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Hiatal Hernia

The structural membrane in the chest that surrounds the thorax (chest cavity), separating it from the abdomen, is called the diaphragm. The esophagus crosses through this anatomical divider at the location where it meets the stomach. A dome-shaped envelope of muscle and connective tissue important to the motion of breathing, the diaphragm serves as a separator for the esophagus and stomach at this portion of the digestive tract, helping to keep the stomach in place below the esophagus. Sometimes this membrane slides down over the stomach or is weakened, with the result that a portion of the stomach may protrude up and through the diaphragm.

Virtua GI doctors can readily diagnose this common condition and resolve symptoms through noninvasive steps for the large majority of patients. Surgery serves as an import option for other patients.

Such an abnormalities are called a hiatal hernia, meaning an outpouching through this diaphragmatic opening (hiatus). A hiatal hernia usually causes no symptoms, but in some patients-especially those with larger hernias-it becomes a source of concern as it leads to:

  • indigestion;
  • reflux;
  • chest pain;
  • upper GI gas;
  • nausea;
  • difficulty in swallowing;
  • shortness of breath due to stress on the diaphragm;
  • heart palpitations (due to irritation of the vagus nerve);
  • and sometimes squeezing off the hernia.
Measured and then Treated with Drugs in Most Patients

In a hiatal hernia, the juncture of the stomach and esophagus along with the top-most portion of the stomach, are forced up above the diaphragm.

Increasing age, as well as obesity and smoking, are known risk factors. Virtua’s GI team, experienced in care of hiatal hernias, uses medical history and symptoms to begin diagnosis. Barium x-ray and endoscopic examination are the two tests mostly likely to help to confirm the condition and characterize the size and location of the hernia.

Often medications to control the manifestations of hiatal hernia are adequate treatment. These are primarily  drugs aimed at stomach acidity. Change in habits around eating can also help.

Laparoscopic Repair for Most Difficult Cases

In a small portion of patients, conservative care does not resolve severe symptoms. Or, an urgent complication arises, such as strangulation of the hernia or obstruction of the esophagus. In these uncommon cases, the GI team can refer to the Virtua surgical service to fix the hernia through a repair operation. Virtua’s general surgical staff can normally perform this step with minimally invasive laparoscopy. Only occasionally is open surgery necessary. Such procedures serve to reposition the bulging portion of the stomach and reinforce the structure needed to keep it below the diaphragm.

This surgical hiatal hernia repair is the same procedure used in treatment of  gastroesophageal reflux disease. The surgeon inserts a laparoscope through one small incision and surgical instruments through another. After locating the defect, the surgeon will pull the stomach through the diaphragm, out of the chest and back into the abdomen, if it is out of position. The surgeon then tightens the opening of the diaphragm with stitches or a mesh graft to help keep the stomach from slipping through again. Finally, the surgeon pulls a portion of the top of the stomach around the bottom of esophagus and stitches it in this position, in a step called fundoplication, to help tighten this juncture and restrict stomach acid from flowing back up.

Virtua specialists always seek the least invasive route for treatment  or for surgical repairs, to minimize recovery time. Treatment for hiatal hernia is usually successful, and patients often appreciate a dramatic reversal of longstanding gastrointestinal symptoms as a result.

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