What is it?
Hiatus Hernia is a common condition that involves the part of the stomach in the chest rather than that in the abdomen. There are usually few symptoms but you may experience heartburn, or in more severe cases, pain and vomiting.
How is it treated?
Paraoesophageal hernias are a rare type of hiatus hernia and generally need surgery. Sometimes these are called giant hiatal hernias. Most of these can be fixed using keyhole surgery. It is important to realise that not all hiatus hernias cause problems. Before recommending treatment thorough investigation is needed prior to any surgery.
Large Hiatal Hernia
These hernias are relatively rare. Essentially the stomach and sometimes other organs such as the colon can slip through a large hole in the diaphragm. This means that they will be in the chest cavity rather than the abdominal cavity. The cause of this is largely unknown, however a number of studies suggest that a collagen deficiency may be a factor. Also, there have been good studies showing a condition called kyphosis or a hunched back is associated with this type of hernia.
What is the problem with these hernias?
There may be no problems however there are significant risks associated with these hernias. The stomach can twist in effect and cause sudden severe pain and vomiting. This is known as a volvulus. This can result in death of the stomach if left long enough and therefore needs urgent repair. The risk of this is about 1 percent per year therefore the younger you are the more likely you are to develop a volvulus and require emergency surgery. Most people have more subtle symptoms which may include chest pain, shortness of breath, problems swallowing food and reflux or vomiting. Most of these hernias do cause symptoms and therefore should be repaired.
How do we repair them?
This is a specialised operation and should only be performed by surgeons with experience in advanced laparoscopic surgery and anti reflux surgery. I have performed a large number of these repairs both in my training and in private practice.
The operation is performed keyhole although there is a much higher risk of open surgery than standard anti reflux surgery. We reduce the stomach into the abdomen by dividing the attachments to the diaphragm this is also known as a sac. We then repair the diaphragm with stitches and mesh. This can be very difficult. A fundoplication is then performed and this is stitched to the diaphragm. Sometimes an external drain is used. This attaches the stomach to the muscle and skin and stays in for 6 weeks. In my practice this is uncommon. Even in the very best hands, the recurrence rates for this operation are in the region of 20-30 percent, although most recurrences are not prone to emergency volvulus.