Hiatal hernia (diaphragmatic hernia) – causes, symptoms and treatment in Berlin

At the VenaZiel Hernia Center Berlin (Checkpoint Charlie) we specialize in the diagnosis and treatment of hiatal hernias – using the most modern, minimally invasive surgical methods and many years of experience. This detailed guide explains all forms of hiatal hernia, their causes, symptoms and treatment options, so that you are well informed.

We show when a diaphragmatic hernia operation and what needs to be considered during aftercare. We also provide tips on nutrition and behavior as well as answers to frequently asked questions (FAQ).

What is a hiatal hernia (diaphragmatic hernia)?

A hiatal hernia refers to the passage of abdominal organs (usually parts of the stomach) upwards through the diaphragm into the chest cavity. Normally, the esophagus and gastric junction pass through a narrow opening in the diaphragm, and the diaphragm supports the lower esophageal sphincter in holding the stomach contents down. In the case of a hiatal hernia, this support structure is weakened or stretched.

Consequence: The upper part of the stomach or the stomach entrance (cardia) can slide upwards. As a result, part of the stomach is suddenly in the chest cavity instead of the abdominal cavity. This ” High slides” of the stomach through the diaphragmatic hiatus is the core of the hiatal hernia. A distinction is made between Hiatal hernia types (see below), depending on which part of the stomach has shifted and how large the hernia is. Small hernias often cause no problems, while larger ones can lead to symptoms such as heartburn can lead to heartburn.

Overall, the hiatal hernia is one of the most common hernias in the abdominal area – especially in older people: it is estimated that over 50 % of people over 50 have a small hiatal hernia, often unnoticed.

Anatomical representation: normal condition is shown at the top, a hiatal herniaat the bottom . In the picture below, the entrance to the stomach slides up through the diaphragm into the chest cavity (pink part of the stomach above the brown diaphragm). In this position, the sphincter muscle between the esophagus and stomach can no longer work properly, which often leads to leads to reflux.

Different forms of hiatal hernia

Not every diaphragmatic hernia is the same. Doctors distinguish between Several forms of hiatal hernia depending on the extent and location of the organ displacement. Essentially there are axial (sliding) and paraesophageal (Roll) hernias as well as mixed forms and special cases. The most important types of hernia are

• Axial sliding hernia (type I):

This is the most common form (over 90 % of cases, with glides the transition from the esophagus to the stomach (cardia) upwards through the hiatus. The The entrance to the stomach and part of the stomach move into the chest cavity, while the esophagus slides up with it. This sliding hernia often leads to heartburn as the natural closure mechanism is disturbed. The displaced cardia can be seen in the chest cavity on an X-ray or gastroscopy.

• Paraesophageal hernia (roll hernia, type II):

More rarely, the stomach entrance occurs in its normal position, but part of the stomach (usually the upper gastric fundus) bulges next to of the esophagus upwards through the diaphragm. This is called a “rolling” hernia because the stomach rolls next to the esophagus into the thorax while the cardia remains below. This form often initially causes but can cause mechanical problems – e.g. feelings of pressure or a risk of incarceration. Paraoesophageal hernias are less common, but are considered more dangerous because parts of the stomach can become trapped.

• Mixed hernia (type III):

In this case, elements of both of the above forms are present. Both the entrance to the stomach and a larger part of the stomach move into the chest cavity. There is therefore both a sliding part (axial) and a rolling part. Such mixed forms usually occur with larger hernias and can therefore cause both reflux symptoms and the risk of incarceration.

• Rare type IV (large hernia):

In very pronounced cases, the hiatal opening is dilated to such an extent that other organs slide into the hernia sac. For example, loops of the intestine, the omentum and, more rarely, even the spleen or parts of the liver can move upwards. An extreme case is the “Thoracic stomach”in which almost the entire stomach is located in the chest cavity. Such large hernias (type IV) are rare, but are associated with severe symptoms (shortness of breath, heart problems) and usually require prompt surgical treatment.

Schematic representation of different types of hiatal hernia (side view).

• Anormal anatomy without hernia (esophagus green, stomach pink remains completely under the diaphragm, purple line).
• B: incipient displacement (preliminary stage),
• Caxial sliding hernia (cardia and upper stomach slide upwards),
• Dparaesophageal hernia (part of the stomach rolls next to the esophagus through the diaphragm).

In reality, mixed forms (combination of C and D) also occur.

Good to know

In addition to acquired hiatal hernias (which develop in adulthood), there are very rare cases of congenital diaphragmatic hernias due to developmental disorders. One example is the Cardiofundal malposition – where the stomach entrance is in the wrong place from birth (an anatomical anomaly). However, such cases are exceptional and often manifest themselves in infancy. At the Adult Hernia Center, we mainly deal with acquired hiatal hernias (type I-IV above).

