Hiatal hernia surgery and fundoplication for reflux

The food pipe passes into the abdomen through an opening in the diaphragm called the hiatus. When that opening widens, part of the stomach moves up into the chest: a hiatal hernia. You can have one without knowing, because many cause no symptoms (NHS).

When symptoms appear they are mostly those of acid reflux: heartburn, acid coming up into the throat, bad breath, bloating, feeling sick, and difficulty or pain when swallowing (NHS). In a less common type, a larger part of the stomach rolls up beside the food pipe, and this type is assessed more carefully.

For most people, treatment starts without surgery. The NHS recommends smaller, more frequent meals, raising the head of the bed by 10 to 20 cm, not eating within 3 to 4 hours of bedtime, losing weight if needed, avoiding trigger foods and tight waistbands, and not smoking (NHS).

Antacids and alginates ease symptoms in the short term, and a doctor can prescribe stronger medicines when they do not help (NHS). Proton pump inhibitors (PPIs) lower stomach acid, work better than H2 blockers and can heal the lining of the food pipe in most people with reflux disease (NIDDK). If these measures control your symptoms, surgery is usually not needed.

Referral for surgery usually happens only if other treatments have failed and very bad symptoms continue (NHS). Surgery may also be considered for people who want to stop long-term reflux medicines, but complications are more likely from surgery than from medicines (NIDDK).

The SAGES guideline panel suggests that selected patients without symptoms may be offered repair, using defined criteria, while most such hernias are simply watched (SAGES). Surgery is less suitable when tests show the symptoms are not caused by reflux, or when heart, lung or other conditions make a general anaesthetic risky, so other causes are ruled out first (Guy's and St Thomas').

Before any operation the diagnosis needs confirming. An upper endoscopy passes a thin camera through the mouth to look at the food pipe and stomach and take samples, and oesophageal pH monitoring, the most accurate way to detect acid in the food pipe, confirms reflux (NIDDK). A barium swallow or a pressure test of the food pipe (manometry) may be added to plan the wrap.

At a pre-assessment visit your history, medicines and blood tests are reviewed, and you are told when to stop eating and drinking and which medicines to pause (Guy's and St Thomas'). Losing excess weight and stopping smoking beforehand also ease reflux (NHS).

Under general anaesthetic the surgeon makes 4 or 5 small cuts in the tummy and inflates it with carbon dioxide; the procedure normally takes about 1 hour to 1 hour 30 minutes (Guy's and St Thomas'). The steps are:

1. The stomach is brought back down into the abdomen and the widened hiatus is narrowed with stitches.
2. The top of the stomach is wrapped around the lower food pipe to create a one-way valve (Guy's and St Thomas').
3. The gas is released and the cuts are closed.

The wrap can go fully around (Nissen, 360 degrees) or partly (Toupet, 270 degrees; Dor or Watson, 180 degrees) (Guy's and St Thomas'). SAGES suggests routinely adding a fundoplication when a hiatal hernia is repaired, while evidence on mesh is mixed (SAGES). If needed, the surgeon converts to an open cut of about 15 to 30 cm (Guy's and St Thomas').

You usually go home 1 to 3 days after the operation. On the first day you drink only water, avoiding fizzy drinks; a liquid diet starts the next day, and then all food is cut up or blended to a smooth paste for up to 4 to 6 weeks, eaten as small, soft, frequent meals and chewed well (Guy's and St Thomas').

Light activity is fine within a couple of days, but avoid heavy activity for 6 weeks. Expect 2 to 3 weeks or more off work depending on your job, drive only when you can make an emergency stop confidently, and attend the check-up usually booked 6 to 8 weeks after surgery (Guy's and St Thomas'). It can take up to 6 weeks before you eat normally (NHS).

Difficulty swallowing is the most common side effect. It is worst just after surgery because of swelling and gradually improves; bloating and wind are also common and usually settle with time (Guy's and St Thomas'). Recovery from bloating, flatulence and swallowing problems can take a few months, and some people need further surgery (NHS).

Neck and shoulder pain from the gas can last up to a week (Guy's and St Thomas'). As with any keyhole operation, rare complications include injury to an organ or blood vessel, blood clots and conversion to open surgery (NHS). The wrap can also loosen or slip over time, especially after repeated vomiting, which is one reason for follow-up.

Contact the surgical team or your doctor if you develop a high temperature, pain much worse than expected, or nausea and vomiting that stop you eating properly (Guy's and St Thomas').

Go to the nearest emergency department straight away if you have (Guy's and St Thomas'):

• severe chest or tummy pain
• vomiting that stops you keeping fluids down
• vomiting blood
• food getting stuck so that you cannot swallow

Fundoplication is the most common operation for reflux disease and, in most cases, leads to long-term improvement of symptoms (NIDDK). Many people stop or reduce their reflux medicines afterwards, though that is not certain for everyone.

The trade-off is the early soft-food period and swallowing tightness, which improve over weeks to months (NHS). Some patients need a second operation later if the wrap loosens or the hernia returns, so it helps to keep up the follow-up visits.

The table shows how the options fit together, from first steps to surgery.

The cost in Cairo depends on the tests before surgery (endoscopy, pH monitoring, imaging), the size of the hernia and whether mesh is used, the hospital and room class, the anaesthetic, and the number of nights you stay. A large or repeat hernia takes longer and costs more.

Ask for a written quote covering the surgeon, anaesthesia, hospital stay and follow-up visits. Dr. Yasser, FRCS (Edinburgh, 1996), trained in advanced laparoscopy at the Aramco Dhahran Health Centre and also performs laparoscopic hernia repair and gallbladder removal. You can book a consultation with Dr. Yasser to review your endoscopy and discuss whether surgery makes sense.