A hiatal hernia occurs when the upper part of your stomach bulges through the diaphragm, the large muscle separating your abdomen and chest, and protrudes into the chest cavity, often behind the heart. The top part of your stomach gets pinched, and stomach acid can back up (reflux) through the opening. This may cause heartburn and other symptoms. There are 2 types of Hiatal hernias:
- 1. Sliding Hiatal Hernia
Sliding hiatal hernia is the most common type of Hiatal Hernia. It happens when part of the stomach, and the place where the stomach and esophagus meet, slide up into your chest through the opening (hiatus).
- 2. Paraesophageal HerniaParaesophageal hernia is the second type of Hiatal Hernia. This type of hernia Is less common but can be more serious, and occurs when part of your stomach pushes up through the opening (hiatus) into your chest and is next to your esophagus.
Causes of a Hiatal Hernia
Experts do not know conclusively what causes Hiatal hernias. That said, anecdotal evidence suggests that some causes may include:
- Obesity
- Coughing
- Straining while having a bowel movement
- Vomiting
- Smoke
- Pregnancy
- Sudden physical effort
- Are over the age 50
Symptoms of a Hiatal Hernia
In many cases, a hiatal hernia has no symptoms. However, some people do have symptoms that may include:
- Excessive Burping
- Nausea
- Vomiting
- Acid reflux
- Heartburn
- Regurgitation
Difficulty swallowing (Dysphagia)
Paraesophageal hernias may have more severe symptoms, including:
- Abdominal or chest pain
- Pain in the middle, upper abdomen
Abdominal bleeding, or Stomach ulcer
- Shortness of breath
- Blood loss (anemia)
- Trouble swallowing solid foods
- Early or prolonged satiety, the feeling full after eating only a small amount of food
In some cases, a paraesophageal hernia can lead to a medical emergency. The stomach or abdominal organs may turn or twist, causing intense pain. There is a danger that the stomach’s blood supply may be cut off (strangulation). This is an emergency. You will likely need surgery right away.
The symptoms of a hiatal hernia may look like other health problems. Always see your healthcare provider to be sure.
Robotically-Assisted Hiatal Hernia Repair with The Da Vinci® Robotic Surgical System
Surgical robotics for minimally invasive surgery
As a Board-Certified General Surgeon, Dr. David W. Ford operates with a minimally invasive robotic to repair Hiatal hernias. This minimally invasive approach only requires one or a few small incisions that doctors use to insert surgical equipment and a camera for viewing.
Robotically-assisted Hiatal Hernia surgery utilizes an advanced robotic platform that is not autonomous but is controlled by the surgeon who is seated in the operating room and operates via the Surgeon Console that controls the Patient Cart’s robotic devices, including various surgical instruments and a camera. The da Vinci Surgical System allows surgeons to perform minimally invasive hernia repairs with clinically supported precision and accuracy. Robotically assisted surgery uses a laparoscope (a thin lighted tube with a camera on the tip) that is inserted through one of several small incisions, made away from where the hernia has occurred.
The images gathered from the laparoscope’s camera are magnified, high-definition 3D, which are sent to a monitor that Dr. David W. Ford uses to guide the surgical system during the operation. If needed, the abdomen can be inflated with a harmless gas (carbon dioxide), which creates space to allow the doctor to view the inside of the body.
This hiatal hernia repair method occurs similarly to the open surgery, where the stomach is pulled back into place from the chest cavity, tightening of the esophageal sphincter, usually via fundoplication occurs, and the hiatus in the diaphragm is tightened and reinforced, usually with a synthetic mesh material. Various mesh configurations can be used, depending on the location of the hiatal hernia and its relation to the heart and lungs. After the procedure is completed, the small incisions in the abdomen are closed with stitches or surgical tape. Dr. David W. Ford’s use of the state-of-the-art da Vinci Surgical System in his robotically assisted hernia repair surgeries has allowed him to set an exceedingly high standard of expertise that can combine this method with traditional Open Surgery if required.
Many robotically-assisted surgical systems are FDA approved and in use today. However, many are specially designed for specific organs, procedures, or conditions, such as lung or pulmonary surgeries or knee and other extremity replacement surgeries. The da Vinci Robotic Surgical System is the premier system specialized in hernia repair surgery. Dr. David W. Ford is not only an expert board-certified surgeon but also certified in the use of this leading-edge technology.
