A diaphragmatic hernia is the movement of part of the abdominal contents into the chest through an opening or weak point in the diaphragm, the muscle that separates chest from abdomen. The commonest form in adults is a hernia at the oesophageal opening of the diaphragm, where the upper stomach rises into the chest and weakens the natural barrier that prevents acid reflux. There is also a congenital form that presents in newborns and is managed as an emergency by paediatric surgery, and a form that follows severe chest or abdominal trauma. Usual symptoms in adults are heartburn and acid reflux, food or sour fluid rising into the throat, pressure or pain in the upper abdomen or behind the breastbone, early fullness, frequent belching, and sometimes night-time cough, hoarseness or pain on swallowing. A small hernia may cause no symptoms and be found incidentally at endoscopy or on imaging. A large hernia can cause difficulty swallowing, anaemia from repeated minor bleeding, or breathlessness after meals. Diagnosis relies on upper endoscopy, contrast imaging of the upper gastrointestinal tract, and sometimes oesophageal motility and acid studies before surgery. Treatment decisions are based on clinical assessment together with these results, not on symptoms alone and certainly not on reading about the condition. Treatment starts non-surgically in most cases: smaller meals, avoiding lying down after eating, weight reduction, raising the head of the bed, stopping smoking, and acid-reducing medication prescribed and monitored by a doctor. Surgery is considered when this fails or requires permanent escalating treatment, when the hernia is large or sliding with pressure symptoms, anaemia or a risk of becoming trapped, or when complications develop in the oesophagus. Surgery is usually laparoscopic: the stomach is returned to the abdomen, the hernial sac is excised, the diaphragmatic opening is narrowed with sutures and reinforced if required, and a valve is fashioned from the top of the stomach and wrapped around the lower oesophagus to prevent reflux. The aim is to restore the mechanical barrier without narrowing swallowing. Limits of the procedure: surgery corrects a mechanical defect. It does not cure oesophageal hypersensitivity, irritable bowel syndrome or chest pain of cardiac origin, which is why cardiac causes must be excluded before chest pain is attributed to the hernia. It is not a weight-loss operation and does not reduce stomach size for that purpose. Recurrence of the hernia or of symptoms is possible, particularly with weight gain, chronic cough or heavy lifting. Afterwards you may have temporary difficulty swallowing, bloating and an inability to belch or vomit; some patients need months to settle their eating, and a proportion continue on acid-reducing medication.
Procedure steps
- 1
Diagnosis and defining the hernia type
The symptom history and its relationship to food and sleep are reviewed, and upper endoscopy plus contrast imaging define the type and size of the hernia and the condition of the oesophagus. Cardiac causes of any chest pain are excluded before it is attributed to the hernia.
- 2
Non-surgical treatment first
Mechanical factors are addressed first: smaller meals, not lying down after eating, raising the head of the bed, weight reduction and stopping smoking, together with acid-reducing medication prescribed and monitored by the doctor. The response is assessed before surgery is considered.
- 3
Pre-operative work-up
Once surgery is decided, functional oesophageal studies are requested when needed to choose the appropriate type of wrap, your medicines and chronic conditions and cardiac and respiratory fitness are reviewed, and what to expect afterwards is explained in detail.
- 4
Laparoscopic repair and fundoplication
Under general anaesthesia the camera and instruments are inserted through small ports, the stomach is returned to the abdomen, the sac is excised, the diaphragmatic opening is sutured to an appropriate calibre, and part of the upper stomach is wrapped around the lower oesophagus and fixed as an anti-reflux valve.
- 5
Recovery and staged diet
You begin with fluids, then pureed then soft food before returning to a normal diet over several weeks, following written instructions. Temporary difficulty swallowing and bloating are common and ease gradually. Follow-up visits are scheduled to review symptoms and adjust diet or medication.
Before the procedure
Tell your doctor the details of your symptoms: when they began, how they relate to meals and sleep, and whether you have difficulty swallowing, weight loss, vomiting blood or black stools, since these change the assessment plan. Give a full list of your medicines and how long you have used acid-reducing drugs and at what prescribed doses, and stop nothing on your own. Report heart or lung disease and any previous chest pain, earlier abdominal operations and drug allergies. Before elective surgery: stop smoking as far as possible, ask about a weight-reduction plan if your weight is high since this lowers the risk of recurrence, and treat chronic cough and constipation. Follow the fasting instructions given by your team, and a pre-operative fluid regimen may be requested. Bring your endoscopy and imaging reports and insurance card, and arrange someone to take you home.
After the procedure
Follow the staged diet exactly as written: fluids, then pureed, then soft, then normal food over several weeks; chew well, eat slowly in small portions, drink between rather than with meals, and do not lie down after eating. Expect temporary difficulty swallowing, a bloated feeling and inability to belch during the first weeks, and avoid fizzy drinks, straws and chewing gum, which increase gas. Walk from the first day, and avoid heavy lifting and straining for roughly four to six weeks or as your surgeon specifies, since early strain threatens the repair. Keep the small wounds clean and dry and take pain relief as prescribed. Discuss with your doctor any acid-reducing medication you still need afterwards, and neither stop nor continue it on your own. **Seek care immediately if you develop: inability to swallow or keep fluids down; repeated vomiting; severe worsening chest or abdominal pain; shortness of breath or a racing pulse; high fever or shivering; vomiting blood or black stools; severe abdominal distension with no passage of gas; redness, pus or leakage from a port site.**
Expected duration
Laparoscopic repair with fundoplication usually takes 90 to 180 minutes, longer for large hernias; hospital stay is typically one to three nights.
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