Hiatal hernia and reflux surgery is a surgical treatment method performed to correct the upward herniation of the stomach through the diaphragm (hiatal hernia) and the accompanying backflow of stomach contents into the esophagus (reflux). The main goal of this operation is to repair the hernia and permanently prevent reflux by strengthening or recreating the valve mechanism beneath the esophagus. In this way, the underlying anatomical problem is resolved and the reflux complaints that reduce the patient’s quality of life are eliminated.
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What Is a Hiatal Hernia and How Is It Related to Hiatal Hernia and Reflux Surgery?
Hiatal hernia is, simply put, the upper part of our stomach sliding upward into the thoracic cavity through an opening (hiatus) in the diaphragm muscle that separates the chest and abdominal cavities. Normally, our stomach is entirely within the abdominal cavity. Our esophagus also passes through this hiatus to reach the stomach. We call the stomach’s protrusion upward through this opening a hiatal hernia. This is an internal hernia; it cannot be seen from outside. When it causes or worsens reflux complaints, hiatal hernia and reflux surgery may become relevant.
What Are the Causes and Types of Hiatal Hernia and Do They Require Hiatal Hernia and Reflux Surgery?
Hiatal hernia is quite common and becomes more prevalent with age, especially after fifty. While the exact cause is not always known, weakening over time of the muscles surrounding the hiatus generally plays a role. Aging, increased intra-abdominal pressure (from severe coughing, heavy lifting, obesity), previous surgeries, or a congenitally wide hiatus can contribute. Obesity is a significant risk factor.
The most common type is the “sliding” hernia, in which the esophagogastric junction moves upward and is usually accompanied by reflux. The rarer “para-esophageal” types involve part of the stomach slipping upward beside the esophagus. These can be more dangerous, causing issues like obstruction and may require hiatal hernia and reflux surgery.
What Does Reflux Disease (GERD) Mean and How Is It Connected to Hiatal Hernia and Reflux Surgery?
Reflux disease, or GERD in medical terms, is the regular backflow of stomach contents—acid and food—into the esophagus. This is not the occasional heartburn; GERD is a persistent problem. The acidic contents that rise from the stomach irritate the esophagus, causing discomfort and potential damage if untreated. Because a hiatal hernia can be an underlying cause, hiatal hernia and reflux surgery becomes a treatment option.
What Are the Causes and Complications of Reflux Disease and Is Hiatal Hernia and Reflux Surgery Necessary?
The main cause of reflux is the lower esophageal sphincter (LES) failing to function properly. This valve normally prevents stomach contents from moving upward. If it is weak or relaxes at inappropriate times, reflux begins. A hiatal hernia can weaken this valve. Obesity, pregnancy, certain foods, and smoking also trigger reflux.
Prolonged reflux can cause problems in the esophagus: inflammation (esophagitis), ulcers, strictures that make swallowing difficult, and even Barrett’s esophagus—a precancerous condition. When such complications appear or medication therapy is insufficient, hiatal hernia and reflux surgery generally becomes necessary.
How Does the Mechanical Link Between Hiatal Hernia and Reflux Influence the Decision for Hiatal Hernia and Reflux Surgery?
There is a direct physical connection between hiatal hernia and reflux. The hernia disrupts natural anti-reflux mechanisms. The LES both changes position and moves away from the supporting diaphragm muscles, weakening it. The normal angle between the esophagus and stomach also changes, facilitating backflow. Acid accumulating in the herniated stomach portion escapes upward more easily.
Because of this mechanical defect, the root cause in stubborn reflux cases often lies in the hernia. Hiatal hernia and reflux surgery aims to correct this defective anatomy. Thus, the hernia’s presence and size greatly influence the decision to operate.
What Are the Typical Symptoms of Hiatal Hernia and Reflux and Do They Indicate a Need for Hiatal Hernia and Reflux Surgery?
Not everyone with a hiatal hernia has symptoms. When complaints begin, reflux symptoms usually dominate. The best-known are heartburn and a bitter or sour taste in the mouth. Heartburn typically worsens after meals or while lying down. The bitter fluid rising to the mouth is stomach content reaching the throat.
Other symptoms may include difficulty swallowing, a sticking sensation, non-cardiac chest pain, abdominal bloating, and frequent belching. If these complaints impair quality of life, occur frequently, and persist despite medication, hiatal hernia and reflux surgery may be considered.
What Are the Atypical and Alarm Symptoms of Hiatal Hernia and Reflux and Do They Require Hiatal Hernia and Reflux Surgery?
Reflux can sometimes manifest differently: persistent cough, hoarseness, a constant tickle or lump sensation in the throat, wheezing, or shortness of breath. These are called atypical symptoms. Large hiatal hernias can also cause shortness of breath by compressing the lungs.
“Alarm symptoms” such as vomiting blood, black tarry stools, unintended weight loss, progressively worsening difficulty swallowing, and severe persistent pain require urgent medical attention. These serious or treatment-resistant complaints can necessitate hiatal hernia and reflux surgery.
Which Tests Are Used to Diagnose Hiatal Hernia and Reflux and How Do They Help Plan Hiatal Hernia and Reflux Surgery?
When hiatal hernia and reflux are suspected, several tests help confirm the diagnosis and assess its extent. These tests also provide important information for potential surgery. Endoscopy is usually performed first to view the esophagus and stomach. X-rays after swallowing barium (barium swallow) can be taken. In more specific cases, esophageal manometry and 24-hour pH monitoring may be necessary.
