What Is Hiatal Hernia Surgery?
Medically reviewed by Robert Burakoff, MD
Hiatal hernia repair is a surgical procedure used to treat a hiatal hernia. A hernia occurs when your internal tissues and organs push through a tear or weak spot in your muscles, causing a bulge or bump. A hiatal hernia occurs when the upper stomach bulges into the chest through the hiatus, a small opening in the diaphragm. As a result, the diaphragm cannot keep stomach acid from flowing into the esophagus.
Unlike other hernias, a hiatal hernia does not cause a visible bulge. However, it leads to symptoms like acid reflux and heartburn. It can also lead to severe complications.
Hiatal hernia surgery returns the stomach to the abdominal cavity. The goal is to fix the hernia and prevent it from returning.
Types of Hiatal Hernias
There are two main types of hiatal hernia: sliding hernia and paraesophageal hernia. Both types involve the stomach bulging through the hiatus into the chest cavity. However, they differ in symptoms and treatment.
Sliding Hernia (Type I )
About 95% of hernias are sliding hernias. About 15-20% of adults experience at least one at some point in their lives. Many sliding hernias do not cause symptoms and do not require surgical repair. A sliding hernia is a risk factor for gastroesophageal reflux disease (GERD). Your healthcare provider may recommend surgery for a sliding hernia that leads to GERD and daily symptoms.
Paraesophageal Hernia (Type II)
A paraesophageal hernia is much less common than a sliding hernia, but it's much more serious. This type of hernia needs to be repaired surgically because it has a high risk of incarceration, which happens when the stomach gets stuck in the chest cavity. This can lead to a loss of blood supply to the stomach (ischemia) and is considered a medical emergency.
Purpose of Surgery
The goal of hiatal hernia surgery is to fix the hernia by moving the stomach back into the abdominal cavity. The surgeon also reinforces the area surrounding the hiatus to help prevent the stomach from slipping through it again.
When You Might Need Hiatal Hernia Surgery
Not everyone with a hiatal hernia needs treatment. If your hernia is not causing symptoms or any other issues, your healthcare provider will likely recommend observing it over time.
Most people who undergo a hiatal hernia repair have significant symptoms that are not controlled by medication, including:
Heartburn
Acid reflux
Nausea
Feeling very full after meals
Upper abdominal pain
A feeling of fullness or heaviness in the upper abdomen
Difficulty swallowing
Dyspnea (shortness of breath)
Other possible reasons for surgery include:
A paraesophageal hiatal hernia with symptoms, especially with bowel obstruction or evidence of it
Evidence of severe injury to the esophagus, including an ulcer (sore on the stomach or lower intestinal lining), stricture (narrowing of the esophagus), or Barrett's mucosa (damaged esophagus lining due to acid reflux)
Experiencing symptoms for a long period of time
Being on lifelong therapy for a defective lower esophageal sphincter (LES), a valve between the esophagus and stomach that prevents food from moving back into the esophagus
A large hernia with or without symptoms, which can lead to future complications
When You Might Need Emergency Surgery
You might need emergency hiatal hernia surgery if your hernia is stuck or strangulated, meaning the blood supply to the hernia has been cut off. Signs of this condition include:
Redness in the hernia area
Sudden tenderness or severe pain in the hernia area
A growing hernia bulge
Bowel obstruction symptoms like nausea or bloating
Types of Surgery
There are two main types of hiatal hernia surgery: laparoscopic and open.
Laparoscopic surgery: The surgeon uses a laparoscope (a thin telescope with a light and a camera that helps the surgeon see inside the body), which is inserted via a small incision in your abdomen. Mesh is often used to close and strengthen the abdominal wall. Some surgeons do the surgery using a robot that they control from a nearby console.
Open surgery: The surgeon makes an incision in the groin to access and repair the hernia, then uses stitches and sometimes mesh to close and strengthen the abdominal wall. This type of surgery is riskier than laparoscopic surgery.
Specific surgical procedures for a hiatal hernia include:
Nissen fundoplication: This involves wrapping the upper portion of the stomach (fundus) around the lower esophagus to reinforce the lower esophageal sphincter and prevent the backward flow of stomach acid. The Nissen uses a 360-degree wrap, meaning the fungus is completely wrapped around the esophagus. This type of surgery can be open or laparoscopic.