This robotic platform offers Dr. David W. Ford fully wristed instruments and a 3D high-definition camera with 10x magnification. As a result, the repair can be done with more precision, and complex hernias can be fixed with small incisions. Furthermore, the robot does not get tired, and Dr. Ford sits during surgery, so there is less surgeon fatigue. For the patient, this translates into quicker recovery, less pain, and fewer complications. This is the preferred approach for medium to large hernias and many umbilical hernias as it combines the best of open and laparoscopic surgeries. Also, Dr. Ford is more likely to be able to sandwich the mesh between layers of the abdominal wall to keep the mesh from coming into contact with the intestines.
Other benefits of robotic hernia surgery include:
- Access to clear three-dimensional images (unlike laparoscopic surgery’s two-dimensional images) of the inside of the abdomen for more precise surgery.
- Dr. Ford can easily use stitches to sew tissue and meshes into the inside of the abdomen.
- The patient is left with smaller scars rather than one large incisional scar.
- The possibility of much less pain, faster recovery, and quicker return to normal diet and activities after surgery are observed, compared to all other types of hernia repair surgery.
Should robotically-assisted surgical laparoscopic surgery be recommended as part of treatment for your Hiatal hernia repair, Dr. David W. Ford and his team will have the best state-of-the-art technology at their disposal to usher in your recovery.
How The Da Vinci® Robotic Surgical System works
Da Vinci surgical systems are comprised of three components: surgeon console, patient-side cart, and vision cart.
Surgeon Console
Patient Cart
The patient-side cart is positioned near the patient on the operating table. It is where the instruments used during the operation move in real time in response to your surgeon’s hand movements at the surgeon console.
A camera provides a high-definition, 3D magnified view inside your body. Every hand movement your surgeon makes is translated by the da Vinci system in real time to bend and rotate the instruments with precision.
Vision Cart
The vision cart makes communication possible between the components of the system possible, and supports the 3D High Definition vision system.
Open Hiatal Hernia Repair
A complex hernia repair may require mesh removal, resection of the abdomen and/or its organs, or removal of extraneous skin or fat, and therefore is easier with open surgery.
The open surgery requires that an open incision be made in the abdomen exactly on the location where the hernia has occurred. A tube may be inserted into your stomach through the abdomen to keep the stomach wall in place. This tube will be taken out in about a week. The stomach is then pulled back into place from the chest cavity, and tightening of the esophageal sphincter, usually via fundoplication occurs.
The fundoplication, if necessary, can use stitches or clips. If this is unnecessary, then Dr. Ford moves to the reconstruction, tightening, and reinforcement of the hiatus in the diaphragm, usually with a synthetic mesh material. This can be done with various mesh configurations, depending on the location of the hiatal hernia and its relation to the heart and lungs. Finally, the skin is usually closed with dissolvable stitches and glue.
Non-Surgical Options:
- Conservative, watch & wait management is helpful for patients with minimal or no symptoms.
- The hernia itself should not limit your ability to engage in your usual daily activities.
Surgical Options:
Hernia repair involves an operation, with overall one of two main approaches:
- Mesh repair – the use of mesh to enhance the repair & provide further reinforcement
- Non-mesh repair – closing the abdominal defect with stitches, creating some tension
Safety of Surgical Mesh:
- There is a large volume of data on the outcome of various hernia operations and different types of mesh, and the use of mesh to repair the majority of hernias has been the preferred method in the US, UK, and worldwide for over 30 years.
- When surgeons themselves have hernias that require surgery, they opt for mesh repairs.
- Patient safety is a critical component, and therefore, different meshes used in surgery are tightly regulated in both the US and UK.
What is the “Gold Standard”?
- Using mesh has become the gold standard in hernia repairs – and has a lower recurrence rate.
- Many patients with hernias have tissue weakness and often do not hold stitches well, which may explain why non-mesh repairs have a higher failure/recurrence rate than with mesh.
- For the vast majority of patients, mesh poses little if any additional risk.
Risks of Mesh:
- Mesh is a foreign material, like synthetic implants, such as dentures, crowns, heart valves, etc.
- It is possible for mesh to become infected, but this is rare.
- Some patients develop chronic pain after surgery. There is no strong relationship with the use of mesh and chronic pain. Furthermore, non-mesh repairs can result in similar pain outcomes.
Post-operative Treatment of Hiatal Hernias will vary due to the repair surgical procedure chosen, the severity of the hernia, its location, and any complexities in either surgery or comorbidities of the patient. Usually, hernia repair surgery only requires a hospital stay of a day or less, and most patients go home the same day. At first, you may need to rest in bed with your upper body raised on pillows, to help you breathe easier and lessen post-surgery hernia pain. Both cold and heat can help lessen some types of post-op pain.
