Many people are unaware that they have a hiatal hernia because in most cases it’s a problem that you belch away and think about mentioning to the doc but eventually forget…but what exactly is a hiatal hernia? In this article, we’ll delve deep into what a hiatal hernia is, the types of it, and what you should or shouldn’t do about it.^3,4

Overview

Hernia occurs when an internal organ in your body moves into a different area in your body where it doesn’t belong. There are various types, stages of severity, treatment options and predisposing factors for one to develop a hernia.⁵ Now as for what a “hiatal” hernia is:

Let’s break down the anatomy of your upper body to make it a little simpler. Usually, our stomach lies just beneath a thin, muscular structure called the diaphragm. There is an opening in the diaphragm called the hiatus and the food pipe (oesophagus) passes down this opening. 

The diaphragm usually separates our chest cavity from our digestive system. In people with hiatus hernia, the stomach moves up to the chest cavity because of a weakness in the diaphragm.

The exact cause for a hiatal hernia is not concrete yet but there is a higher chance of having a hiatal hernia if you are over the age of 50, overweight, injury to that area because of a seatbelt accident, living with a chronic cough or pregnant.⁶ Sometimes people are born with a weak muscular tone which can also lead to developing a hiatal hernia. People who do manual labour and are constantly exposing their abdomen to increased pressure can also develop a hiatal hernia. With people with an existing hiatal hernia without their knowledge, they’ll notice that it gets tough to tolerate spicy or greasy foods, they cannot eat large amounts of food without feeling a sense of acid and regurgitation. After food consumption there may be a feeling of heartburn, a feeling of bloatedness and sometimes even bad breath.

Types of hiatal hernia

There are two main types of hiatal hernias, namely, sliding and paraesophageal.^11,12

Sliding Hiatal Hernia occurs when the food pipe and stomach can move up and down through the opening in the diaphragm. This is the more common type of hiatal hernia and almost 1 in 4 adults over 40 will have a sliding hiatal hernia; they may be symptomatic or asymptomatic.

Paraesophageal hiatal hernia is the more concerning type of hiatal hernia because the food pipe and stomach stay in place but other intestinal organs such as the intestines, can come out on top of the diaphragm and cause a lot of distress to someone with this condition. Some cases of this also may not have any symptoms but this type of hernia can also lead to very serious consequences needing immediate medical attention.

In most cases, the condition is very mild and it can be controlled conservatively by eating a good, fibrous and clean diet, taking antacids and anti-gastric secretory medication, making lifestyle adjustments (losing weight, stop smoking, eating small quantities) and sleeping in an elevated position. However, in rare cases, people with this condition may have great discomfort and this ailment could affect their quality of life, in which cases surgical treatment is considered.

When do we need to resort to surgery?

Symptoms that lead to surgery:⁷

1. If conservative treatment has proven to be ineffective and there’s persistent symptoms
2. Chest pain/burn because of food regurgitation after consumption
3. Persistent inability to eat, feeling of acid in the throat region
4. Feeling pain and constant discomfort
5. Further investigations should be done if there’s trouble swallowing food, if undigested food keeps coming up

Complications that may occur with a pre-existing hernia that will require surgical correction:

1. The organs that travel upwards could get strangulated and cause a lot of severe complications
2. Internal bleeding due to hiatal hernia
3. Obstruction of the internal organs leading to problems with digestion and passing stool
4. Paraesophageal hernias can cause stomach ulcers (Cameron’s Erosion) to form, which slowly causes chronic blood loss and an anaemic state
5. Loss of weight due to prolonged satiety when the stomach and intestines are entangled

What kind of surgical treatment is available?

Nissen fundoplication

This is a surgery that is usually done to correct gastric reflux. The aim is to keep the stomach and food pipe tightened in their original intended place and minimise the size of the opening in the diaphragm that connects the stomach to the oesophagus. The surgeon will use permanent stitches to keep all the organs in place.^1,2

Toupet fundoplication

This surgery is usually done for people that struggle with swallowing food because of the reduced motility of the oesophagus. This is a less common surgery that can now be done with the assistance of robotic surgical systems: Robot-assisted Laparoscopic Toupet Fundoplication. The aim is to close the opening in the diaphragm and directly connect the oesophagus to the stomach, this will prevent the stomach and other organs moving upwards through the diaphragm opening and promote smoother digestion.

