Because of age, obesity or smoking, patients may have a condition called Hiatal Hernia. This situation is very common in patients over 50 years old.
Hiatal Hernias is also very typical for patients undergoing bariatric surgery. One study found that 42% of patients who intend to undergo gastric sleeve surgery have either Hiatal Hernia or Para-Esophageal Hernia.
If patients are found to have Hiatal hernias, bariatric surgeons need to perform Hiatal Hernia Repair, before they can successfully perform bariatric surgery. Patients are urged to contact our staff if they have GERD or see how our surgeons repair Hiatal hernias.
What are Hiatal Hernias?
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 a section 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).
A small hiatal hernia may not produce any symptoms or signs, but a large hiatal hernia can create these symptoms:
- Chest Pain
- Problem Swallowing
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.
Treatment Needed 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 of 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 it Needs 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.
Some Definitions for Hiatal Hernia:
- 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
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.
Case Study: Patient Undergoing a Hiatal Hernia Repair:
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.
Acid Reflux and GERD
When patients have acid reflux for an extended period of time, 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 a process 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. The gastric bypass is the best procedure for fundoplication patients.