Causes and risk factors

A diaphragmatic hernia is usually caused by a combination of tissue weakness and increased pressure in the abdominal cavity. In the course of life, the connective tissue surrounding the opening in the diaphragm (hiatus) can give way. If there is often high pressure in the abdominal cavity at the same time, the stomach is pushed upwards – a hiatal hernia develops. The most important Causes and risk factors are:

• Age and connective tissue weakness

With increasing age the tissue ligaments loosen on the diaphragm. The tissue becomes weaker and more elastic, so that the hiatus gives way more easily. This is why hiatal hernias often occur in people over 50. A congenital weakness of the connective tissue (e.g. collagenoses) can also increase the risk.

• Overweight (obesity)

Severe obesity leads to chronically increased abdominal pressureas a lot of fatty tissue pushes the organs upwards. Obesity (BMI > 30) is a significant risk factor for hiatal hernias. Rapid weight gain also favors a hiatal hernia.

• Pregnancy

During pregnancy, the growing uterus increases the abdominal volume and pushes the organs upwards. This increases the pressure on the diaphragm enormously. This can contribute to the formation of a hiatal hernia, especially in the last trimester. Multiple pregnancies further increase the risk.

• Chronic pressing or lifting

Activities or conditions that require regular heavy pressing promote a diaphragmatic hernia. These include Chronic constipation (heavy pushing during bowel movements), heavy lifting at work or intensive strength training. Constantly carrying heavy loads also increases abdominal pressure.

• Chronic coughing and sneezing

Persistent cough – such as chronic bronchitis, asthma or smoker’s cough – leads to frequent sudden increases in abdominal pressure. The same applies to allergic sneezing over years. These strains can gradually widen the diaphragmatic opening. Smokers are particularly at risk, as they often combine weak connective tissue and coughing.

• Frequent or severe vomiting

Repeated vomiting (e.g. in the case of eating disorders or stomach diseases) is an extreme strain on the diaphragm and can – like straining – promote a hernia.

In addition to these factors, in rare cases Accidents or previous operations on the diaphragm can lead to hernias (traumatic diaphragmatic hernias). In most cases, however, it is the Long-term effect of pressure and tissue weakness that leads to a diaphragmatic hernia. People with Weak connective tissue (e.g. due to genetic predisposition) should therefore exercise particular caution and reduce risk factors such as obesity as far as possible.

Symptoms: How can you recognize a hiatal hernia?

Small hiatal hernias often go unnoticedas they hardly cause any symptoms. Many sufferers find out about their diaphragmatic hernia by chance – for example during a gastroscopy for another reason. Larger hernias, on the other hand, can cause a range of symptoms, which are mainly caused by Heartburn (acid reflux) are characterized. Typical Hiatal hernia symptoms are:

• Heartburn and acid regurgitation:

This is the most common symptom. Stomach acid rises into the esophagus ( Reflux due to diaphragmatic hernia), which causes a burning sensation behind the breastbone. It often intensifies when lying down or after a hearty meal.

• Pain in the upper abdomen or behind the breastbone:

Many patients complain of a dull feeling of pressure or pain in the upper abdominal area, sometimes radiating to the chest or back. Sometimes this pain is mistaken for heart problems.

• Difficulty swallowing (dysphagia)

Swallowing food can be difficult, especially with larger hernias. Either because the esophagus is kinked due to the displacement or because part of the stomach is stuck next to the esophagus. Those affected have the feeling, Food gets stuck.

• Belching, bloating and flatulence

The altered anatomy leads to more frequent air regurgitation. Many sufferers also report a rapid feeling of fullness after eating or a bloated stomach (bloating).

• Chronic cough or hoarseness:

The constant reflux of acid can irritate the airways. Nightly regurgitation of acid (silent reflux) often leads to Irritable coughthroat clearing or hoarseness in the morning, as the vocal cords are irritated. Even asthma-like symptoms can be triggered by reflux.

• Shortness of breath and heart problems

Very large hernias (e.g. thoracic stomach) can press on the lungs or heart. This manifests itself as Shortness of breathespecially when lying down, or as a heart stumble. Such cases are rare but serious. Those affected often only eat small meals, as larger portions immediately trigger pressure in the chest.

The important thing is: The symptoms differ slightly depending on the type of hernia. In the case of an axial sliding hernia, heartburn and acid regurgitation are often the main symptoms, as the lower oesophageal sphincter no longer functions properly. With a paraesophageal hernia, on the other hand, patients tend to complain of a feeling of pressure, pain after eating or difficulty swallowing, while heartburn may be less pronounced. Often there are no symptoms at all for a long time until symptoms suddenly arise due to a complication. For example, an initially silent hernia may only be noticed when an incarceration occurs.

Note

As the symptoms are varied, a diaphragmatic hernia should be considered when chronic heartburn or unexplained chest/upper abdominal pain – especially if risk factors such as obesity are present. A medical examination (e.g. by endoscopy) will provide certainty.

Possible complications of a diaphragmatic hernia

Untreated or large hiatal hernias can lead to serious complications over time . can lead to a serious illness. It is therefore important to take warning signs seriously. Here are the main complications of a hiatal hernia:

• Chronic reflux and esophagitis

The hiatal hernia often leads to permanent acid reflux. In the long term, this can cause inflammation of the esophageal mucosa (esophagitis). Signs of this are pain when swallowing and possibly difficulty swallowing. If the inflammation persists, ulcers and bleeding can occur in the oesophagus. The body also forms scar tissue, which can lead to a narrowing of the oesophagus(stricture) – you can then feel that food is slipping badly.