Partial fundoplication: This involves a partial wrapping of the fundus around the esophagus. The Dor procedure is a posterior wrap (around the back of the esophagus), and the Toupet procedure is an anterior wrap (around the front of the esophagus).
Endoluminal fundoplication: This newer surgery does not require incisions. A tube with a camera is inserted into your mouth and down your esophagus. The surgeon uses this tool to insert clips where the esophagus meets the stomach.
Repair surgery: This repositions the stomach back into the abdomen and closes the opening in the diaphragm to reduce herniation.
Collis-Nissen gastroplasty: This lengthens the esophagus by creating a new section using part of the stomach. The surgeon then uses Nissen fundoplication to address the acid reflux.
How Does It Work?
Hiatal hernia preparation, surgery, and recovery depends on your specific procedure. However, there are some general commonalities. Talk to your healthcare provider before your procedure for more information on what to expect.
Before the Surgery
Here are a few basic things to expect before a hiatal hernia surgery:
Tests: You may need tests before the surgery, including blood tests, x-rays, and upper endoscopy (a test to look at the lining of your upper gut—including your esophagus, stomach, and upper part of the small intestine (duodenum).
Paperwork: You'll complete a questionnaire and waiver before the procedure. The pre-questionnaire helps identify any potential risks that would prevent you from having the procedure, such as pregnancy.
Prep: Once you are taken back for surgery, you will be asked to change into a hospital gown. Before surgery, you will wait in the pre-operative area. Your surgeon and an anesthesiologist (a medical doctor who specializes in anesthesia and pain management) will talk with you about the procedure. The medical staff may check your blood pressure, oxygen levels, and pulse.
When it is time for your procedure, a healthcare provider will wheel your bed into the operating room and help you climb onto the operating table. The anesthesiologist will administer medication to help you relax and fall into a deep sleep. Hiatal hernia surgery requires general anesthesia, so you will not feel any pain or remember the surgery. The surgery generally takes 2-3 hours.
During the Surgery
During surgery, the surgical team will place a nasogastric (NG) tube through your nose and throat into your stomach. This tube will provide nutrition until you are ready to eat normally.
For open surgery, your surgeon will make one large incision. For laparoscopic surgery, they will make 3-5 small incisions, then insert the laparoscope into one of the incisions and other surgical tools into other incisions.
Your surgeon will carefully move the part of your stomach that has slipped into the chest cavity back into place. They will then repair the area of the diaphragm around the hiatus to help ensure that the stomach does not slip through it again. The surgery may include fundoplication (wrapping the upper stomach around the lower esophagus) with stitches and possibly mesh.
After the Surgery
Once your surgeon has completed the repair, you will be taken to the post-anesthesia care unit (PACU) to recover. You might feel groggy and disoriented when you wake up. Nurses will monitor you and administer pain medication as needed.
A provider will transport you to your hospital room once the medical team has determined that you are stable and fully recovered from anesthesia.
You may need to stay in the hospital for a few days, or up to about a week if you have open surgery. You will likely need to have the NG tube in place for a few days. Your medical team will remove the tube when you’re able to tolerate small, frequent meals.
Hiatal Hernia Surgery Recovery
It's common to feel bloated and have difficulty swallowing. You might experience some pain and nausea, but OTC pain relievers are usually sufficient. You might experience some chronic pain up to several months afterward.
Recovery includes specific diet and movement recommendations.
Diet
You will start on a clear liquid diet and progress to a diet of soft or pureed foods as tolerated. You might continue this diet for about two weeks, and perhaps up to six weeks if you experience dysphagia (difficulty swallowing). This can lead to weight loss—for example, about 10-15 pounds.
Post-operative diet recommendations will likely include eating small meals frequently, eating slowly, and sitting upright for up to 60 minutes after each meal.
Movement
Your healthcare provider will likely encourage you to start incorporating regular movement as soon as possible post-surgery. This can help reduce constipation and the risk of blood clots.
You will want to avoid heavy lifting or excessive straining, which can increase pressure in the abdomen and affect the hernia repair. For example, your healthcare provider might tell you lift no more than 15 pounds for up to six weeks.
