The oesophagus passes from the chest into the abdomen through an opening in the diaphragm called the hiatus. A hiatal hernia is when that opening widens and part of the stomach moves up through it. In the common sliding type, the junction of the oesophagus and stomach slides upward, which tends to cause reflux. In a paraoesophageal hernia, part of the stomach rolls up alongside the oesophagus — a less common but more consequential pattern.
Small sliding hernias are very common and often need nothing more than reflux treatment. Large paraoesophageal hernias behave differently: they can cause pressure symptoms, interfere with eating, and, rarely, allow the stomach to twist — which is the reason they are usually repaired.
Signs and symptoms
- Heartburn and acid reflux, particularly lying down or after meals — the hallmark of a sliding hernia.
- Regurgitation, a sour taste, or a chronic cough and disturbed sleep from night-time reflux.
- With a large paraoesophageal hernia: chest or upper abdominal discomfort, fullness or breathlessness after eating, and difficulty swallowing.
- Anaemia, in some long-standing large hernias, from slow bleeding at the diaphragm.
When to seek care urgently. Sudden severe chest or upper abdominal pain with retching but inability to vomit, in someone with a known large hernia, can mean the stomach has twisted. This is an emergency — seek care immediately.
When surgery is the right call
A small sliding hiatal hernia with manageable reflux is treated medically — acid-suppressing medication and simple measures usually suffice. Surgery is considered when reflux is severe, fails to settle on medication, or has caused complications, and when a patient would rather not take lifelong medication. A large or paraoesophageal hernia is more often repaired, because of its symptoms and the small but real risk of the stomach obstructing or twisting. The decision rests on careful assessment, usually including endoscopy.
The repair
Repair is almost always laparoscopic — keyhole surgery through small incisions, and increasingly performed with a robotic platform, whose fine control helps with closing the diaphragm and constructing the anti-reflux wrap.
- The stomach is gently returned to the abdomen and the hernia sac dealt with.
- The widened hiatus in the diaphragm is closed back to the right size, sometimes reinforced.
- An anti-reflux wrap (fundoplication) is usually added — the upper stomach is wrapped around the lower oesophagus to recreate a valve and control reflux.
For large paraoesophageal hernias the same operation is more involved, because the whole sac and the surrounding attachments must be carefully freed before the repair.
Recovery
Most people stay one to two nights. There is a deliberate adjustment period: a soft or sloppy diet for a few weeks while any tightness from the wrap settles, building back to a normal diet. Most return to light activity within a couple of weeks and to full activity within a month or so, avoiding heavy lifting early on. Clear, specific dietary guidance is given for your repair.
Risks, honestly
Laparoscopic hiatal repair is well established and generally safe. Early on, some people notice difficulty swallowing or bloating after a fundoplication, which usually settles. Reflux can return over the years in a proportion of patients, and large paraoesophageal hernias have a higher chance of recurring than small ones — a trade-off discussed honestly before any decision.
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