Laparoscopic Para-Oesophageal Hernia Repair
WHY SHOULD A HIATUS HERNIA BE TREATED BY SURGERY?
If a large (Type II, III or IV) hiatus hernia is causing bad symptoms, which are not effectively being treated by dietary and lifestyle modification, or putting you at risk of serious health problems then surgical repair is an option to consider.
HOW IS THE PROCEDURE PERFORMED?
Although this is a major operation it is now normally carried out by standard keyhole surgery through the abdomen. Before this technique was available, surgery had to be carried out through large incisions in the chest or abdomen.
Small incisions are made in the upper abdomen (usually two 12mm and three 5mm).
The stomach and other organs are gently brought out of the chest and back into the abdomen. Not all of this may be possible straight away, and so the hernia sac, which is the stretched tissue between the diaphragm and the oesophagus (phreno-oesophageal ligament) is carefully dissected. This gradually releases and separates them from the organs in the chest including the lungs, heart and major blood vessel (aorta).
Great care is taken not to damage the oesophagus which is inevitably scarred and shrunken due to inflammation and compression, as well as the nerves (vagus) which run along with it. Once this has been successfully completed, the redundant sac is excised.
Further dissection may be necessary in the chest to make sure enough oesophagus (usually at least 3cm) is in the abdomen. It is important that there is no tension on the oesophagus pulling it back into the chest (tension-free). Once this has been confirmed, reconstruction can start.
Depending on how wide it is, and what the state of the tissues are, the hiatus can be repaired with usually with stitches alone, but sometimes incorporating the use of a biologic mesh may be necessary. The mesh is made of natural tissues, and not synthetic like the meshes used in other abdominal wall repairs as this is a dynamic area, where both strength and flexibility are required. Synthetic meshes can damage the oesophagus and are therefore never used.
Once the defect is satisfactorily closed around the oesophagus (a small gap is left to enable movement and swallowing) a fundoplication is usually performed. This not only prevents reflux, but also helps fix the stomach in the abdomen. A partial fundoplication is generally made because a weak oesophagus (dysmotility) is inevitably associated with this condition. If a fundoplication is not performed, then the stomach is sutured to the abdominal wall (gastropexy) to help keep it in place.
The operation typically take 3-4 hours and is performed under a general anaesthetic.
Our patients say . . .
I just want to say a huge BIG thank you to for doing my hiatus hernia operation – I feel like a new person and am so grateful for all your care and consideration that has made such a difference for me.
WHAT IS RECOVERY LIKE?
Providing the operation is successfully carried out by keyhole surgery, recovery is relatively rapid.
A contrast swallow is carried out the day after surgery to confirm satisfactory repair. Patients are then started on fluids, and if swallowing is fine, then a soft or mouse diet is commenced. This needs to be continued for about six weeks after the operation to allow the oesophagus to get used to the new configuration and recover its peristaltic activity. Sometimes medication may be prescribed for a few weeks to help the stomach function and empty, as this becomes less effective if it has been stuck in the chest for a long time.
Following on from this recovery period, a normal healthy and balanced diet can be established. Patients are always advised to chew their food well and drink plenty of fluids.
Most patients can go home 2-3 days after the procedure.
WHAT ARE THE RISK OF HERNIA SURGERY?
Damage to any of the organs involved in the abdomen or chest is rare, but a risk of this procedure. The oesophagus, vagus nerves, pleura (lining of lungs) and stomach are vulnerable as they are come indirect contact during the operation. In most cases, if an injury does occur, then this can be dealt with by keyhole surgery and has minimal impact on further recovery or outcomes.
Re-herniation in the early post-operative period is another rare risk, and therefore diet, and the use anti-sickness medication to prevent vomiting is very important to enable the tissues to heal. If this does occur, then re-operation is usually necessary.
Bleeding, infection, thrombo-embolic complications, and the risks of a general anaesthetic are common to all major operations.
Some minor difficulty in swallowing may be a problem for some patients, and usually relates to underlying oesophageal weakness rather than the procedure itself, and in most cases, settles down with time. Minor side-effects relating to the fundoplication such as bloating and flatulence have been reported, but are rarely problematic.
WHAT ARE THE OUTCOMES LIKE?
Following successful repair of para-oesophageal hernia, the symptomatic outcomes are usually excellent. Normal swallowing function is restored, and other symptoms such as chest pain, breathing, respiratory problems and anaemia are resolved.
The use of extensive mediastinal (chest) dissection to create a tension-free oesophagus in the abdomen, coupled with a tension-free repair of the diaphragm have led to very successful outcomes in our series.
Traditionally, this operation has been associated with high levels of recurrence (repair breakdown) and other problems. However, our experience in Exeter, which is amongst the most extensive in the UK have been very good and we have reported very low rates of recurrence after 5-years and very few occasions when further surgery or intervention has been necessary.
We have published and presented our own data at National and International Meetings, and continue to improve and modify our technique. This is also an area in which we are collaborating with the University of Exeter in active research.