hiatal hernia : When is surgery necessary?

If the hiatal hernia is in danger of becoming constricted or strangulated (so that the blood supply is cut off), surgery may be needed to reduce the size of the hernia.

In addition, people with a hiatal hernia who also have severe, chronic esophageal reflux may need surgery to correct the problem if their symptoms are not relieved through other medical treatments. If left untreated, chronic gastroesophageal reflux can cause complications such as esophagitis (inflammation), esophageal ulcers, bleeding or scarring of the esophagus.

During surgery, gastroesophageal reflux is corrected by creating an improved valve mechanism at the bottom of the esophagus.

Pre-surgical evaluation
The pre-surgical evaluation lasts about one day and is scheduled a few weeks before your surgery date.
During the evaluation, you will:

• Have a complete physical examination

• Have several tests to make sure you are physically ready for the surgery. Depending on your age and general health, the tests may include a chest X-ray, blood test, electrocardiogram (EKG) or other tests as ordered.

• Meet with several health care providers, including the surgeon, who will ask you questions about your condition and your health history

• Meet with an anesthesiologist (a physician who specializes in sedation and pain relief), who will discuss the type of pain medication (anesthesia) you will be given during surgery. You will also discuss the type of pain control after surgery.

• Have the opportunity to ask questions about the procedure


The day of surgery
• Do not eat or drink anything after midnight the evening before surgery
• Please do not bring valuables such as jewelry or credit cards

• Plan to arrive to the hospital at least two hours before your surgery time. Register at the admitting desk in the main lobby on the first floor of the H building.

• After registering, you will be taken to the TCI Center (“To Come In”). One family member or friend may come with you at this time. Others can join you once you are ready for surgery.

• In the TCI Center, you will be asked to change into a hospital gown and get into bed. You will be given a bag for your clothing; the person with you will be asked to take your personal belongings.

• An intravenous tube (IV) will be placed in your arm to deliver fluids and medication

• You will be asked to remove contact lenses and dentures

• A nurse may give you medication through your IV to help you relax

• Your family will wait in the family lounge; they will receive periodic reports about your progress throughout the surgery

• Once the surgeon is ready for you, you will be taken to the operating room

During the surgery
• An anesthesiologist will inject medication into your IV that will put you to sleep

• After you are asleep, the nurses will clean your abdomen with antibacterial soap and cover you with sterile drapes

• A six-inch vertical incision is made from the sternum to the navel. Frequently, surgical staples are used to hold the wound together.

• To correct GERD, the surgeon wraps the upper part of the stomach (called the fundus) around the lower portion of the esophagus. This creates a permanently tight sphincter so that food will not reflux back into the esophagus.

• Finally, your surgeon will check that there are no areas of bleeding, rinse out the abdominal cavity and then close the incision.

After the surgery
When you wake up from surgery you will be in a recovery room called the Post Anesthesia Care Unit (PACU). You will have an oxygen mask covering your nose and mouth. This mask delivers a cool mist of oxygen which helps eliminate the remaining anesthesia from your system and soothes your throat.
Your throat may be sore from the breathing tube that was present during your surgery; this soreness usually subsides after one or two days.

Once you are more alert, the nurse in PACU will switch your oxygen delivery device to a nasal cannula, a small plastic tube that hooks over your ears and lies beneath your nose. Your nurse will frequently check your blood oxygen level. Depending on the percentage of oxygen measured in your blood, you may need to keep the oxygen in place after you are transferred to your hospital room.

Recovering from surgery
Once you have recovered from anesthesia, you will be transferred to your hospital room. After your surgery, the nurses will measure your “intake and output” – they will document all the fluids that enter your body and measure and collect any urine or fluids you produce, including those from tubes or drains placed during surgery. A tube that is passed from your nostril into your stomach (a nasogastric tube) during surgery will remain for several days.

Diet
You will begin to drink clear liquids once your bowel function returns. Once you have passed gas (flatus) from the rectal area or have had a bowel movement, you will gradually be able to eat more solid foods (within 3 to 4 days after surgery).

Activity
You will be encouraged to get out of bed, starting the first day after surgery. The more you move, the less chance for complications such as pneumonia or blood clots in the veins in your legs.

Your recovery at home
Normally, you will be discharged from the hospital 5 to 6 days after surgery, after a barium swallow test confirms that the surgical site is healing correctly.

Activity
For six weeks after surgery do not lift or push anything over 5 pounds. Avoid activities that increase abdominal pressure, especially sit-ups. For 8 to 12 weeks after surgery, continue to avoid strenuous activities. However, you are encouraged to gradually increase your activity level. Walking is great exercise! Walking will help your general recovery by strengthening your muscles, keeping your blood circulating to prevent blood clots and helping your lungs remain clear.

Diet
A registered dietitian will visit you on your day of discharge to review your dietary instructions. You will be following a soft diet; follow this diet until your next appointment. Also avoid caffeine, carbonated beverages and citrus drinks.
Incision Care
You may notice some minor swelling around the incision; this is normal. However, call your health care provider if you have a fever, excessive swelling, redness, bleeding or increasing pain.

Follow-up appointment
A follow-up appointment will be scheduled about one week after your surgery. You will have a chest X-ray and your surgeon will assess the wound site and your recovery. The surgeon will provide guidelines about your activity and diet at this time.

© Cleveland Clinic 2001