Hiatal hernias differ from other abdominal hernias in that they occur inside the abdomen.
A hiatal hernia occurs when a gap is created in the diaphragm, the muscle separating the chest and abdominal cavity. This gap allows the intra-abdominal viscera (stomach, intestine, liver) to move into the chest cavity, causing a series of symptoms and complications for the sufferer.
What is the reason for its appearance?
Hiatal hernias can be congenital or acquired.
Congenital are those that are present from birth and are due to some anatomical dysfunction/abnormality.
Acquired ones can occur after an injury that leads to a ruptured diaphragm, after some other surgical procedure, or more commonly due to certain factors related, for the most part, to the patient's lifestyle and habits.
The main risk factors for creating hiatal hernia are chronic cough, weight lifting, obesity, constipation, and pregnancy, which can lead to chronically increased intra-abdominal pressure.
What are its symptoms?
Hiatal hernia symptoms can vary depending on the size and severity of the hernia. Small hiatal hernias may be asymptomatic and discovered as an incidental finding on gastroscopy.
Depending on the morphology of the hiatal hernia, four categories are distinguished.
Noteworthy is the fact that hiatal hernia is a major cause of gastroesophageal reflux, resulting in these two conditions being often confused.
Typical symptoms of a hiatal hernia are:
• Dyspepsia
• Back pain/burning
• Bloating
• Belching (burping)
• Heartburn
• Bitter and/or sour taste
How is the diagnosis made?
The diagnosis of hiatal hernia can be achieved by taking the patient's medical history and physical examination combined with the study of imaging tests (CT scan of the chest and upper abdomen, ultrasound of the upper abdomen).
For the best diagnosis and the design of the appropriate treatment plan, gastroscopy, manometry, and pH measurement of the esophagus, x-ray of the esophagus with barium, radiological control with contrast, and the study of gastric emptying, as indicated by the surgeon, are necessary.
How is hiatal hernia treated?
At an early stage, hiatal hernia can be treated conservatively to limit symptoms. Depending on the case, medication with prazoles is usual.
It is recommended that the patient avoid lying down immediately after meals and adopt a balanced diet low in fat, with small and frequent meals and daily physical activity.
Losing excess weight has beneficial effects on symptom control by reducing intra-abdominal pressure.
Symptoms recur in patients where the problem does not subside with conservative treatment. In more severe cases, surgical treatment with minimally invasive methods is recommended.
Laparoscopic and robotic surgery allows, with small holes of 5-10 mm, the treatment of hiatal hernia with the advantage of minimal post-operative pain, reduced blood loss and a faster return of the patient to normal activity.
Surgery aims to return the intra-abdominal viscera above the diaphragm to their normal position, restore the gap in the diaphragm with or without mesh placement, and finally, restore the normal anti-reflux mechanism to eliminate the reflux of acid content into the esophagus.
Coloplasty is the folding of the dome, which is part of the stomach, around the lower part of the esophagus, strengthening the function of the lower esophageal sphincter.
Patients with coexisting morbid obesity (BMI>35kg/m2 according to the 2022 IFSO guidelines) benefit more from the combination of hiatal hernia gap repair with bariatric surgery (eg gastric bypass).
In Conclusion
Diaphragmatic hernia, once diagnosed, can be effectively treated initially conservatively with lifestyle modification and, upon failure or indications during the initial diagnosis, surgically with minimally invasive methods with excellent results.
Surgical reconstruction requires appropriate surgical education and training by a specialised team, whether laparoscopic or robotic. HYGEIA, specifically the First Surgical Clinic, has been distinguished and certified as a centre of excellence for such surgeries.
Dr Periklis-Iosif Chrysocheris is a Surgeon and Director of the 1st Surgical Clinic HYGEIA. Translated by Paul Antonopoulos.
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