Hiatal Hernia

Unlike ventral or inguinal hernias that occur when organs or tissues push through the abdominal wall, a hiatal hernia happens when part of the stomach pushes through an opening in the diaphragm and into the chest cavity.

The diaphragm is a muscle that separates the abdomen from the chest cavity. It also helps keep stomach acid from backing up into the esophagus. Hiatal hernias can allow acid to back up into the esophagus and cause acid reflux symptoms.

There are two main types of hiatal hernia: Sliding hiatal hernia and paraesophageal hiatal hernia.

Sliding Hiatal Hernia

Sliding hiatal hernias are common, and about one in four adults have them by age 40, according to Medical College of Wisconsin. In this type of hernia, the point where the esophagus meets the top part of the stomach slides up into the chest cavity.

Paraesophageal Hiatal Hernia

In a paraesophageal hiatal hernia, more of the stomach pushes up through the opening in the diaphragm.

These hernias are more at risk of becoming incarcerated or strangulated. This means a part of the stomach twists or gets squeezed by surrounding muscles, cutting off blood flow or causing an obstruction. Strangulated hernias require emergency surgery.

Most small hiatal hernias don’t have symptoms. These hernias are common, but less than 10 percent of people have symptoms, according to Johns Hopkins Medicine.

Common hiatal hernia symptoms resemble GERD or acid reflux symptoms. Symptoms such as chest pain and shortness of breath could be a sign of a heart problem and shouldn’t be ignored.

Weakened muscles that allow the stomach to protrude through the diaphragm lead to hiatal hernias, but it’s not always clear why this happens.

People who smoke, are older, are obese or are pregnant are at greater risk for hiatal hernias.

Most people with hiatal hernias receive a diagnosis when they seek treatment for acid reflux, GERD, abdominal pain or chest pain. Imaging tests are the most common way to diagnose hiatal hernias.

These hernias aren’t usually serious, and people with no symptoms or problems don’t require treatment. Patients can manage mild symptoms with lifestyle changes or acid reducing medications. More serious hernias may need surgery to repair.

In most cases, hiatal hernias aren’t medical emergencies. But hernias that become strangulated require emergency surgery. Strangulation can result in “necrosis (tissue death) or perforation of the stomach (a hole in the stomach tissue),” according to Carrott.

Medications for Symptoms

In some cases, acid-reducing medication can manage hiatal hernia symptoms. These include antacids such as Tums, H2 blockers and proton pump inhibitors.

H2 Blockers

H2 blockers include drugs such as Pepcid (famotidine) and Zantac (ranitidine). In April 2020, the FDA requested manufacturers withdraw all ranitidine products from the market because of cancer concerns. In 2021, a new Zantac formula made with famotidine returned to the market.

Proton Pump Inhibitors

Proton pump inhibitors, or PPIs, are another type of drug that helps reduce stomach acid. These include Nexium (esomeprazole), Prilosec (omeprazole) and Protonix (pantoprazole).

Surgical Hiatal Hernia Repair with Mesh

Hiatal hernia repair surgery is a relatively safe but complex operation that requires general anesthesia.

Surgeons most often repair hiatal hernias with synthetic mesh. Some doctors may decide to use sutures or native tissue to repair the hernia, but studies have shown synthetic mesh helps prevent the hernia from coming back.

Recurrence was the most common complication before the hernia mesh’s invention. Research is mixed on how long a mesh hernia repair will last. A 2022 study followed 100 patients for ten years after a ventral abdominal hernia repair.

No recurrence was recorded after three years, while about 10% had a recurrence after roughly eight years. Two patients had a central breakdown of the mesh at about seven years. Mesh had stretched across the defect by an average of 21%. Mechanical testing showed that the mesh lost its elasticity at low forces.

If the hernia is smaller, surgeons can use minimally invasive laparoscopic surgery to repair the hiatal hernia. The doctor makes several tiny incisions and inserts tools through the small holes. This makes recovery quicker because there is less blood loss and scarring. But if the hernia is very large, doctors may need to switch to open repair.

Some complications occur right after surgery, but others may occur months or even years later.

Mesh Complications

Mesh made of polypropylene plastic is the gold standard of care for most hernias.

But some studies have shown synthetic mesh used at the hiatus can cause rare but serious medical problems and the need for reoperation, according to a 2020 review article by Drs. Colette S. Inaba and Brant K. Oelschlager published in Annals of Laparoscopic and Endoscopic Surgery.

Complications arising from mesh used in hiatal hernia repairs, include: Mesh erosion, narrowing of the esophagus (esophageal stenosis) and large amounts of scar tissue.

Recovery After Surgery

Hiatal hernia surgery is a major operation. It can take weeks to months to fully recover from hernia surgery. Patients who have minimally invasive surgery may be able to return to work within two weeks.

Patients typically manage pain with prescription or over-the-counter pain relievers for the first few days. Immediately after surgery and for the first few days, patients should remain on a liquid diet and can add creamy or soft foods as instructed by the surgeon.

Swelling from the esophagus might make it difficult to swallow solid food. This can last up to eight weeks after the operation. Bowel changes include constipation and diarrhea.

If you suffer any severe pain, fever, redness at the surgical site, severe swallowing problems or inability to pass gas or stool, talk to your surgeon right away.