Indications for surgical repair of hiatal hernia include failure of strict medical management (intractability); reflux esophagitis with ulcerations, stricture, or bleeding; recurrent aspiration pneumonia; large sliding hernias; and all paraesophageal hernias. The purpose of surgery is twofold: to reposition the stomach below the diaphragm and to reestablish gastroesophageal competence. Three approaches (transabdominal, transthoracic, and laparoscopic) and three primary techniques (Belsey, Hill, and Nissen) are used, depending on the preference of the surgeon. If the procedure is performed well, the magnitude of surgical stress is low. General endotracheal anesthesia is typically used and the operative time is 2 to 3 hours. Intraoperative blood transfusions are rarely required.

Usual postoperative course

Expected postoperative hospital stay

Ranges from 7 to 10 days for open procedures and 2 to 5 days for the minimally invasive approach. Length of stay is also influenced by the age and associated medical condition of the patient.

Operative mortality

Under 1%.

Special monitoring required

Intraoperative assessment of the lower esophageal sphincter zone is performed by pressure manometric studies.

Patient activity and positioning

If a transthoracic approach is used, a chest tube is inserted and removed after 24 hours, after which ambulation is allowed.

Alimentation

A nasogastric tube is usually left in place for the first 24 hours. Patients are then given clear liquids and food intake is advanced to a soft diet, which is maintained until hospital discharge.

Antibiotic coverage

A second generation cephalosporin is given during the 24-hour perioperative period.