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Laparoscopic Hiatus Hernia

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Overview

Laparoscopic Hiatal Hernia Repair & Nissen Fundoplication in India


Hiatal Hernia

The esophagus passes through an opening in the diaphragm (i.e. 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.


Symptoms

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
  • Bleeding
  • Stomach twisting and perforation
  • Obstruction


Diagnosis

Several studies are helpful to your doctor in making the diagnosis of hiatal hernia including : -


  • Chest X-ray : -
    1. Air fluid level in the chest
  • Esophagram (Barium UGI): -
    1. Assess the function of the esophagus
    2. Identifying structural abnormalities (twisting of the stomach)
    3. Reveal associated problems (e.g. aspiration, poor gastric emptying)
  • Upper GI Endoscopy (EGD): -
    1. Identify damage caused by reflux (e.g. esophagitis, Barrett's esophagus, malignancy)
    2. Biopsy esophagus for evaluation of malignancy
  • Esophageal Manometry : -
    1. Assess the function of the LES
    2. Assess the wave-like motion (propulsive function) of the esophagus
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Surgery

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.


Recovery

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.

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Laparoscopic Hiatal Hernia Repair FAQ's

1. What is a hiatal hernia?

A hiatal hernia occurs when part of the stomach protrudes through the diaphragm and up into the chest. Although hiatal hernias are present in approximately 15%-20% of the population, only a minority of those patients are afflicted with symptoms. Most patients require a repair of the herniated tissue.

Normally the esophagus or food tube joins the stomach through an opening in the diaphragm called the esophageal hiatus. In individuals with hiatal hernias, the opening of the esophageal hiatus is larger than normal, and a portion of the upper stomach passes through the hiatus and into the chest. This usually takes years to develop. The sliding hernia is the most common, where stomach contents passes back to the esophagus. This is also known as reflux.


2. What causes a hiatal hernia?

The exact cause is unknown, but some experts suspect that increased pressure in the abdomen from coughing, straining during bowel movements, pregnancy and delivery, or substantial weight gain may contribute to the development of a hiatal hernia. It is also thought that hiatal hernias are caused by a larger-than-normal esophageal hiatus, or can occur when the muscle tissue surrounding this opening becomes weak.


3. What are the symptoms of a hiatal hernia?

Symptoms include heartburn (30-60 minutes after eating), regurgitation (worsened with lying flat), regurgitation, nausea, excessive belching, chest pain, difficulty or pain with swallowing, and acid reflux. Hiatal hernias may also produce gastroesophageal reflux disease or GERD.
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4. How is a hiatal hernia diagnosed?


Hiatal hernias are typically diagnosed when testing is performed to determine the cause of upper gastrointestinal symptoms such as upper abdominal pain. Diagnostic tests are done to assess the function of the esophagus and identify any structural abnormalities or damage caused by reflex. Tests include chest x-ray, upper GI series and endoscopy.


5. How is a hiatal hernia repaired?

In many cases, when symptoms are mild, medications can be prescribed to reduce acid secretion. Stress reduction techniques may be prescribed, or if overweight, weight loss may be indicated.

When hernia symptoms are severe and chronic acid reflux is involved, surgery is sometimes recommended. Cruroplasty and Nissen fundoplication is the procedure of choice for repair of a hiatal hernia and can be done laparoscopically. The procedure is performed through five quarter-inch incisions through which a camera and instruments are placed. In fundoplication, the upper part of the stomach is wrapped around the inferior part of the esophagus, preventing herniation of the stomach through the hiatus in the diaphragm and the reflux of gastric acid. The laparoscopic 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.


6. What is the recovery period after hiatal hernia?


Patients recover sooner after laparoscopic cruroplasty 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.

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The list of of Minimal Access Hospitals in India is as follows : -


Apollo Hospitals Bangalore Apollo Hospitals, Bangalore, India
Apollo Hospital Chennai Apollo Hospital, Chennai, India
Apollo Hospitals Hyderabad Apollo Hospitals, Hyderabad, India
Apollo Hospitals Delhi Indraprastha Apollo Hospital, Delhi, India
Apollo Hospitals Kolkata Apollo Gleneagles Hospital, Kolkata, India
Apollo Hospital, Goa, India Apollo Hospital, Goa, India
Wockhardt Hospital Bangalore India Wockhardt Hospital, Bangalore India
Wockhardt Hospital hyderabad, India Wockhardt Hospital, hyderabad, India
Wockhardt Hospital Mumbai, India Wockhardt Hospital, Mumbai, India
Fortis Hospital, Delhi, India Fortis Hospital, Delhi, India
Fortis Hospital Mohali, India Fortis Hospital, Mohali, India
Fortis Hospital Noida, India Fortis Hospital, Noida, India
Escorts Heart Institute Hospital, Delhi, India Escorts Heart Institute Hospital, Delhi, India
Manipal Hospital, Bangalore, India Manipal Hospital, Bangalore, India
MIOT Hospital, Chennai, India MIOT Hospital, Chennai, India
Narayana Hrudayalaya Heart Hospital, Bangalore, India Narayana Hrudayalaya Heart Hospital, Bangalore, India
Narayana Cancer Hospital, Bangalore, India Narayana Cancer Hospital, Bangalore, India
Sparsh Hospital, Bangalore, India Sparsh Hospital, Bangalore, India
Artemis Hospital, Gurgaon ( Delhi ) , India Artemis Hospital, Gurgaon ( Delhi ) , India
Max Devki Devi Heart and Vascular  hospital,  Delhi, India Max Devki Devi Heart and Vascular hospital, Delhi, India
Max Super Specialty hospital,  Delhi, India Max Super Specialty hospital, Delhi, India
BGS Global Hospital Bangalore, India BGS Global Hospital, Bangalore, India
BGS Global Hospital Chennai, India BGS Global Hospital, Chennai, India
BGS Global Hospital Hyderabad, India BGS Global Hospital, Hyderabad, India


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