The diaphragm is a flat muscle that separates the chest cavity from the abdominal cavity. Hiatal hernia develops as an abnormal opening in the diaphragm. The most common type of hiatal hernia occurs in the oesophageal opening in the diaphragm where the oesophagus passes into the stomach. This opening sometimes enlarged, allowing the stomach, omentum and sometimes even other abdominal organs to slide up into the chest.
The majority of hiatal hernias are initially small, but with time hernia may become large, some time this hernia becomes so large that it gives way to whole stomach omentum and even other abdominal organs.
A small hiatal hernia may symptom free. Even large hernias sometime can be present without the knowledge of patient. The typical symptoms caused by hiatal hernia is as follows.
After eating the pressure of a full stomach push everything in the sac of hernia up into the chest. The larger the hernia the more it will go up causing chest or abdominal pain, shortness of breath, or other symptoms. The part of the stomach that is entrapped in the chest becomes slow to empty, the ingested material causes nausea vomiting or regurgitation. Patients with hiatus hernia sometimes feels better after vomiting.
Hiatal hernia does not generally causes life threatening problems but if the symptoms are intense it causes severe debilitation of health.
The symptoms of hiatal hernia is so confusing that general physician can think about a heart attack. Patients with hiatal hernia often goes for a unnecessary checkups of heart disease. Some time the stomach can become twisted, resulting in ulcers. These ulcers sometimes bleed profusely. Twisting of the stomach can also lead to strangulation and even rupture of the stomach with fatal results. Fortunately these are relatively rare problems of hiatal hernia.
In mild condition dietary measures (small frequent diet), weight reduction, antacids, H2 receptor antagonist, Proton pump inhibitors and are helpful. But in severe cases it may become necessary to repair the hernia. If surgical treatment is required the oesophagus and stomach should be examined by endoscopy. Oesophageal motility test and barium meal x-ray is also performed.
The hernia can be repaired by either conventional or laparoscopic methods. Repair of hiatal hernia is a common operations that general surgeons perform. Laparoscopic Herniorrhaphy is being done at a time when Laparoscopic Cholecystectomy has shown definite benefits over the open technique. Over the last few years, laparoscopic hiatal hernia repair has become a widely accepted surgical treatment. This technique allows the surgeon to pull the sac of the hernia down out of the chest and repair the hole in the diaphragm. The mesh repair of the hiatus hernia is also very effective by laparoscopic method. after the repair of the hernias defect fundoplication can be performed laparoscopically if needed In this operation the fundus of the stomach which is on the left of the esophagus and main portion of the stomach is wrapped around the back of the esophagus until it is once again in front of this structure. The portion of the fundus that is now on the right side of the esophagus is sutured to the portion on the left side to keep the wrap in place. The fundoplication resembles a buttoned shirt collar. The collar is the fundus wrap and the neck represents the esophagus imbricated into the wrap. This has the effect of creating a security valve in the esophagus not to allow the stomach to go up into the chest.
Laparoscopic approach has several advantages:
1. Tension free repair with mesh application.
2. Less tissue dissection and disruption of tissue planes
3. Less pain postoperatively.
4. Low intra-operative and postoperative complications.
5. Early return to work.
The majority of hiatal hernias can be repaired successfully with a laparoscopy. However, if the patient has had prior upper abdominal operations, than the surgeon may be unable to see the anatomy clearly with the laparoscope. It may be difficult, to repair an extremely large hiatal hernia using the laparoscopic technique. In these situation it may be necessary to convert the laparoscopic procedure into open.
Sometime the oesophagus become shorter than normal and it is not possible to mobilise it to bring in the abdomen without tension. These patients can develop hernia even after successful surgery. In some case it may be necessary to perform an oesophageal lengthening procedure. This involves making a tube of the upper part of the stomach and joining it with oesophagus to make it lengthy. This procedure is called a Collis Gastrostomy.
The general anaesthesia and the pneumoperitoneum required as part of the laparoscopic procedure do increase the risk in certain groups of patients. Most surgeons would not recommend laparoscopic hernia repair in those with pre-existing disease conditions. Patients with Cardiac diseases and COPD should not be considered a good candidate for laparoscopy. The laparoscopic hernia repair may also be more difficult in patients who have had previous upper abdominal surgery. The elderly may also be at increased risk for complications with general anaesthesia combined with pneumoperitoneum.
The mesh used is the same as the one used for open operations over last 30 years. Its safety and efficacy is beyond doubt as proved by the numerous trials all over the world.
The cost of laparoscopic equipment and instrument that is used to fix the mesh inside increases the cost of surgery. Unfortunately these are still imported and will remain expensive till thy are locally produced. However, the increased cost should be compared with the gain associated by a quicker and more productive return to work by the majority of the patients. The hidden lowering of cost is due to less leave, early return to normal activity and work, and also from the greatly reduced disruption of the family routine.