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Hiatal Hernia
When Does It Require Surgery?
What Is a Hiatal Hernia?
A hiatal hernia occurs when part of the stomach moves through the diaphragm and into the chest cavity. The diaphragm normally separates the chest from the abdomen, with a small opening (the hiatus) allowing the oesophagus to pass through.
Hiatal hernias are very common, and many people may have one without experiencing any symptoms. In many cases, the condition is discovered incidentally during investigations for digestive symptoms such as acid reflux or heartburn.
Importantly, the presence of a hiatal hernia does not automatically mean surgery is required.
According to Mr Ash Rohatgi, Consultant Upper GI and Laparoscopic Surgeon in London, gastrointestinal surgery has evolved through three major stages:
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Open surgery
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Laparoscopic (keyhole) surgery
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Robotic-assisted surgery
Each stage has improved surgical precision, reduced trauma to the body and improved patient recovery.
The Link Between Hiatal Hernia and Acid Reflux
Although a hiatal hernia itself may not cause symptoms, it can contribute to gastro-oesophageal reflux disease (GORD).
Reflux occurs when stomach acid flows back into the oesophagus, causing symptoms such as:
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Persistent heartburn
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Regurgitation
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Chest discomfort
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Difficulty swallowing
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Chronic cough or throat irritation
A hiatal hernia can make reflux worse by affecting the normal anatomy of the junction between the stomach and oesophagus.
However, most cases of reflux are initially treated without surgery.
When Is Surgery Needed for a Hiatal Hernia?
Surgery is usually considered only when reflux symptoms cannot be managed effectively with medication and lifestyle changes.
If medical treatment fails to control severe reflux, surgery may be recommended to:
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Repair the hiatal hernia
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Restore the normal anatomy of the stomach and oesophagus
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Reduce or eliminate reflux symptoms
During this procedure, the hiatal hernia is repaired and the anatomy of the upper stomach is reconstructed to create an environment that helps prevent reflux.
Giant Hiatal Hernia (Paraoesophageal Hernia)
Another important condition is known as a giant hiatal hernia, also called a paraoesophageal hernia.
In this situation, more than half of the stomach moves into the chest cavity.
Interestingly, even large hiatal hernias may sometimes be discovered incidentally and may not always require immediate surgery if they are completely asymptomatic.
However, surgery becomes necessary when symptoms develop.
Symptoms That May Require Surgical Treatment
A large or paraoesophageal hiatal hernia may require surgical repair if it causes symptoms such as:
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Difficulty swallowing
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Severe acid reflux
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Shortness of breath
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Reduced ability to walk or exercise due to breathlessness
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Chest discomfort or pressure
These symptoms may indicate that the stomach is significantly affecting the surrounding structures in the chest.
Potential Complications of Giant Hiatal Hernias
Large hiatal hernias also carry a small risk of gastric volvulus, where the stomach twists within the chest.
If this occurs, the stomach may lose its blood supply, which can lead to severe chest pain and a potentially serious emergency.
For this reason, symptomatic giant hiatal hernias are often recommended for surgical repair.
Modern Surgical Treatment for Hiatal Hernia
When surgery is required, it is typically performed using minimally invasive laparoscopic (keyhole) techniques.
This approach allows surgeons to repair the hernia and restore normal anatomy through small incisions, offering several advantages for patients, including:
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Reduced post-operative pain
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Shorter hospital stay
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Faster recovery
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Smaller scars
Minimally invasive surgery has significantly improved outcomes for patients requiring hiatal hernia repair.
Expert Surgical Care
Mr Ash Rohatgi is a Consultant Upper GI and Laparoscopic Surgeon in London with extensive experience in the diagnosis and treatment of hiatal hernias, acid reflux and other upper gastrointestinal conditions.
His practice focuses on providing clear information, careful assessment and modern surgical treatment when required, helping patients make informed decisions about their care.
Patients experiencing symptoms of persistent reflux, difficulty swallowing or unexplained breathlessness may benefit from specialist evaluation to determine whether a hiatal hernia is contributing to their symptoms.