After recovery, you can usually return to work or school within 2 to 3 days. You will not be able to lift anything over 10 pounds, climb, or do strenuous activity for 4 to 6 weeks following surgical repair of a ventral hernia. Always wash your hands before and after touching near your incision site.
Losing weight relieves excess pressure on the abdomen, which can prevent a hernia from developing, improve hernia symptoms, and avoid complications such as strangulation.
As a preventative measure to assist in healing, patients are usually requested to continue acid-reducing medications for one week after surgery, with first clear foods followed by a soft, easy-to-chew and swallow diet. There may be some initial resistance to the passage of food, causing more air to be swallowed, causing episodes of a gas-bloat syndrome, where abdominal distention, nausea, flatulence, and difficulty in belching or vomiting occurs. Also, dysphagia or difficulty swallowing may last for 6 weeks or longer, usually temporary, due to post-surgical swelling at the wrapped site. Patients are encouraged to eat small, frequent meals that are chewed well, and to avoid using straws, gum, caffeine, tobacco alcohol, or carbonation (to reduce air swallow), or eating foods that cause stomach gas or stomach distention, such as corn, beans, peas, onions, broccoli, cauliflower, cabbages, dried fruit, seeds or coarse foods.
Prescription Refill Hours:
Monday – Thursday 8:30 AM – 4:30 PM
Friday before 2:00 PM
- Please call if you experience any of the following:
- Temperature greater than 101 degrees
- Incisions with increasing areas of redness, thick or colored discharge, worsening tenderness
- Nausea and vomiting or an inability to tolerate anything by mouth
- Progressively worsening pain
You may call or email with any problems, questions, or concerns below:
Pain
- Acetaminophen (Tylenol)
- 650mg to 1000mg every 6 – 8 hours for first 3 days, scheduled
- After 3 days, may continue as needed for pain
- Do not exceed 4000mg in 24 hours
- Avoid if history of hepatic (liver) impairment, alcohol abuse
- Non-Steroidal Anti-Inflammatories (NSAIDs), choose one:
- Ibuprofen (Advil, Motrin) 400mg by mouth every 6 – 8 hours, as needed
- Naproxen (Aleve) 440mg by mouth every 12 hours, as needed. Avoid if history of renal (kidney) impairment, or a history of coronary artery disease (CAD), hypertension. Avoid multiple NSAIDs at once (e.g. Ibuprofen + Naproxen)
- Narcotics and Opioids
- Oxycodone, Hydrocodone & combo pills are for severe breakthrough pain ONLY
- If a combo pill (e.g. Percocet, Lortab, Vicodin, Norco), do NOT take with Tylenol.
- Do not drive or operate machinery while taking narcotic pain medication.
- Narcotics can be habit-forming, have addiction potential, and cause constipation, so be careful – and use sparingly.
- Tramadol
- Tramadol (Ultram) is for severe breakthrough pain & often used in place of opioids
- It is not a true narcotic but can be habit-forming with long-term use.
- Avoid if history of seizures
- Simethicone
- Simethicone (GasX) 40 to 125 mg every 8 hours as needed for gas pain & bloating
- Do not exceed 500mg in 24 hours; this is sold over-the-counter
Hygiene
- You may shower and use soap and water on surgical site incisions, the day after surgery
- Keep dressing clean and dry for 24 hours, you may replace as needed for drainage
- Do not swim or soak; no hot tub, pool, beach, lake, etc. for at least 7 days
Constipation
- Post-operatively & within 2 days, should be having regular, soft bowel movements (BMs)
- Hydrate & drink plenty of water (8 –10 glasses per day)
- PEG 3350 (Miralax) 17g by mouth each day for BMs each day
Other alternative recommendations, as needed – Use at least one if have not had a BM for 2 days:
- Magnesium Hydroxide (Milk of Magnesia) 15 – 30 mL by mouth once a day, as needed
- Magnesium Citrate 200 – 300 mL by mouth once a day, as needed
- Docusate (Colace) 100mg by mouth twice a day, as needed
Activity
- Ambulate and increase activity as tolerated post-operatively
- Simply walking often improves mentation, decreases pain & bloating, and improves BMs
- Avoid heavy lifting (greater than 20 pounds) until follow-up after laparoscopic and open surgeries
- Avoid prolonged straining and strenuous activity until follow-up
- Wear your abdominal binder after hernia repair
- Resume all home medication as directed
Wound Care
- The raised, firm area called a healing ridge is normal, and should resolve over time
- Remove your dressings/bandages 2 days after surgery, unless told otherwise by Dr. Ford himself
- You may shower and use soap & water on surgical site incisions, the day after surgery