When do reflux and a hiatal hernia need surgery?

Reflux and a hiatal hernia do not always require surgery. If symptoms are controlled with changes to eating habits and appropriate medication, that treatment is often continued. Surgery is discussed when significant symptoms persist in someone with confirmed reflux, for some large hernias that cause problems, and in other selected circumstances.

Are heartburn and a hernia the same thing?

Reflux is the return of stomach contents into the oesophagus. When this happens frequently and causes discomfort or damage, it is called reflux disease. A burning sensation behind the breastbone, sour fluid coming into the mouth and symptoms worsening when lying down after a meal may suggest this. A cough and voice changes sometimes occur too, but reflux is not diagnosed without investigating other possible causes of these symptoms.

The diaphragm is the muscle that separates the chest from the abdomen. The oesophagus passes through an opening in it to reach the stomach. A hiatal hernia occurs when part of the stomach moves up through this opening into the chest. This change can make reflux more likely. But the link is not inevitable. Not everyone with a hernia has reflux, and reflux can occur without a hernia.

A small sliding hernia may be found by chance during a test performed for another reason. The word hernia on a report is not, on its own, an indication for surgery. Some hernias in which a larger part of the stomach moves into the chest can cause a feeling of pressure after meals, difficulty swallowing and other problems. Assessing these cases differs from treating ordinary heartburn.

What can you expect from medication?

Eating a large evening meal and lying down straight afterwards can worsen symptoms. Leaving time between eating and going to bed, raising the head of the bed for night-time symptoms and losing weight if you are overweight may help. Since not everyone needs the same long list of foods to avoid, noticing which foods cause you discomfort can be more useful than unnecessarily restricting entire food groups.

Medicines called proton pump inhibitors reduce acid production in the stomach, helping the damaged lining of the oesophagus heal and relieving recurrent heartburn. The medicine reduces acidity; it does not move the displaced part of the stomach back into position. Even so, if symptoms are controlled and there are no other problems, treatment without surgery may be enough.

When and how you take the medicine affects the result. If symptoms persist, the way it is taken, the dose and the diagnosis are reviewed first. Sometimes a person takes the medicine only when heartburn starts, even though they have been given a regular dosing schedule. Rather than stopping it or increasing the dose yourself, the treatment plan needs to be clarified with your doctor.

If you need medication long term, its benefits, possible side effects and your preferences are discussed with your doctor rather than automatically moving on to surgery. Surgery has risks of its own, and there is no guarantee that you will never need medication again afterwards.

Which tests guide the decision about surgery?

A poor response to medication is not enough on its own: to assess whether surgery could help your particular symptoms, it is first necessary to show that reflux really is their cause. During endoscopy, a camera passed through the mouth examines the inside of the oesophagus and stomach, providing information about inflammation, narrowing and a hernia.

Acid measurement, or pH monitoring, investigates how much acid returns to the oesophagus and how this relates to symptoms, while another test called manometry measures how the oesophageal muscles work. Before surgery, this information helps identify swallowing problems and plan the procedure. The tests do not replace each other.

In confirmed reflux, persistent regurgitation and heartburn despite appropriate medication, severe damage or difficulties continuing drug treatment may prompt a discussion about surgery. With a large hiatal hernia, obstruction to the passage of food and the risk of the stomach twisting are also considered separately. The decision is made by assessing the hernia's anatomy, symptoms and general health together.

How is Nissen fundoplication performed?

Fundoplication involves wrapping the upper part of the stomach around the lower end of the oesophagus and stitching it in place. In the Nissen technique, this wrap forms a complete circle and strengthens the barrier against reflux. If a hernia is present, the stomach is returned to the abdominal cavity and the enlarged opening in the diaphragm is appropriately narrowed.

The procedure is often performed laparoscopically: a camera and instruments are inserted through small incisions in the abdomen. The operation is carried out under general anaesthesia, with the patient asleep. After oesophageal function, the expected benefit and the possible effect on swallowing have been assessed together, a partial fundoplication rather than a complete wrap may be considered more suitable for some patients.

You can see how a hiatal hernia is treated with this technique in the Nissen fundoplication video. The video contains surgical footage intended for adults and shows the course of one operation. Information about bleeding, infection, injury to neighbouring organs and the possibility of switching to open surgery forms part of the individual surgical discussion.

Swallowing difficulties and bloating during recovery

Swelling around the junction after surgery may temporarily make swallowing difficult. The diet usually progresses gradually from liquids to soft foods; the surgical team provides the exact plan. Small mouthfuls, thorough chewing and eating slowly are helpful. There is no need to rush. Feeling well does not mean you are immediately ready to eat large, dry mouthfuls.

Difficulty burping, abdominal bloating and a feeling of trapped wind may also occur. Fizzy drinks can make these worse. Mild symptoms may ease over time, but an inability to swallow even liquids, repeated vomiting and increasing difficulty swallowing require urgent contact with the surgeon, because further investigation and sometimes another procedure are needed.

Whether they occur before or after surgery, sudden severe chest or abdominal pain, breathlessness, vomiting blood or loss of consciousness requires emergency medical care. Do not assume that chest pain is reflux; heart disease can also begin this way. If heartburn and regurgitation return later, tests are used to assess whether reflux or the hernia has recurred.