Hiatal Hernia Repair and Bariatric Surgery
Hiatal Hernia is a frequent side effect associated with obesity and morbid obesity. As the body mass increases, so do the risks of Acid Reflux and GERD.
Nearly 42% of gastric sleeve surgery patients either have a Hiatal Hernia or Para-Esophageal Hernia which must be resolved before or during the weight loss procedure.
So if you are diagnosed with a hiatal hernia and planning on undergoing bariatric surgery, here is everything you need to know to find the right procedure!
What is Hiatal Hernia?
A hiatal hernia is a condition where the patient’s stomach is partitioned, unnaturally, by the diaphragm. Creating a section of the stomach above the diaphragm and below the diaphragm.
This pushes up the Lower Esophageal Sphincter (LES) and away from the hiatus, losing its support to keep acid and stomach contents from backing up into the esophagus (reflux). The hiatal hernia is caused by factors like age, obesity, body mass index, and even smoking. This diagnosis is very common in patients over 50 years old.
About Hiatal Hernia – What Does it Mean?
- Diaphragm – is the muscular wall separating the chest cavity from the abdominal cavity
- Lower Esophageal Sphincter (LES) – a bundle of muscles at the low end of the esophagus, where it joins the stomach
- Hiatus – opening located in the diaphragm
- Hernia – internal body part pushes into an area outside of its domain
A small hiatal hernia may not produce any symptoms or signs, but a large hiatal hernia can create these symptoms:
What are the Symptoms of a Hiatal Hernia?
- Chest Pain
- Problem Swallowing
Which Bariatric Surgery Should I Get if I have a Hiatal Hernia?
The size of the hiatal hernia typically determines the procedure that is best for you. If the diaphragm of the hernia is small, the surgeon will fix the hernia and the gastric sleeve. If the hernia is large and there is less pressure on the diaphragm, gastric bypass surgery is recommended to relieve it. Gastric bypass is best for large hernias, the sleeve is best for small ones. The way you can tell is through an endoscopy.
Hiatal Hernia Repair Before Bariatric Surgery
Because of the location of the stomach, patients undergoing any bariatric surgery will need to put the stomach back in its original position. It is necessary to complete this task laparoscopically, just like other bariatric surgeries, allowing our bariatric surgeons not to create additional incisions.
After the stomach is below the hiatus (opening the diaphragm), the doctor can continue with the bariatric surgery. Because of the unknown nature of a hiatal hernia, it may return after surgery has taken place.
Why Does a Hiatal Hernia Need to Be Repaired?
A hiatal hernia needs to be removed during bariatric surgery. If a hiatal hernia is not fixed, the “smaller stomach” can be pulled further up through the muscle wall. This can cause a major complication, as the stomach can become strangulated.
Patient Undergoing a Hiatal Hernia Repair with Gastric Sleeve
If a hiatal hernia is not repaired during Laparoscopic Vertical Sleeve Gastrectomy (VSG) surgery, the higher pressure in the new stomach causes vomit and/or severe acid reflux. Mexico Bariatric Center (MBC) surgeons repair a Hiatal Hernia during gastric sleeve if present.
After the stomach is released by longitudinal resection along the greater curvature and fully separated from the spleen & bowels, the surgeon checks for the presence of a hiatal hernia and repairs it if it is needed.
Types of Hiatal Hernia
Hiatal hernias are classified as sliding or para-esophageal:
Sliding Hiatal Hernia
Sliding hiatal hernia is the most common type of Hiatal hernia – 95% of all cases. It occurs when the gastro-esophageal junction (the junction of the esophagus and stomach), and part of the stomach slide into the chest through the hiatus.
Fixed Hiatal Hernia
Para-Esophageal Hernia (PEH) or Fixed Hiatal Hernia is the least common type of Hiatal hernia. It occurs when the gastro-esophageal junction stays at its spot (at the level of the diaphragm), but part of the stomach slides into the chest through the hiatus. This type of Hiatal hernia is more serious, and there is a risk of blood flow blockage to the stomach.
Common Causes of Hiatal Hernia
- Predisposed to Hiatal Hernia, unusually large hiatus
- Accident or Injury to the area
- Pressure, constant and powerful, from surrounding muscles can occur through coughing, straining during a bowel movement, lifting heavy objects, or vomiting.
Acid Reflux and GERD
When patients have acid reflux for an extended period, GERD can arise. Acid reflux and GERD occur when the valve is weak or not working appropriately. Laparoscopic Nissen fundoplication is used to treat Hiatal Hernias or GERD. The fundoplication procedure is where the stomach gets wrapped around the –valve– to stabilize the stomach pressure so the acid won’t continue going up.
If a patient has had fundoplication surgery before bariatric surgery, the fundoplication has to be cut away and isn’t redone after the weight loss procedure. This is why we recommend getting the Roux-en-Y or gastric bypass surgery. Gastric bypass is the best procedure for fundoplication patients.