A hernia is a weakness in the abdominal wall resulting in abnormal protrusion of abdominal contents (e.g. intestines) through the defect. Hernias enlarge over time and may become incarcerated (fail to reduce) or strangulated (loss of hernia contents due to lack of blood supply). A hernia should be surgically repaired. Although most hernias occur in the groin (eighty percent), they may also be located in the navel, upper-inner thigh, and along previous abdominal incisions.
Increased abdominal pressures caused by lifting heavy objects, coughing, substantial weight gain, or straining with bowel movements and the like may call a patient's attention to a hernia. Symptoms may include:
- Abnormal bulge
- Pain or tenderness
- Abdominal distention
- Failure to pass flatus
- Fevers or chills
- Nausea and vomiting
History and physical are the most useful tools in the diagnosis of a hernia. If clinical uncertainty persists after examination, an ultrasound or CT may provide your doctor with information showing bowel protruding through an abdominal wall defect.
Laparoscopic hernia repair may be considered in nearly all patients diagnosed with an abdominal wall hernia. Laparoscopic repair involves quarter-inch incisions through which a camera and instruments are placed. Open hernia repair requires a 3-5 inch incision. The abdominal wall defect is repaired with mesh and secured under direct vision of the laparoscope. Patients with hernias in both groins may be repaired through the same incision.
Many types of hernias can be safely repaired laparoscopically:
- Ventral and incisional hernias on the abdomen
- Inguinal or femoral hernias in the groin
- Hiatal or diaphragmatic hernias in the chest
Patients recover sooner after laparoscopic hernia repair. Return to activities can occur within 2-3 days, compared to 2-4 weeks with an open approach. Pain experienced by the open technique is greater and longer lasting. Wound infections occur less frequently with the laparoscopic technique.
Laparoscopic Hiatal Hernia Repair & Nissen Fundoplication
The esophagus passes through an opening in the diaphragm (esophageal hiatus) as it courses through the chest to the abdomen, eventually ending at the stomach. This opening is usually adequate for passage of the esophagus and nothing else. However, patients that have a hiatal hernia have an enlarged opening. There are four different types of hiatal hernias described. The sliding hernia is the most common of the four, representing more than eighty percent of all hiatal hernias. The lower esophageal sphincter – the high pressure zone near the junction of the stomach and esophagus – fails and allows stomach contents to reflux into the esophagus.
The symptoms associated with the hiatal hernia are variable but generally include:
- Heartburn – 30-60 minutes after eating
- Regurgitation – worsened with lying flat
- Excessive belching
- Aspiration – stomach contents refluxed into the airway
- Asthma – chronic result of aspiration
- Chest Pain – burning mid-chest pain
- Difficulty swallowing
- Pain with swallowing
- Stomach twisting and perforation
Several studies are helpful to your doctor in making the diagnosis of hiatal hernia, including:
- Chest X-ray
- Air fluid level in the chest
- Esophagram (Barium UGI)
- Assess the function of the esophagus
- Identifying structural abnormalities (twisting of the stomach)
- Reveal associated problems (e.g. aspiration, poor gastric emptying)
- Upper GI Endoscopy (EGD)
- Identify damage caused by reflux (e.g. esophagitis, Barrett’s esophagus, malignancy)
- Biopsy esophagus for evaluation of malignancy
- Esophageal Manometry
- Assess the function of the LES
- Assess the wave-like motion (propulsive function) of the esophagus
Laparoscopic Hiatal Hernia Repair and Nissen fundoplication is the procedure of choice for repair of a hiatal hernia. Patients that have paraesophageal hernia which allows the fundus to be displaced into the chest above the GE junction, or patients with other abdominal organs (e.g. spleen, colon, liver) displaced into the chest, should be repaired urgently. Repair will help prevent complications such as bleeding, intestinal disruption, strangulation and the like. Elective repair is recommended only for patients that are asymptomatic and have a sliding hernia. This group of asymptomatic patients may also be followed clinically seeking surgery only when symptoms arise.
In the past, open surgery was the only option for repair. This approach is associated with prolonged recovery time and a large painful incision. With the new minimally invasive approach, surgery is now a viable initial therapy even for patients who are asymptomatic.
The laparoscopic hiatal hernia repair and Nissen fundoplication is performed through five quarter-inch incisions through which a camera and instruments are placed. The hernia is reduced from the chest into the abdomen. This may require separation of abdominal organs from the lung and middle chest structures. The hiatus is then re-approximated to the appropriate size. Some hernias are so large and tissues are so poor that prosthetic material must be used to prevent recurrence. Hernia defects greater than 5 cm are buttressed with mesh. This significantly decreases the recurrence rate. After adequate repair of the hiatus, a new lower esophageal valve is constructed by wrapping a two-centimeter portion of the stomach around the lower most portion of the esophagus. This collar is then anchored to the tough fibers of the diaphragm. The procedure typically lasts for two to four hours depending on the size and contents of the hernia. Patients are started on clear liquids the next morning and are discharged in the afternoon. The open surgical technique involves an 8-10 inch upper abdominal incision with a hospital stay of 5-7 days.
Patients recover sooner after laparoscopic hiatal hernia repair and Nissen fundoplication. Return to activities can occur within 2-7 days, compared to 4-6 weeks with an open approach. Wound infections occur less frequently with the laparoscopic technique. Also, less pain has been reported with laparoscopy. Most importantly, greater than ninety percent of patients are symptom-free ten years after the procedure.