• Barrett’s esophagus (precancerous stage)

Long-term, untreated reflux due to a hiatal hernia can cause the mucous membrane of the oesophagus to remodel. Doctors call this a Barrett’s oesophagus – the normal mucous membrane is replaced by intestine-like tissue. Barrett’s itself does not cause any noticeable symptoms, but is considered a precursor to oesophageal cancer, as the altered tissue can degenerate. People with chronic heartburn (over 5-10 years) are therefore advised to have regular gastroscopies to detect Barrett’s changes at an early stage.

• Stomach inflammation and ulcers (gastritis, ulcer)

Parts of the stomach that are trapped in the hernia may be less well supplied with blood and more susceptible to inflammation. Acid can also accumulate in a hernia sac. This favors stomach ulcers or mucosal damage in the area of the hernia (so-called Cameron lesions). Such ulcers can bleed and lead to anemia. Signs would be black stools (tarry stools) or vomiting blood – in such a case, immediate medical attention is required.

• Incarceration (pinching)

One of the most feared complications is acute incarceration of the stomach in the diaphragmatic hiatus. This mainly occurs with paraesophageal hernias or mixed forms. A part of the stomach is trapped in the hiatus so that neither food nor blood can pass through normally. Such a strangulation causes severe pain in the upper abdomen/chest, nausea, vomiting and possibly signs of shock. In the strangulated part of the stomach, the blood supply can be cut off (ischemia), which would lead to tissue death within a short time. An incarceration is an absolute emergency and must be treated surgically immediately. Fortunately, this rarely occurs, but in the case of large hernias there is a certain lifelong risk.

• Gastric torsion (volvulus) and intestinal obstruction

In the case of very large diaphragmatic hernias, the stomach can twist in the hernia sac (gastric volvulus). A twisted stomach is no longer passable, resulting in an ileus (intestinal obstruction) with bloating, vomiting and acute pain. Parts of the intestine can also slip into a large hernia sac and become blocked. Such situations also require immediate surgery.

• Aspiration pneumonia

Night-time reflux can cause tiny amounts of stomach acid to enter the airways (especially in older patients during sleep). This risk of aspiration is increased with severe reflux and can lead to chronic lung irritation or even pneumonia. Caution is required, especially if there is also a swallowing disorder.

As you can see, “simple” heartburn caused by a hiatal hernia can have serious long-term consequences. Early treatment (medical or surgical) therefore aims not only to relieve symptoms but also to prevent complications. Doctors advise proactive treatment, particularly for paraesophageal hernias, as there is a risk of incarceration here – even if there are few symptoms at first.

Diagnosis: How is a hiatal hernia diagnosed?

Several diagnostic procedures are available to clarify a suspected hiatal hernia available. Often the Medical history (patient interview) and description of the symptoms. A physical examination can occasionally suggest a diaphragmatic hernia (e.g. by palpation of hernia sacs in large hernias, rarely palpable). However, imaging and endoscopic examinations provide more certainty. Typical Diagnostic methods are:

• Gastroscopy (gastroscopy)

An Endoscopy of the esophagus and stomach is a key diagnostic tool. A flexible tube with a camera is inserted through the mouth. The doctor can see directly whether the entrance to the stomach is above the diaphragm. A so-called “Hernia orifice” or a displaced Z-line junction (esophagus/stomach junction). In addition Mucosal damage due to reflux (e.g. oesophagitis, Barrett’s). Gastroscopy also allows samples (biopsies) to be taken if Barrett’s or inflammation is suspected.

• X-rays with contrast medium (swallowed porridge)

A X-ray sip is a special X-ray procedure in which the patient drinks a contrast medium (barium slurry). X-ray images are taken while swallowing and afterwards. This makes it possible to see live whether contrast medium has entered a Hernia protrusion flows. A hiatal hernia often manifests itself as Contrast-filled bulge above the diaphragm. Also Movement disorders of the esophagus and possible constrictions can be assessed. This procedure is painless and provides dynamic information on how large the hernia becomes under swallowing stress.

• Esophageal manometry (pressure measurement)

If necessary, a Pressure measurement of the esophagus is carried out. A thin probe measures the pressure from the throat to the stomach. Manometry can indicate whether the lower oesophageal sphincter is weakened and whether Coordination disorders are present. It is less important for the diagnosis of the hernia itself, but it helps to rule out concomitant problems (e.g. achalasia).

• 24-hour pH-metry

This procedure measures the acid reflux into the esophagus over 24 hours . A small probe is inserted through the nose into the esophagus and connected to a portable recorder. The pH measurement shows how often and for how long Reflux episodes occur and whether they correlate with symptoms. If a hiatal hernia with atypical symptoms is suspected, this can serve to objectify reflux. pH-metry is often combined with manometry.

