Hiatal Hernias (Diaphragmatic Hernias)
A hiatal hernia is a form of hernia that occurs in the diaphragm. The natural opening between the two parts of the diaphragm which allows the esophagus to pass between the chest and the abdomen widens. This widened gap allows the various portions of the stomach to move into the chest which can cause varying issues, including acid reflux. Hiatal hernias are produced by a combination of increased abdominal pressure and muscular or fascial weakening, resulting in an abnormal widening in the diaphragm. Any activity that increases intrabdominal or core pressure increases the risk of forming a hiatal hernia, healthy activities and unhealthy ones. Common causes include pregnancy, smoking, weight gain, weight training, coughing, smoking and simply aging.
Approximately 90% of patients with gastroesophageal reflux disease have a hiatal hernia. Diaphgragmatic hernias are frequently diagnosed when individuals present with GERD symptoms.
Symptoms of Hiatal Hernias
Hiatal hernias are very common and 50% of people will have a small hiatal hernia by the time they turn 50. The majority of these are asymptomatic. Common symptoms associated with hiatal hernias are reflux disease, chest pain after eating, regurgitation, nausea, feeling full quickly, esophageal spasm, shortness of breath, anemia due to ulcers from the hernia. In certain types of diaphragmatic hernias there is a risk that the stomach can get stuck and twist in the hernia, causing death to the stomach and the patient. Hiatal hernias have been historically classified into various types ( sliding, paraesophageal , mixed) but with advances in research and understanding through modern diagnostic testing, it is recognized that all symptomatic hiatal hernias should be addressed.
Diagnosis of Hiatal Hernias
Diaphgragmatic hernias are diagnosed using either endoscopy where a camera is placed in the mouth and into the stomach. This technique is good at diagnosing the presence of a hiatal hernia but the actual size is difficult to assess. The other method of diagnosing hiatal hernias is through a barium esophagram study which is a video xray that is performed while a patient is swallowing barium. This method is better at assessing size of the hernia and can diagnose strictures, but does not tell us anything about what is going on inside such as esophagitis, Barrett’s esophagus, esophageal cancer, etc.
Hiatal Hernia Treatment
The only treatment for a symptomatic hiatal hernia is a surgical procedure. Although Dr. Grandhige believes in and is open to discussing alternate holistic modalities for management of many diseases and symptoms, these modalities cannot fix the hernia.
Dr. Grandhige repairs hiatal hernias both robotically and laparoscopically depending on patient preference and patient anatomy.
The repair of the hiatal hernia is the most challenging and longest part of any anti-reflux surgery. It involves:
Step 1: Moving all the surrounding structures and any scar tissue from previous surgery out of the way in order to see the hiatus
Step 2: Freeing up all attachments that are keeping the stomach in the chest in order to bring it back down in a tension free manner to the abdomen
Step 3: Freeing up all attachments around the esophagus to assist in a “tension-free” repair
Step 4: Repair the opening in the diaphragm to return it to the size of the esophagus
Step 5: Then one of the antireflux procedures such as LINX, fundoplication or TIF is added since most patients with hiatal hernias also have reflux
