Effective Hernia Treatment in Delhi – Find the Best Options Here

Hernia is an Abnormal protrusion of an organ or body part outside its normal cavity. Also known as an Anatomical gap in the structure. Hitas Hernia is a protrusion of an organ i.e., stomach into the chest.

A Hitas Hernia is a hole or gap that is wider than normal in the diaphragm which separates the chest cavity from the abdominal cavity. It is a horizontal sheet and it allows normally, the gullet of the oesophagus to go through the tiny hole, but you have a hiatus hernia, it means that hole has become wider than usual, and that has allowed the stomach to pass across upward through the widened hole, so that the part of the top part of the stomach is now in the chest cavity rather than being entirely in the abdominal cavity and this is known as hiatus hernia

Increased intra-abdominal pressure is the main risk factor:

1. Obesity

2. Pregnancy

3. Chronic coughing

4. Heavy exercises

5. Decreased muscle elasticity (Diaphragm/ sphincters)

6. Trauma (seat belt injury)

7. Previous surgery

8. Congenital (significantly rare)

Most of the patient with hiatus hernia is asymptomatic. Most important cause of Gastrointestinal reflux disease (GERD) are: 

1. Heartburn

2. Regurgitation

3. Acidic taste in the mouth

4. Burping/Belching

5. Nausea/Vomiting

These symptoms are intermittent and worsen after the meal. Other symptoms are: 

• Persistent nocturnal cough or wheeze

• Severe chest pain

• Dyspnea

• Shortness of breath

• Anxiety

• Bowel obstruction (if bowel loop moves into the chest or stomach twist itself forming a gastric volvulus)

Types of Hiatus Hernia

The stomach is snuck up above the diaphragm and there can be a varying degree of this, it can be a little bit like in a sliding hiatal hernia or it can be a large majority of the stomach is up like paraesophageal hernia

1. Type I Sliding Hitas Hernia (95%)

2. Type II Paraesophageal Hernia (5 %)

3. Type III combination of Type I and Type II, in Type III both fundus and gastroesophageal junction herniates through the hiatus

4. Type IV Apart from the stomach herniation through the hiatus other content of the bowel like small bowel, colon, omentum, peritoneum or spleen can herniate and can cause ischemia or obstructions 

Diagnosis:

• Barium swallow can predict the size of hernia and location of hernia along with the motility dysfunction, stenosis, stricture related to GERD

• Endoscopy can evaluate the erosive esophagitis, Barrett’s esophagus, malignancy, swallowing difficulties and analysis of esophageal mucosa

• Manometry to evaluate a luminal pressure and contractility, achalasia, and other motility disorder

• PH monitoring can give the quantitative analysis of reflux episodes

• CT scan can identify the volvulus, obstructions, and perforation

Treatment of Hiatus Hernia:

If patient is asymptomatic no treatment unless high anatomical risk

• Lifestyle Modifications:

First line of treatment is lifestyle measures:

• Weight reduction

• Small meal/avoid before bed

• Stop smoking

• Reduce alcohol intake

• Avoid tight clothing

• Medications: 

Proton pump inhibitors 

Antacids H2 receptors blockers

• Surgery:

In a symptomatic patient, if medication is not relieving the symptoms surgery is the treatment.

Patients with high risk of ulcers or volvulus or obstructions should plan surgery to avoid life threatening complications.

Lifestyle modifications for the treatment of hiatus hernia

1. Avoid prolong fasting and large meal at a time. Develop a habit of taking small and frequent meal

2. Quit smoking as smoking can worsen the symptoms

3. Elevate the head of bed six inches higher to maintain gravity which prevent the movement of the stomach content.

4. If symptoms persist antacids or H2 blockers can help

Indications for surgery:

Hiatus hernia is a mechanical problem where the hole in diaphragm is bigger than normal anatomy, there is no medication to make the hole smaller. It’s a mechanical problem and abnormal anomaly, and therefore it has to be fixed surgically

Patients with complications of severe reflux issues for a long time should go for surgery.

Consequences of avoiding surgery for longer duration:

1. Long term antacids intake can cause nutrition deficiencies as acid production is natural physiological process and body need acid for the absorption of nutrients like iron, vitamins like b12 etc., Disrupting the natural phenomena can cause side effects 

2. Sometimes the hernia contents like stomach or bowel can stuck in the hernia sac and disrupt the blood supply and can cause obstructions.

