Surgery has generally been recommended for all hernias to avoid complications such as strangulation, in which a loop of intestine becomes tightly trapped in a hernia, cutting off the blood supply to that part of the intestine. But surgery may not be needed if the hernia is small and you do not have symptoms. Consult with your doctor to decide if you need hernia repair surgery.
If a hernia in an adult can be pushed back (reduced), surgery can be done at the person’s convenience. If it cannot be pushed back, surgery must be done sooner. The use of synthetic patches or mesh for hernia repair is the standard for adult surgery. The mesh or patch is used to strengthen the abdominal wall and prevent hernias from recurring. Previously, these were used mostly for hernias that were large or hard to repair.
During surgery, the hernia sac is removed and occasionally a couple of stitches are used to close the opening of the inguinal canal nearest the abdominal cavity (internal ring). Most hernia repairs are done as outpatient surgery. Anesthesia can be local, spinal, or general. The risk of a hernia coming back after surgery varies depending on a surgeon’s experience, the type of hernia, if mesh is used, and the person’s age and overall health.
The chance of a hernia coming back after surgery ranges from 1 to 10 out of 100 surgeries done. Recurrence rates after hernia repair are lower when experienced surgeons perform the procedure, especially for laparoscopic techniques.
A hiatal hernia occurs when the upper part of the stomach pushes through an opening in the diaphragm, and up into the chest. This opening is called a esophageal hiatus or diaphragmatic hiatus.
Studies have shown that the opening in the diaphragm, where the esophagus connects with the stomach, acts as an additional sphincter around the lower part of the esophagus. Normally, the hiatus and the lower esophageal sphincter (LES) rely on each other to keep stomach contents from backing up into the esophagus. It is believed that a hiatal hernia can weaken the LES, and make it easier for stomach acid to back up into the esophagus.
Types of Hiatal Hernias
There are two categories of hiatal hernias, sliding or para-esophageal.
A sliding hiatal hernia is one in which the gastro-esophageal junction and part of the stomach slides into the chest. This may occur because of weakening of the anchors of the esophagus to the diaphragm, from years of longitudinal esophageal muscle contractions, or from increased pressure in the abdomen. This junction and part of the stomach reside permanently in the chest, or just “slide” into the chest during swallowing. As an individual swallows, the esophagus contracts and shortens, and pulls on the stomach. After the swallow, the junction falls back into the abdomen. Approximately 90% of all hiatal hernias are the sliding type.
A para-esophageal hernia is one in which the gastro-esophageal junction remains where it belongs, but part of the stomach is squeezed up into the chest beside the esophagus. These hernias remain in the chest at all times. With this type of hernia, complications can occur, such as incarceration and strangulation. Incarceration means the hernia is stuck and being squeezed. Strangulation results from the lack of blood supply, leading to death of the tissues involved, when incarceration persists too long. Surgical intervention is required.