• Computed tomography (CT) or MRI

A CT scan of the chest and upper abdomen can help in unclear cases. It shows in great detail which organ parts are located where. Especially with large hernias or suspected incarceration, a CT scan is performed – e.g. if unclear structures are visible on the X-ray image or if there is an emergency. Complications such as gastric wall ischemia or volvulus formation can be detected by CT. An MRI is used less frequently, but can be used as an alternative in cases of contrast agent allergy or special issues.

• Sonography

An ultrasound examination of the abdomen or heart can provide indirect indications (e.g. high stomach bladder in the thorax). However, ultrasound is limited by bone/air and plays a subordinate diagnostic role in hiatal hernias.

In most cases, a gastroscopy combined with an X-ray of the stomach is sufficient to confirm the diagnosis of hiatal hernia and assess its extent. If necessary, further tests are carried out to reflux strength (pH-metry) and motility (manometry), especially before a planned operation. It is also important to rule out other causes of symptoms – e.g. a heart attack in the case of chest pain or a stomach ulcer as the source of upper abdominal pain. Depending on the symptoms, the doctor will therefore also arrange for appropriate examinations (ECG, blood tests, etc.).

When is surgery necessary? Indications for diaphragmatic hernia surgery

Not every hiatal hernia needs to be operated on immediately. Small, low-symptom hiatal hernias can often be treated conservatively (i.e. without surgery) – e.g. with medication for heartburn and lifestyle changes. However, surgery is recommended or necessary if there are certain indications:

• Pronounced symptoms despite therapy

If an axial sliding hernia causes severe discomfort – especially chronic heartburn that persists despite medication (proton pump inhibitors, etc.) – surgical correction should be considered. Repeated oesophageal burning, pain or swallowing disorders that impair quality of life are also a reason for surgery. Surgery is recommended for refractory reflux, especially in younger patients who do not want to take medication for the rest of their lives.

• Paraesophageal hernia or mixed hernia with symptoms

The following applies to all types of hernia in which parts of the stomach are located next to the oesophagus: surgery should be performed as soon as symptoms occur. In particular, chest and upper abdominal pain after eating, difficulty swallowing or a feeling of fullness indicate that the stomach is partially obstructed. There is a high risk of incarceration here. Experts therefore recommend Symptomatic paraesophageal hernias should always be treated surgically. Also Larger asymptomatic paraesophageal hernias are often operated on preventively, as the probability of later complications is considerable.

• Complications or their precursors

If the hiatal hernia has already caused complications – such as bleeding, ulcers, severe esophagitis or even incarceration – surgery is indicated. For example, in Barrett’s oesophagus (as a result of chronic reflux), surgery is often advised to correct the reflux and stop the progression. Acute incarceration requires emergency surgery anyway. However, even without an acute emergency situation, the following applies: If ulcers or anemia caused by the hernia are detected during diagnostics, surgery should be considered in order to prevent further damage.

• Hernia enlargement

Some initially small hiatal hernias become larger as they progress. If checks show that the hernia increases – for example from a pure sliding hernia to a mixed form – prophylactic surgery may be advisable , before incarceration occurs.

• Desire for a definitive solution

Some patients opt for surgery because they want a permanent solution. Younger, active people in particular often do not want to constantly take medication or accept dietary restrictions. A successful operation can solve the problem for good, which is an important aspect for many people.

Summarized: Large hiatal hernias and those with symptoms usually require surgery, especially if parts of the stomach are located next to the esophagus (type II-IV). Small hiatal hernias (type I) without significant symptoms can be treated conservatively. Here, for example, the focus is on reflux therapy with medication (acid blockers, antacids) combined with measures such as weight loss and adjusting sleeping position.

However, data show that even in the case of asymptomatic paraesophageal hernias, the preventive surgery often makes sense, as the risk of a fatal complication (1-2% per year cumulative) is estimated to be higher than the risk of surgery. The decision should always be made individually with the patient – if in doubt, we at the Hernia Center Berlin will advise you in detail about the benefits and risks of a Diaphragmatic hernia surgery.

Treating a hiatal hernia: Modern therapy methods

The treatment of a hiatal hernia depends on the symptoms and the type of hernia. Basically there are Two therapeutic approaches: conservative (without surgery) and surgical. Mild cases, especially axial hernias, can often be treated conservatively – with medication and lifestyle changes to reduce the risk of hernias. Relieve reflux. However, if the hernia is larger or causes complications, there is usually no way around surgery.

Fortunately , modern, minimally invasive surgical methods are available today . which are very successful and gentle on the patient. In the following we explain the common Treatment options:

• Conservative therapy (medication & lifestyle)

Smaller sliding hernias, which mainly cause reflux symptoms can initially be treated without surgery. The main pillars are Proton pump inhibitors (PPI) such as omeprazole, which reduce stomach acid and thus relieve heartburn. Also H2 blockers or antacids can also be used.

Also important are Lifestyle measuresWeight loss if you are overweight, avoiding large meals late in the day, avoiding alcohol/nicotine (increases reflux), sleeping with your upper body slightly elevated and avoiding heavy pressing or lifting. These measures can significantly improve the symptoms. However fix the hernia itself – the hernia remains. Conservative treatment is therefore particularly suitable if the symptoms can be controlled and there is no high risk of complications.

