Hiatal Hernia Repair: When and Why?

Hiatal Hernia Repair: When and Why?

Hiatal Hernia Repair: When and Why?

Kim from Houston sent us this question: “Would you do hiatal hernia repair on a 2 cm hiatal hernia causing possible extreme symptoms?”

Dear Kim,

Hiatal hernias come in different sizes and forms. Hiatal hernia size, however, does not always correlate with acid reflux symptoms. You may have a large hiatal hernia with no acid reflux, and you may have a small hiatal hernia with severe acid reflux symptoms. Consequently, acid reflux treatment does not and should not depend on hiatal hernia size. This is a common misconception I frequently encounter among patients and gastroenterologists in Houston.

Indeed, the pathophysiology of acid reflux is far more complex than hiatal hernia size. There is no doubt in my mind that acid reflux causes a hiatal hernia to develop. In return, hiatal hernia exacerbates acid reflux. This vicious circle of acid reflux leading to hiatal hernia formation and hiatal hernia exacerbating acid reflux is central to GERD pathophysiology and disease progression with time. This is the reason why acid reflux is described as a chronic and progressive disease. Acid reflux does not get better by itself with time. Symptoms start mild and intermittent and over time, they become severe and more frequent. The only way to break that cycle is to restore the anti-reflux barrier and stop acid reflux.

The most effective and reliable solution to restoring the anti-reflux barrier is hiatal hernia repair and Nissen fundoplication. Hiatal hernia repair by itself does not stop acid reflux; Hiatal hernia is more of a consequence of acid reflux and not a cause. Stomach and distal esophagus are reduced back into the abdominal cavity. Now the upper part of the stomach can be used to perform a floppy and short fundoplication around distal esophagus. It is the Nissen fundoplication that reverses GERD pathophysiology to stop acid reflux.

The exact mechanism by which Nissen fundoplication reverses GERD pathophysiology is not well understood. Dr Nissen discovered the procedure by serendipity more than 50 years ago. It has been assumed that the fundoplication creates a mechanical one-way valve around the lower esophageal sphincter. This assumption however is naïve. Nissen fundoplication induces neuromuscular and biomechanical changes in the gastro-esophageal junction. These changes extend beyond the gastroesophageal junction to alter gastric emptying patterns and gastrointestinal neuro-hormonal signaling.

In conclusion, no matter how small your hiatal hernia is, if you have severe acid reflux symptoms hiatal hernia repair and Nissen fundoplication surgery are indicated.