Laparoscopic vs open surgery

Nowadays, laparoscopic surgery is preferred to open surgery because there are fewer complications and risks associated with laparoscopic surgery, people recover faster and can get on with their daily practices faster. Laparoscopic surgery is when small incisions are made in your tummy and the probe with the camera and surgical instruments are entered into the stomach through the small incisions. Usually, to help the surgeon view the surgical field better, it is pumped with gas to increase the surface area. However, in more complex cases, open surgery is preferred. This choice will be made by the surgical team and related to you to allow you to weigh out the risks and benefits.^9,10

Robotic-assisted surgery

With current advancements in surgery, surgeons are looking to treat surgical conditions with the aid of robotic manoeuvres such as the Da Vinci Xi system. These procedures are still relatively new due to the system being expensive but the results have been on a positive trend and are steadily gaining popularity globally. These operations report being very successful in terms of outcomes, results, precision, and minimal long-term complications.⁸

Overview of the surgical procedure

There will be a preoperative assessment with the anaesthetics team before your scheduled appointment to see if you are completely fit for surgery. A few diagnostic tests and pre-screening blood tests would be done to ensure the patient is healthy to undergo surgery. It is crucial to make a few lifestyle shifts for better recovery and a better quality of life in general, this includes, making dietary adjustments, smoking cessation, limiting the amount of alcohol consumed, low-intensity exercises, etc.

The surgical process will be explained to you by the doctor in charge. Usually, the surgery and recovery include a hospital stay of approximately 1-2 days. Gradually, your diet will be shifted from a liquid diet to a solid one and the doctors will advise you on movement, daily activities and set follow-up appointments.

Risks and complications associated with hiatal hernia surgery

As like with any surgery, there are a few risks and complications associated with repairing the hiatal hernia. The most commonly mentioned risks are infection, bleeding, and difficulty swallowing food after surgery. These are promptly treatable with medication but in severe and rarer cases, the doctors may have to perform another surgery to fix the ongoing problem.

There are specific conditions or complications reported post-surgery:

1. Gas bloat syndrome – The name of this condition is quite self-explanatory, when the gas builds up excessive, there is a possibility of abdominal pain associated with it
2. Recurrence of the hernia – this, albeit being a rare occurrence, is still a possibility; it could be due to loose sutures, a new hiatus formation or other reasons that couldn’t have been predicted at the time of the procedure
3. Damage to organs nearby – damage to surrounding organs such as the stomach and oesophagus

Outcomes

The outcomes of hiatal hernia repairing surgery is applauded because of the immense relief felt by the patient and the rate of success in the surgeries performed. The patient will note reduction in the acid reflux, there will be improved swallowing and digestion. People will be able to live their lives in great comfort.

Post operatively, to reduce the chances of recurrence and to improve recovery, it is recommended to keep managing the weight, avoid greasy, dense foods and avoid smoking. Your doctor may prescribe certain medications such as antacids, H2 blockers and others to be used in some instances to suppress the acid build-up.

Summary

In this article, we explored what a hiatal hernia is, its causes, symptoms, types, and available treatments. A hiatal hernia occurs when part of the stomach pushes through the diaphragm into the chest cavity, often going unnoticed until symptoms like heartburn, bloating, or difficulty swallowing appear. We looked at the two main types—sliding and paraesophageal—and discussed how lifestyle factors, age, and physical strain can contribute to its development. While many cases are mild and manageable through diet, medication, and lifestyle changes, more severe or complicated cases may require surgical intervention. We also covered different surgical options, including Nissen and Toupet fundoplication, and highlighted advancements like robotic-assisted procedures. Finally, we outlined potential risks, post-surgery recovery, and the importance of long-term lifestyle adjustments for better outcomes and reduced risk of recurrence.