• Laparoscopic surgery (keyhole surgery)

The standard treatment for surgical hiatal hernia correction today is minimally invasive via laparoscopy. The surgeon inserts a camera and instruments through 4-5 small incisions (0.5-1 cm) in the abdominal wall. The stomach is retracted into the abdominal cavity and the dilated diaphragmatic hiatus is closed with sutures. tightly closed (hiatoplasty).

In addition, a fundoplication The upper part of the stomach (fundus) is loosely wrapped around the esophagus to create a valve against reflux. Laparoscopic procedures have the advantage of small scars, less pain and faster recovery.

We use this technique routinely at our hernia center in Berlin. The procedure usually takes 60-90 minutes and is performed under general anesthesia. The patient can often leave the hospital after 1-3 days, in some cases even on the same day (outpatient hernia surgery).

• Robot-assisted surgery (da Vinci system)

A further development of keyhole surgery is the use of surgical robots such as the da Vinci system. Here, the surgeon sits at a console and uses joysticks to control Robotic instrumentsthat perform minimally invasive surgery in the patient. The robotic arms enable extremely precise movements and a 3D HD view. Complex hiatal hernias in particular can be treated excellently, as fine sutures on the diaphragm can be placed even more precisely.

At VenaZiel Hernia Center Checkpoint Charlie, we use this innovative technique to treat large or recurrent hernias, for example, with the utmost precision. For the patient, the procedure hardly differs from conventional laparoscopy – incisions and recovery time are minimal. Incisions and recovery time remain minimalHowever, the operation is technically supported by the robot. Studies show that the results (reflux control, hernia tightness) with the da Vinci are at least as good, in some cases even better.

• Fundoplication (anti-reflux surgery)

The Fundoplication according to Nissen is a common component of hiatal hernia surgery. In this procedure, the upper stomach (fundus) is placed around the oesophagus – usually laparoscopically – and Cuff fixed. This creates a new Valve mechanismwhich prevents reflux. A 360° cuff (complete wrapping) is called Nissen fundoplication. There are also partial cuffs (270° Toupet or 180° Dor), depending on the patient’s needs. A Nissen or Toupet fundoplication is included in most diaphragmatic hernia operations, as many patients suffer from heartburn. The fundoplication ensures that after the operation No more gastric juice upwards runs – the heartburn disappears completely in ~90 % of cases. Important: The fundoplication is always customized to avoid dysphagia (a cuff that is too tight could initially make swallowing difficult).

• Mesh implantation

In some cases – especially with large hernia gaps or recurring hernias – an additional synthetic mesh is inserted. This special plastic mesh (often made of polypropylene or PTFE) is placed over the closed hiatal hiatus and fixed to the diaphragm. It serves as a Reinforcement of the weakened tissue to prevent it from coming apart again. The use of a mesh for hiatal hernias is somewhat controversial, as the mesh would be close to the esophagus. However, modern meshes and techniques reduce the risks (adhesions, erosions). We use meshes cautiously and only in necessary cases, such as huge hernias (thoracic stomach) or recurrences where the Risk of recurrence is high. The study situation shows mixed results – in some situations, a net can improve the Recurrence of the hernia significantly, in other cases there are hardly any advantages. The surgeon will discuss this with you in detail in advance.

• Open surgery

Traditional open surgery (with an abdominal incision) is rarely necessary today, as minimally invasive methods have been perfected. Nevertheless, there are special cases in which a open procedure is chosen: e.g. for emergencies with complicated incarceration or if adhesions after previous operations make laparoscopy difficult. Also with some High-risk patientswhere every minute counts are opened directly.

Open procedures (e.g. via an incision in the upper abdomen or on the side of the ribcage) have similarly good chances of success, but are associated with a longer healing time. longer healing time and a larger scar. At our hernia center, we always check whether minimally invasive surgery is possible – over 95% of hiatal hernia operations can be performed laparoscopically.

In addition, further measures may be useful in special cases, such as a gastropexy (attaching the stomach to the abdominal wall to prevent it from being pushed up again) or endoscopic therapy. endoscopic therapy (such as endoscopic fundoplication using the EsophyX device). However, these play less of a role in the standard procedure and are decided on an individual basis.

• Prospects of success

Modern surgical methods for hiatal hernia are very successful. After a correctly performed operation, around 90 % of patients are symptom-free and no longer need reflux medication. The operation Corrects both the anatomy and the reflux.

Patient satisfaction is high, especially as the quality of life increases considerably without constant heartburn. Of course, every operation carries risks (bleeding, infection, injury to organs), but serious complications are rare with experienced hernia surgeons.

The mortality risk for elective hiatal hernia surgery is less than 0.5%, for emergency surgery (incarceration) somewhat higher (~1-5%, depending on the study). Overall, the following applies Risks of the operation are significantly lower than the possible complications of a large, untreated hernia.

Course after the operation, aftercare and prognosis

Hiatal hernia surgery is followed by the recovery and aftercare phase on. Thanks to minimally invasive techniques, the course of the operation today is usually Quick and uncomplicated.

