Welcome to the new Swiss1Chirurgie podcast. In this podcast from the Hernia Centre at Swiss1Chirurgie, we look today at the topic of diaphragmatic hernias and their closure by means of a net insert, hiatoplasty or fondopexy.
The podcast was based on an idea and text by Prof. Dr. Jörg Zehetner. Jörg Zehetner is, among other things, the owner of Swiss1Chirurgie and attending physician at the Hirslanden clinic Beau-Site.
This podcast series is intended as patient information for patients and all those who are interested in the topic of hernias, especially diaphragmatic hernias and their treatment with net insertion, hiatoplasty and fundopexy.
In previous podcasts we have already dealt with inguinal hernias and abdominal wall hernias. If you have already listened to these podcasts, you already know what is meant by a hernia. These are always ruptures in the tissue, which cause internal organs to move completely or partially out of their physiologically correct position. This can be associated with more or less severe pain. Depending on the specific fracture, the blood and oxygen supply to the affected organs may be impaired or completely interrupted, which under unfavourable circumstances can lead to the death of the organ parts in the hernia sac and endanger life. Often hernias are visible on the surface of the body or can be felt quite easily by experienced surgeons and general practitioners.
It is different with a hiatal hernia, which is called a hiatal hernia or paraoesophageal hernia in medical parlance. The diaphragmatic hernia is neither visible nor palpable from the outside.
Simple anatomy of diaphragm and cardia
As with other hernias, the hiatal hernia is caused by a tissue weakness, in this case by a weakness at the junction of the oesophagus between the chest cavity and the abdominal cavity. At this transition, the diaphragm forms the boundary between the thorax and abdomen. The oesophagus runs through an anatomically normal opening in the diaphragm. This opening is called the hiatus and refers to the diaphragmatic cuff or thigh as the anatomical passage of the oesophagus through the diaphragm. The transition from the oesophagus into the stomach is called the cardia; the correct medical term here is cardia ventriculi or pars cardiaca.
The cardia is in the true sense not only the entrance to the stomach but also the muscle that prevents gastric acid from being expelled into the oesophagus or food from flowing back out of the stomach. When stomach acid is regurgitated, we speak of reflux. If the cardia is not sufficiently stable in its function as a valve, repeated episodes of reflux can occur, which can lead to oesophageal cancer due to the constant attack of stomach acid on the inner wall of the oesophagus.
Diagnosis diaphragmatic hernia
A hiatal hernia is a condition where the lower end of the oesophagus, or cardia, slips up through the opening in the diaphragm into the chest cavity. This often pulls the upper part of the stomach into the thorax.
In most cases, there are then between two and five centimetres of the stomach in the chest cavity. Since, in contrast to the abdominal cavity, there is a slight negative pressure in the chest cavity, the diaphragmatic hernia favours increased reflux episodes with the corresponding complaints and possible reflux diseases. This ultimately also leads to a further weakening of the already insufficient sphincter muscle at the lower end of the oesophagus.
A special form of diaphragmatic hernia occurs when the lower part of the oesophagus remains in the abdomen but parts of the upper stomach push into the chest cavity. This form of diaphragmatic hernia is the paraoesophageal hernia. In most cases, however, a mixed form of axial and paraoesophageal hernia is observed.
Patients with chronic reflux symptoms, i.e. constant acid regurgitation, are often diagnosed with a hiatal hernia, which can be identified as the actual cause of the reflux symptoms.
A gastroenterologist can recognise the hiatal hernia as such in the course of a gastroscopy and define approximately how big the hiatal hernia is. In addition, the gastroenterologist can also assess whether the axial diaphragmatic hernia can be repositioned, i.e. whether the oranges pushed by the hernia can be pushed back to their anatomically correct position.
A contrast swallow X-ray can visualise the phenomenon of diaphragmatic hernia even better and is one of the preferred methods in imaging techniques. The patient takes small sips of contrast medium while standing, which makes it possible to understand the movement and function of the oesophagus. It is also possible to visualise where the diaphragmatic arch is in different postures, for example when standing and lying down. With these diagnostic methods, axial gleithernias can also be detected well. In the concrete picture, this can look like this: when standing, the stomach pulls the diaphragmatic hernia downwards, but when lying down, the diaphragmatic hernia becomes visible in a swallowing view.
