Hiatus Hernia Repair in Western Australia

A hiatus hernia is a hernia inside the chest. Normally, the stomach sits below the diaphragm and the oesophagus passes through a small opening — the hiatus — to reach it. In a hiatus hernia, part of the stomach has slipped upward through that opening and now sits in the chest above the diaphragm.

There are two main types. A sliding hiatus hernia is by far the most common, where the junction between the oesophagus and the stomach slides up through the hiatus. Sliding hiatus hernias tend to produce reflux symptoms — burning behind the breastbone, regurgitation of food or sour fluid, an unpleasant taste in the mouth, and discomfort after meals. A paraoesophageal or "rolling" hiatus hernia is less common but potentially more serious — part of the stomach rolls up alongside the oesophagus, which can occasionally cause obstruction, food sticking, chest pain, and difficulty swallowing.

Small, asymptomatic hiatus hernias are very common and often do not need surgery. Reflux symptoms can usually be controlled with lifestyle changes, weight loss, and medication. Surgery is considered when symptoms are severe, when medication does not adequately control them, when the patient does not want long-term medication, when complications of reflux develop (such as a Barrett's oesophagus), or when the hernia itself is large and causing mechanical problems with swallowing.

Hiatus hernia is also a particularly important topic for patients who have previously had bariatric surgery — gastric sleeve, gastric bypass, or similar. Approximately one in five of Dr Watson's hernia patients fall into this group and benefit from his combined bariatric and hernia experience.

Hiatus hernias develop when the diaphragmatic opening around the oesophagus stretches and weakens. Risk factors include older age, obesity, multiple pregnancies, chronic cough, repeated heavy lifting and straining, and previous upper-abdominal or oesophageal surgery. Sleeve gastrectomy is particularly associated with the development or worsening of hiatus hernia and reflux in the years after surgery, because of the higher pressure inside the new stomach pouch.

Smoking, alcohol, large meals, and lying down soon after eating do not directly cause a hiatus hernia but worsen the reflux symptoms a hiatus hernia produces, and lifestyle changes in these areas are part of treatment.

Hiatus hernia and reflux surgery is almost always performed laparoscopically (keyhole). The principles of surgery are to reduce the stomach back below the diaphragm, repair the widened hiatus, and add an anti-reflux mechanism using the patient's own stomach tissue. The exact technique is chosen based on the size of the hernia, the severity of reflux, and the patient's history.

Laparoscopic crural repair and fundoplication

The standard operation. The stomach is brought back into the abdomen, the hiatus is narrowed with stitches, and the upper part of the stomach (the fundus) is wrapped around the lower oesophagus to create an anti-reflux valve. A "Nissen" 360-degree wrap and a "Toupet" 270-degree partial wrap are the two most common variations — the choice depends on the strength of the oesophageal muscle on manometry.

Mesh reinforcement

For very large hiatus hernias or recurrent hernias, a piece of biological or synthetic mesh may be used to reinforce the hiatal repair. Mesh use at the hiatus is a careful decision because of the proximity to the oesophagus.

Conversion of sleeve to bypass

For patients with severe reflux after a previous sleeve gastrectomy, the most durable solution is sometimes conversion of the sleeve to a Roux-en-Y gastric bypass rather than hiatus hernia repair alone. Dr Watson can advise on this because he performs both operations.

Recovery from laparoscopic hiatus hernia surgery is different from groin or abdominal-wall hernia recovery, because dietary adjustment is part of the process. Most patients return to desk-based work within two to three weeks and to most normal activities within four to six weeks. Heavy lifting is generally restricted for six weeks. These are general guidelines, not guarantees.

You can expect some difficulty swallowing initially, which improves over four to eight weeks as the swelling around the wrap settles. Most patients are on a soft diet for two to three weeks before gradually returning to normal food. Gas-related discomfort and an inability to belch easily are common in the first weeks and generally resolve. Dr Watson reviews you several times in the weeks and months after surgery.