What can you expect after the operation?

• Hospitalization

Most patients only stay in hospital for a short time after a planned hiatal hernia operation. briefly in hospital. For laparoscopic procedures, the observation time is often 1-3 daysdepending on the individual’s condition. Some minor operations can even be performed on an outpatient basis or with an overnight stay. For open operations, the stay is longer (approx. 5-7 days).

Immediately after the operation, you will spend a few hours in the recovery room. As soon as you are awake and stable, you may drink light fluids.

• Pain and wound healing

Postoperative pain is usually moderate. Due to the small incisions, many patients only experience a feeling of pressure or muscle ache in the shoulder area (from the gas used for the laparoscopy).

You receive needs-based painkillersParacetamol or ibuprofen are often sufficient. The incisions are closed with self-dissolving stitches or staple plasters. After ~10-14 days, the wound is checked (if necessary, the stitches are removed if they are not self-dissolving).

It is normal if swallowing is a little uncomfortable in the first few days or if you feel a lump – this is due to swelling caused by the fundoplication. These symptoms will subside in 1-2 weeks.

• Nutrition in the early phase

Immediately after the operation, the diet is slowly increased. Usually you start on the 1st day with Water, tea and clear broth. If the patient tolerates this, the following day Pureed food or porridge.

In the following days you increase to soft food (e.g. mashed potatoes, yogurt, soft vegetables). Smaller portions, chewing well and eating slowly are important. Carbonated drinks should be avoided at first, as burping can be difficult (the new cuff makes it harder to burp or vomit at first).

After about 2-3 weeks most patients are allowed to resume normal food to eat. Your doctor will give you precise dietary guidelines. Weight lossMany patients lose a small amount of weight (2-5 kg) as a result of the initial diet, which is entirely desirable and supports the healing process.

• Everyday life and protection

In the first 4-6 weeks after the operation you should avoid heavy physical exertion. Do not lift anything heavier than approx. 5 kg (no heavy lifting/carrying) so as not to strain the fresh suture on the diaphragm. You should also avoid pushing hard (during bowel movements) – make sure your stool is soft (drink enough, possibly take a mild laxative as a preventative measure).

Physical protection However, this does not mean bed rest: light exercise such as walking is expressly encouraged as soon as you feel up to it. We will mobilize you carefully the day after the operation.

Career break: Depending on your profession, you will be unable to work for about 2-4 weeks. Office work can often be resumed after 2 weeks, physical occupations after 4-6 weeks (please discuss this with your doctor).

• Follow-up check

We arrange several follow-up appointments. Shortly after discharge, an initial check-up is carried out (wound healing, symptoms, nutrition). Later – usually after ~6 weeks – a detailed check-up is carried out. We check whether all symptoms are eliminated and how the swallowing works.

If necessary, an endoscopy or X-ray examination is performed to verify the situation. In the long term annual check-ups are advisable, especially if complications such as Barrett’s esophagus have previously occurred. In patients with no symptoms and no special features, the GP can take over further care.

Should symptoms recur recur (e.g. recurring heartburn after years), you should present earlier – it could be a small recurrence. recurrence which can be dealt with more easily in the early stages.

• Forecast

The prospects after hiatal hernia surgery are very good. The vast majority of patients report a significantly improved quality of life, as agonizing heartburn, pain or feelings of pressure have disappeared.

As mentioned, the success rate (permanent absence of reflux) is around 90 %. Some patients may occasionally experience mild heartburn, usually after very substantial meals – this can often be well controlled with on-demand medication. Difficulty swallowing may be present in the first few weeks, but usually disappear completely as soon as the cuff has settled.

In rare cases, a certain sensitivity remains when swallowing large bites (in this case it helps to eat slowly and chew well).

• Recurrence rate

Despite careful surgery, a small number of patients may experience a recurrence of the hernia over the years. recurrence of the hernia occur. Studies show recurrence rates of around 5-15% after 10 years, depending on the size of the hernia and risk factors. A recurrence means that tissue slips through the diaphragm again. However, not every recurrence causes symptoms.

If symptoms do reoccur, a second operation can be performed, provided this is justifiable. renewed operation often minimally invasive. Thanks to improved techniques (e.g. reinforcement with mesh if necessary), second operations are also successful today.

Overall, the prognosis of hiatal hernia is excellent, if it is treated adequately. If left untreated, a large hernia would very likely lead to increasing discomfort and possible emergencies. With modern surgery, on the other hand, patients who have undergone surgery can a normal life without major restrictions lead. It is important to follow the aftercare recommendations and maintain a healthy lifestyle in order not to jeopardize the results of the operation.

Recommendations for diet, behavior and exercise after treatment

After treatment – whether conservative or surgical – patients can contribute a great deal to the success of their treatment through their own behavior. Here are some Practical recommendations for everyday life after hiatal hernia treatment:

• Gradual diet build-up after surgery

As mentioned above, the first phase after an operation is a phase of liquid and soft food. Follow your doctor’s diet plan exactly. In the first few weeks several small meals better than a few large ones. Avoid eating in a hurry – Chew well and swallow slowly so that there is little pressure on the oesophagus. After about a month, you can usually eat everything you can tolerate again.