3. Unhealed ulcers after medical treatment

4. In some cases, stomach get twisted and can cause volvulus, surgery is the indications in these cases.

Goal of Hiatus Hernia Surgery:

The goal of hiatus hernia surgery is to correct gastroesophageal reflux by creating an improved valve mechanism at the bottom of the esophagus. This process involves:

Pulling the stomach down below the diaphragm where it was originally situated and this process improvs the valve at the bottom of the esophagus.

Closing the hole in the diaphragm muscle with sutures following an anti-reflux procedure i.e., fundoplication where the upper part of the stomach known as fundus wrap around the lower portion of the esophagus. This procedure creates a tight sphincter or valve to avoid the flow of the stomach content into the esophagus, which can resolve reflux issues.

The gold standard for the surgery of Hiatus hernia is minimal invasive surgery either laparoscopic or robotic due to following advantages:

• Smaller incisions and no stiches

• Minimal blood loss

• Less risk of infection

• Less pain and scarring due to less mechanical injury to tissue 

• A shorter hospital stay and faster recovery.

Pre-Operative preparation for surgery:

This often involve pre-operative work up in the collaborative approach with gastro intestinal physician 

1. A typical work up is undergoing upper endoscopy where long tube with a camera goes down and examine esophagus

2. Barium swallow study where swallowing a liquid followed by x ray

3. Motility study to study the function of the esophagus and determine which kind of repair can be offered

Each patient is unique, surgeon will discuss the pre operative instructions that are specific to patient and surgery.

1. If the patient is on blood thinners such as Aspirin discontinue the blood thinner 3 days prior to surgery

2. Quit smoking before surgery, this will decrease the risk of complications.

3. Do not eat or drink after midnight

In the pre operative area anesthesiologist will insert a cannula for IV access and medications

Anesthesiologist will begin to administer general anesthesia by giving one injection and after that intubation can be started by anesthetist.

SURGERY STEPS:

1. laparoscope is a narrow tube that contains a light source in a small video camera.

2. Using a laparoscope the surgeon is able to operate by making one or more very small incisions through which the sterile laparoscope and other instruments are inserted into the body.

3. The laparoscopic video camera can enable the surgeon to see the inside view and surgeon can explore and inspect the interior of the abdomen with greater details and more clarity rather than human eye alone as laparoscopic camera will give the magnified view

4. Surgeon will apply the antiseptic solutions around the area where the incisions will be made

5. After allowing few minutes to anesthetic to take effects a small incision is made above the umbilicus then a hollow needle will be inserted through the abdominal wall and abdomen will be inflated with carbon dioxide

6. An umbilical port is created for the laparoscope, four other incisions will be made 

7. Once in place the laparoscope will provide the video image so the surgeon can insert the instruments used to locate and pull back the liver in order to see the stomach

8. First the surgeon pulls the stomach away from the hiatus or opening in the diaphragm, then the surgeons cuts away the tissue that connects the liver and the stomach

9. The surgeon can then dissect part of the diaphragm around the esophagus this gives better access to the diaphragm and the esophagus 

10. Next the surgeon pulls the esophagus upwards and closes the hiatus with the suture

11. The fundus is wrapped around the esophagus and the sphincter is tightened during surgery. 

POST SURGERY

1. After the stabilization of vitals and controlled pain patient can be shifted to ward

2. Patient can ambulate after 4 to 5 hours as per the instructions from the surgeon

3. Patients may experience swelling at the operative site due to surgery, that’s why to enhance the healing process patients should be kept on clear liquid diet for 1 week, followed by semi solid diet for another one week and after 15 days patients can start soft diet, Once patient get the confidence, normal diet can be started. 

4. Patient should avoid lifting heavy objects and vigorous exercise till 6 weeks

5. Adequate hydration status should be monitored

6. Patient can resume their work after 1 week post-surgery

7. Hiatus Hernia surgery is elective surgery but it become emergency when the portion of the stomach entering the esophagus is being squeezed so tightly that the blood supply is being cut off and this is an emergency situation