a feeding tube (gastrostomy) is placed into the stomach at the time of a hiatal hernia repair. If this is necessary, you will be given specific instructions on how to care for the tube, including how to clean it, flush it and administer medications or feeding. You will also see a nutritionist who will assist you with learning about the tube and any formulas you may need.
You may shower after 48hrs (after the gauze and clear tape dressing is removed). It is okay to get soap and water on the incisions. Pat the area dry. You will be able to shower in the hospital after 48hrs as well. Your nursing staff can assist you if needed. It is not recommend that you submerge underwater (in a bathtub, pool, or hot-tub) for at least two weeks post-op.
If you notice drainage from your incisions, particularly if it is thick and foul-smelling or associated with a fever, contact your surgeon.
If you notice redness around your incisions, especially if it is getting worse or associated with drainage or a fever, contact your surgeon.
Medications - Pain Management
Pain after a large open operation can be significant. You will most likely be placed
on IV narcotics using a pump (PCA patient controlled analgesia), which allows you
to press a button for additional medication when you need it. This will be weaned
off within a few days of your operation and you will start oral pain medications.
It is very important to us that your pain be well controlled. Your pain should be
controlled well enough for you to begin getting out of bed the morning after surgery
and for you to perform deep breathing exercises. If you have pain that is not well
enough controlled to allow you to walk or breathe deeply, talk to your surgery team.
You may need to have your pain medications changed or increased.
If your hiatal hernia is performed laparoscopically, pain is typically just around the site of incisions. However, you may have more general abdominal pain or even shoulder pain due to the air used to inflate your abdomen during the surgery. Pain from air inflation will go away in 24 to 48 hours. If an open operation is needed, there may be more pain during the first few days after surgery.
You will be discharged with pain medication, typically a mild to moderate strength narcotic. Take as needed and as prescribed. You may also take over-the-counter medications such as ibuprofen for pain. Most narcotic medications prescribed are combined with Tylenol (acetaminophen) and you should not take additional Tylenol if you are taking a narcotic medication that already contains Tylenol.
Nausea
It is very important to control any nausea you might experience after your surgery,
particularly if the stomach is wrapped partially or completely around the esophagus
as part of the surgery to reduce any anticipated postoperative reflux. You will have
access to IV anti-nausea medication throughout your hospital stay. Oral anti-nausea
medication or rectal suppositories that can control nausea will be prescribed as needed
upon hospital discharge. Please let your surgeon know if you develop nausea after
discharge so that he or she can address this further.
Other Medications
You will likely be prescribed a stool softener when you go home. Pain medications
can cause constipation and a stool softener may help. You may also be given nausea
medication if you experience nausea or vomiting from taking your pain medication.
Home Medications
Unless otherwise instructed, you should be able to resume your usual home medications
the night of or the morning following your surgery.
Diet & Bowel Care
Following hiatal hernia surgery, you will be given specific diet instructions and
be seen by a nutritionist.
More details about post-Nissen diet
Many patients will notice their stomach feels very full quickly and have bloating after having hiatal hernia surgery if the stomach wrap is also performed. This happens because you are not able to belch normally after reflux surgery. Eating smaller meals, separating intake of solids and liquids, and avoid foods or drinks that you know make you gassy (such as carbonated beverages, alcohol, some vegetables) will help with these symptoms. You may also need to take nausea medication prescribed by your doctor. This usually gets better within a few weeks after surgery when the swelling of the stomach wrap goes down.
It is common to have some constipation after surgery, especially when taking narcotic pain medications. You will probably be prescribed a stool softener when you are discharged. If you are having trouble moving your bowels after surgery (if your stool is hard or you have to strain excessively) you may need a laxative. Over the counter medications can treat this well. Senna, Miralax, or dulcolax are some of the most common and are available at most drug stores or grocery stores. Take as directed.
If you experience problems having a bowel movement AND have abdominal bloating, nausea or vomiting, and not passing gas, call your doctor.
Follow Up
You will be given a date and time to see your surgeon following surgery, usually in
10 days to 3 weeks. If you are discharged late in the day or over the weekend, you
will be given a number to call the following business day for an appointment. If you
are having trouble making an appointment, call your doctors' office directly for assistance.
Call Your Doctor If
Contact Information
Daytime hours: Call 706-721-4686 or 7597
After hours and weekends: Call 706-721-8400