• Low reflux diet

Irrespective of surgery, it makes sense to follow the principles of a low-reflux diet, especially if heartburn still occurs occasionally. This means Avoid high-fat, very rich mealsas well as strongly seasoned, spicy foods. Citrus fruits, coffee, alcohol and chocolate can promote reflux in sensitive people – test carefully what you can tolerate. In general protein-rich, low-fat foods favorable (lean meat, fish, vegetables, easily digestible food).

• Take evening meals on time

Eat at least 2-3 hours before going to bed Your last meal. Do not go to bed on a full stomach. This will allow digestion to start and less acid will come back. If reflux was an issue at night, sleep with your upper body slightly elevated (e.g. wedge pillow or adjustable slatted frame).

• Keeping an eye on body weight

Reduce Overweightbecause every kilo less relieves the pressure on the abdomen. Many patients already lose weight after surgery – try to maintain this trend. A BMI in the normal range not only reduces reflux, but also the risk of something pushing through again.

• No heavy lifting at the beginning

In the first 6 weeks after surgery you should strictly avoid heavy loads. Do not lift anything over ~5 kg. The following also applies later on: Avoid long-term extreme loads. If your job is physically demanding, discuss with your doctor when you can return to full work. Gradual reintegration may be advisable.

• Encourage moderate exercise

Start early with light exerciseto get your circulation and digestion going. Walks are good from the 2nd day post-op. After 2-3 weeks, you can usually start with moderate exercise: e.g. light cycling (without pushing hard), gymnastics, physiotherapy for core stability. However, avoid exercises that make heavy use of the abdominal press (strength training, heavy trunk flexion) for about 2 months. After about 3 months most patients can resume unrestricted sporting activities – provided they have been cleared by their doctor.

• Listen to your body

Watch out for warning signs. If heartburn recurs regularly despite all measures, do not hesitate to consult a doctor. The same applies to swallowing problems, pain or other unusual symptoms. It is better to check early on whether everything is in order.

• Continue to live smoke-free

If you were a smoker, use the success of your treatment as motivation, smoke-free to stay. Nicotine weakens the esophageal sphincter and promotes acid production – not to mention the general health risks. Patients who give up smoking often report significantly fewer reflux symptoms.

• Keeping aftercare appointments

Follow the recommended check-ups. Especially if you have had Barrett’s esophagus, regular endoscopies are important, even if you are symptom-free. Your doctor will set a suitable schedule with you (often a Barrett’s gastroscopy every 1-3 years for early detection of changes).

These measures will help you to heal and prevent relapses. Many of the points mentioned – such as diet and weight normalization – are also beneficial for general health. Our goal at the Hernia Center Berlin is not only to operate on you successfully, but also to support you in the phase afterwardsso that you benefit from the operation in the long term.

Conclusion

Hiatal hernia (diaphragmatic hernia) is easily treatable. Thanks to modern minimally invasive techniques – including robot-assisted surgery – we are able to VenaZiel Hernia Center Berlin can gently repair almost any hernia. It is important to take the condition seriously: Even if many diaphragmatic hernias appear harmless at first, they can lead to reflux and other problems. Do not hesitate to seek medical advice if you suffer from chronic heartburn or upper abdominal discomfort. With the right treatment – whether conservative or surgical – you will usually get rid of your symptoms completely and be able to get back to normal. Go through life without complaints. If you have any questions, please contact our Special consultation for hiatal hernias at Checkpoint Charlie.

FAQ – Frequently asked questions from patients about hiatal hernia

Does every hiatal hernia require surgery?

No. Small hiatal hernias without or with mild symptoms do not necessarily require surgery. Often a Conservative treatment with medication (for heartburn) and lifestyle adjustments. Surgery is particularly recommended if severe complaints exist or a dangerous form of hernia (e.g. paraesophageal) is present. In particular a paraesophageal hernia should be operated on if you have symptoms, as there is a risk of incarceration. Your doctor will assess with you individually whether surgery is necessary. Note: Not every diaphragmatic hernia needs an operation – but Every large or problematic fracture should be examined by a specialist.

How is a diaphragmatic hernia diagnosed?

The diagnosis is usually made by means of gastroscopy (gastroscopy) and/or an X-ray broad swallow. During the endoscopy, the doctor can see directly whether parts of the stomach have slipped upwards. The X-ray wide swallow shows the Size and shape of the hernia in real time. In addition, a pH-metry (measurement of acid reflux) and manometry (pressure measurement) to assess the influence of the hernia on the reflux. In unclear cases, a CTe.g. in the case of suspected incarceration. In most cases, however, endoscopy + X-ray are sufficient for the diagnosis.

Can a hiatal hernia cause heartburn?