Most people feel back to themselves and are able to resume their usual activities in 4-6 weeks.
Risks and Precautions
Like any surgery, there are risks involved in undergoing a hiatal hernia repair. These risks are rare, but they include:
Pneumothorax (a collapsed lung)
Injury to the stomach, intestine, or esophagus
Injury to the liver or spleen
Dysphasia (difficulty speaking), often due to post-surgery swelling and often resolving on its own
Other general risks of surgery include:
Infection
Bleeding or blood clots
Reaction to anesthesia
There is a risk of recurrence after hiatal hernia surgery. You could develop another hiatal hernia and need to undergo surgery again in the future. Up to 50% of people who have paraesophageal hernia surgery experience a small recurrence.
Possible complications of fundoplication include continued acid reflux (if the wrap is too loose) and difficulty swallowing (if the wrap is too tight). Mesh can also lead to complications, including chronic (long-term) pain.
How to Prepare for Hiatal Hernia Surgery
Knowing what to expect can help you to feel prepared for hiatal hernia surgery. You will need to consider the following:
Location: Hiatal hernia surgery takes place in the operating room of a hospital. This is an inpatient procedure. You will need to stay in the hospital at least overnight and possibly up to about one week depending on the type of surgery.
Attire: You will likely wear a hospital gown during your time in surgery and in the hospital. Wear loose, comfortable clothing to the hospital, and pack an extra outfit for going home. Leave any jewelry or valuables at home.
Food and drink: You will receive general anesthesia for the surgery. Your surgeon will ask you to not eat or drink anything for a certain amount of time beforehand. Most people do not eat or drink for at least eight hours before surgery. Ask your surgeon how long you'll need to fast.
Medications: Ask your surgeon if it is safe to take your regular medications and supplements before surgery. If you take any blood-thinning medications, such as aspirin, stop taking them before surgery. They can increase your risk of bleeding.
Items to bring: Bring your insurance card, identification card (such as a driver’s license), and any paperwork that you received from the hospital. Plan to bring any comfort items you’d like to have with you during your hospital stay. This may include a pillow, books, or a favorite pair of slippers.
Emotional support: Ask your healthcare team about the hospital’s visitor policy. Most hospitals allow a support person to stay in the waiting room during your surgery and accompany you to your hospital room.
Cost and insurance: Call your insurance company after you make the surgical appointment. Clarify the cost of the surgery and how much you're responsible for paying. Talk with the hospital billing department about which bills to expect after surgery and how long you have to pay them.
Alternatives
Lifestyle modifications and medications can sometimes reduce symptoms if your hiatal hernia isn't serious enough to warrant surgery. Surgery may be needed if these approaches do not improve your symptoms.
Lifestyle Modifications
Your healthcare provider will likely recommend lifestyle modifications if a sliding hiatal hernia starts to cause symptoms. Recommendations might include:
Avoid foods that can trigger acid reflux, such as tomatoes, citrus, and spicy foods
Eat smaller meals more frequently
Sit upright after eating
Avoid eating three hours before bedtime
Elevate your head during sleep
Wear loose-fitting clothing
Related: Foods To Help Heartburn
Medications
Medications that help control stomach acid and acid reflux can help relieve GERD-related hiatal hernia symptoms. These include:
Antacids: Over-the-counter (OTC) antacid medications that can provide temporary relief by neutralizing stomach acid
H2 receptor blockers: Medications that reduce stomach acid production
Proton pump inhibitors (PPIs): Medications that help reduce stomach acid production and alleviate symptoms of acid reflux and heartburn
A Quick Review
Hiatal hernia surgery is a type of surgery that is used to fix a hiatal hernia. A hiatal hernia occurs when part of the stomach slips or bulges through the hiatus into the chest cavity. A hiatal hernia may not cause symptoms at first, but you may develop symptoms over time, such as heartburn, upper abdominal pain, and trouble swallowing.
The goal of hiatal hernia surgery is to return the stomach to the abdominal cavity and prevent the hernia from recurring. Most people spend a few days in the hospital after the surgery. Speak to your healthcare provider before the procedure to make sure you understand the procedure, risks, and any other important information.
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