Often the medical language here is a little confusing. Especially in the definition of diaphragmatic hiatus as the passage of the oesophagus into the abdominal cavity and the actual diaphragmatic hernia, misunderstandings often arise regarding the size of the hernia itself. Other examinations measure the distance between the diaphragmatic passage and the entrance to the stomach to determine the size of the hernia.
Another possible examination is a pressure measurement in the oesophagus, also called manometry or oesophageal manometry. In this procedure, a thin probe with several pressure sensors is pushed through the patient’s nose into the oesophagus and into the stomach. The patient is given water in small sips and the movement of the oesophagus is recorded very precisely by the highly sensitive pressure sensors. If the act of swallowing as such is completely normal and powerful, one speaks of normal oesophageal function. -depending on how many of the swallows administered are completely normal, the functionality of the oesophagus can be normal, weakened and severely weakened. Especially for surgeons, a clear statement about the effectiveness or ineffectiveness of oesophageal function is crucial for choosing the most appropriate surgical methods.
Medical care for diaphragmatic hernias
Most diaphragmatic hernias are not even noticed by the patients themselves. In this case, therapeutic treatment is usually not necessary. A hiatal hernia is often only diagnosed in connection with reflux symptoms, but it does not always have to be treated surgically.
When is surgical treatment of a diaphragmatic hernia necessary?
A diaphragmatic hernia as an incidental finding in patients without reflux symptoms in the size of one to three centimetres does not need to be treated surgically. However, if the patient has reflux symptoms, an existing diaphragmatic hernia is always corrected in the course of reflux surgery. You can find out when reflux surgery is useful and necessary in the Swiss1Chirurgie information material on the website www.swiss1chirurgie.ch. The need for reflux surgery can also be clarified during an appointment at a Swiss1Chirurgie clinic in Bern, Brig or Solothurn.
It should be noted that reflux can also be treated with medication, but only the symptoms are treated and not the causes. If, despite taking reflux medication, infections of the oesophagus are detected or the symptoms of acid regurgitation do not subside, it is advisable to consult a specialist surgeon at Swiss1Chirurgie or the Gastroenterology Group Practice GGP in Bern.
A minimally invasive, so-called laparoscopic operation, as a reflux operation or, if applicable, as a hiatus hernia operation can then be the appropriate therapy.
For diaphragmatic hernias of four to seven centimetres in size, surgical correction of the diaphragmatic passage by means of net insertion will be the most practical and best solution. Depending on the findings, a slow or fast absorbing net can be used. It is also possible to place a permanent net that closes the hiatus correctly. Permanent nets are only justified in hiatus surgery in absolutely exceptional cases, as such nets can lead to tissue adhesions or adhesions that can impair the functionality of the diaphragm or the diaphragmatic passage.
The experts at Swiss1Chirurgie also rely on the Bard nets for the treatment of larger diaphragmatic hernias. As one of only a few clinics in Switzerland, Swiss1Chirurgie can dispose of slowly absorbable nets that reinforce the hiatus for a period of ten to 18 months and thus safely close the diaphragmatic hernia. During this time, the tissue can completely replace itself with a scar plate. A recurrence of the diaphragmatic hernia then occurs only very rarely.
With a hernia size of seven centimetres or more, the probability of a new diaphragmatic hernia, i.e. a recurrent hernia, is relatively high at over ten percent. That is why Swiss1Chirurgie attaches great importance to a well-structured and regular follow-up of patients after surgery for a diaphragmatic hernia. Even in the case of minor recurring hernias, the necessary corrections are then made again to avoid a major hiatus hernia.
If you have already had a hiatal hernia or paraoesophageal hernia corrected surgically and are not satisfied with the result, you are welcome to visit a Swiss1Chirurgie clinic in Bern, Brig or Solothurn. Our experts take your complaints seriously and work with you to make initial assessments for further treatment.
For further questions about diaphragmatic hernias in general and the therapeutic options and surgical methods, please feel free to contact the specialists at Swiss1Chirurgie. In addition, we provide further information material on our website www.swiss1chirurgie.ch. You can also use the contact options at www.swiss1chirurgie.ch or call one of our clinics.
Thank you for your interest and for your attention!
This podcast is part of the Helvetius.Life podcast series.
Helvetius.Life is the in-house newspaper of Helvetius Holding AG.This is where Swiss1Chirurgie, the Centre for Bariatric Surgery ZFBC, the Gastroenterology Group Practice GGP and the Bern Clinic PZBE combine their expertise and services in the interests of our patients’ health.
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