Yes, that is very common the case. The diaphragmatic hernia causes the Closing mechanism at the stomach entrance weakened because the lower esophageal sphincter is displaced upwards into the chest cavity. This allows stomach acid to easily flow back into the oesophagus, resulting in Heartburn (reflux). Especially the Axial sliding hernia often causes severe heartburn. Many patients first notice their diaphragmatic hernia because they Chronic acid regurgitation have. In other forms of hernia (paraesophageal), heartburn may also be absent, in which case the focus is on mechanical symptoms. Overall, the following applies: Reflux and hiatal hernia often occur together – up to 90% of people with chronic reflux have a (usually small) hiatal hernia.

How does the operation for a hiatal hernia work?

In most cases, the operation is minimally invasive (laparoscopic) performed. The patient is given general anesthesia. The surgeon inserts a camera and fine instruments through small incisions. First the the displaced part of the stomach is retracted into the abdominal cavity. Then the Diaphragmatic gap reducedusually through a few sutures in the area of the hiatus (this is called hiatoplasty). If necessary, a small mesh is attached for reinforcement. The surgeon then often forms a Fundoplication – i.e. a gastric sleeve around the esophagusto improve the closing mechanism. Once everything is in place, the instruments are removed and the small incisions are closed. The operation usually takes 1-2 hours. In difficult cases or emergencies Open surgery (longer abdominal incision), but this is rare. After the operation, you wake up from the anesthetic and remain under observation. Overall, the procedures very safely and routinely in specialized centers.

What are the risks of hiatal hernia surgery?

As with any operation, there are certain risks. These include: Injury to neighboring organs (esophagus, stomach, rarely spleen) – but very unlikely with experienced surgeons. Bleeding or secondary bleeding can occur, but can usually be controlled. Infections in the wound area or in the abdominal cavity (peritonitis) are rare, as the procedure is minimally invasive and the gastrointestinal tract is not opened. Specifically, the following can occur after fundoplication Difficulty swallowing can occur if the cuff is too tight – this can be remedied by endoscopic dilation or, in rare cases, re-operation. It is very rare for the cuff to slip down again prematurely or for a Recovering hernia elsewhere. Thromboses or pulmonary embolisms are general surgical risks, and prophylactic injections are given to prevent these. The Mortality rate for a planned hiatal hernia operation is extremely low (<<1 %). Overall, the operation is considered safe. Your surgeon will go through all the risks and complications with you during the consultation.

How long does it take to heal after the operation?

The initial healing of the internal sutures on the diaphragm takes about 6 weeks. During this time you should take it easy (no heavy loads, as described above). Superficially, the small skin incisions heal within ~2 weeks. Many patients already feel quite fit after 1-2 weeksespecially in the case of laparoscopic surgery, and can take up lighter activities. Full weight-bearing capacity (sport, lifting) is usually restored after 8-12 weeks again when the scars are stable. It is important to build up the diet slowly – after approx. 4 weeks you can eat normally again once everything has healed well. A certain Swallowing caution (chew well, small bites) is advisable for about 2-3 months until everything has healed internally soft and scarred. Your doctor will usually recommend a Follow-up appointment ~6 weeks post-op to check on the healing process. Many people report that from then on they almost forget that they have had surgery – except that the heartburn is gone.

Can a hiatal hernia come back?

Yes, in principle there is the possibility of a recurrence (recurrence). Despite careful surgery, a diaphragmatic hernia can recur in around 10% of patients within 5-10 years. Reasons can be Tissue weakness (the original cause persists), persistent high pressure (e.g. heavy pressing, renewed weight gain) or, in a few cases, failure of the failure of the material (suture tears). However, not every small recurrent hernia leads directly to symptoms. Many recurrent hernias are asymptomatic and are only discovered by chance. However, if again Symptoms (recurring heartburn, feeling of pressure), this should be clarified. Minor recurrences can initially be treated conservatively. In the case of larger or symptomatic recurrences, a Revision surgery This is often minimally invasive, sometimes also robot-assisted. The chances of success of a second operation are also good, although somewhat lower than with a primary operation. After the first operation, it is important to Minimize risk factors (no smoking, normal weight, no heavy lifting) in order to prevent a recurrence as far as possible.

What can I do myself to alleviate the symptoms?

A few things! Especially for mild heartburn caused by hiatal hernia Lifestyle changes can achieve a lot. Losing weight is the be-all and end-all if you are overweight – just 5-10 kg less can significantly improve reflux. Eat a reflux-friendly diet: Eat less fat, don’t eat too much at once, eat earlier and lighter in the evening. Avoid triggers such as alcohol, nicotine and coffee in excess. Sleep with your head elevated if you suffer from heartburn at night. Avoid pressing – Treat constipation early (fiber, drink plenty of fluids). Lift heavy things from your knees, not from your back with forced breathing. For acute symptoms, over-the-counter antacids (such as Maaloxan) can provide short-term relief – but if the problem persists, please consult a doctor. Physiotherapy or special breathing exercises can strengthen the diaphragm muscles and thus indirectly support them. Ultimately, by adopting a healthy lifestyle, you can ensure that the Hiatal hernia causes as few symptoms as possible. Although this does not replace any necessary surgery, it can delay the time or make an operation superfluous if the symptoms disappear.