Why Are Endoscopy and Barium Radiography Important Before Hiatal Hernia and Reflux Surgery?
Endoscopy is typically the first and most informative test when hiatal hernia and reflux surgery is considered. Through a thin tube with a camera, we directly see the esophagus and stomach: whether a hernia exists, its type, and whether reflux has caused damage. This helps decide whether surgery is necessary and how to perform it.
Barium radiography is useful when swallowing difficulties exist or when we need a clearer picture of the hernia. By drinking a white liquid and taking X-rays, we gauge the hernia’s size and esophageal movements.
How Do Manometry and pH Monitoring Influence the Decision for Hiatal Hernia and Reflux Surgery?
Manometry and pH monitoring are specialized tests performed before surgery. Manometry measures esophageal contractions and LES pressure, guiding the type of fundoplication. pH monitoring records acid exposure in the esophagus over 24 hours, confirming reflux when endoscopy is normal. These tests allow precise patient selection and surgical planning.
Which Lifestyle Changes Can Be Applied Instead of Hiatal Hernia and Reflux Surgery?
Surgery is not always necessary. Simple lifestyle modifications can be very effective in mild cases. Losing excess weight reduces intra-abdominal pressure. Eating small, frequent meals eases the stomach. Avoid eating within three to four hours of bedtime. Elevating the head of the bed by 15–20 cm reduces nighttime symptoms. Quitting smoking helps valve function, and avoiding tight clothing and trigger foods (fatty, spicy, acidic) also helps.
Which Medications Are Used Instead of Hiatal Hernia and Reflux Surgery?
If lifestyle changes are insufficient, medications that target stomach acid are used. Antacids neutralize acid quickly but briefly. H₂-receptor blockers reduce acid production longer. Proton pump inhibitors (PPIs) are most effective, powerfully suppressing acid production and allowing healing, but they do not correct the hernia or valve defect.
Exactly When and to Whom Is Hiatal Hernia and Reflux Surgery Recommended?
Surgery is considered when PPIs fail to control symptoms, or when patients prefer not to take medication for life. Serious esophageal damage (esophagitis, strictures, Barrett’s esophagus) warrants surgery. Large para-esophageal hernias usually require surgical correction due to their risks. Severe, persistent reflux symptoms that greatly reduce quality of life can also justify surgery.
What Is the Fundoplication Procedure Performed During Hiatal Hernia and Reflux Surgery and Are There Different Types?
Fundoplication creates a stronger valve to prevent reflux by wrapping the stomach’s fundus around the lower esophagus. The best-known method is Nissen fundoplication (360° wrap). Partial wraps, such as Toupet (posterior) or Dor (anterior), are used when esophageal motility is weak to reduce swallowing difficulty. Technique choice depends on patient specifics and test results.
How Are Laparoscopic and Robotic Methods Used for Hiatal Hernia and Reflux Surgery?
Laparoscopy, involving small incisions with a camera and instruments, and robotic surgery, where instruments are controlled from a console, are minimally invasive. They offer less pain, shorter hospital stays, quicker recovery, and smaller scars, making them the preferred methods.
When Are Open Surgery and Endoluminal Methods Considered for Hiatal Hernia and Reflux Surgery?
Open surgery, through a larger incision, is now rare but used for very large hernias, significant adhesions, or when minimally invasive methods are unsafe. Recovery is longer. Endoluminal methods, like TIF, are incision-less procedures performed via endoscopy, but long-term effectiveness and ideal patient selection are still being evaluated.
Is Mesh Use Necessary During Hiatal Hernia and Reflux Surgery?
If the hiatus is very large (over 5 cm) or the hernia has recurred, mesh may reinforce the repair and reduce recurrence risk. Meshes can be permanent synthetic or absorbable biological materials. Mesh use is not routine; it depends on hernia size, patient factors, and surgeon experience.
Step-by-Step How Is Laparoscopic Hiatal Hernia and Reflux Surgery Performed?
Under general anesthesia, several small incisions are made. Carbon dioxide creates working space. A camera and instruments are inserted. The stomach is pulled down, the hernia sac is separated, and the hiatus is narrowed with sutures (mesh if needed). A fundoplication wrap is then created. Finally, instruments are removed and incisions closed.
How Is Open Hiatal Hernia and Reflux Surgery Performed?
Open surgery also uses general anesthesia but involves a larger incision, giving direct access to the hernia. The steps—reducing the hernia, repairing the diaphragm, and performing fundoplication—are similar, but recovery takes longer and postoperative pain is greater.
How Successful and Effective Is Hiatal Hernia and Reflux Surgery?
When performed on the right patient with proper technique and experience, success rates in controlling reflux are generally 85–95 percent. Most patients are relieved of heartburn and regurgitation. Unlike medications, surgery corrects the anatomical defect, offering a long-term solution, and many patients can discontinue acid-suppressing drugs, markedly improving quality of life.
Op. Dr. Ahmet Bekin was born in Istanbul in 1983. He graduated from the Faculty of Medicine at Kocaeli University in 2006 and completed his specialty training in the Department of General Surgery at Istanbul University Çapa Faculty of Medicine in 2011. After his specialization, he worked in the fields of hernia surgery, reflux surgery, obesity surgery, advanced laparoscopic surgery, and robotic surgery. In addition, he received training in endocrine surgery, oncological surgery, and minimally invasive surgery. He is currently accepting patients from Turkey as well as from countries such as Germany and France at his private clinic located in Istanbul.
