Hiatus hernia repair and fundoplication: a patient guide

The gullet passes through a small opening in the diaphragm, the hiatus, to reach the stomach. In a hiatus hernia, part of the stomach moves up through that opening into the chest. The NHS lists a burning feeling in the chest after eating, acid reflux, bad breath, bloating, nausea and swallowing difficulty as typical symptoms. Many hernias cause nothing at all.

The hernia itself is often less of a problem than the reflux that goes with it, because the valve effect at the bottom of the gullet is weakened. That distinction matters, because the operation is mainly aimed at reflux and at large hernias that cause obstruction or pain.

The NHS says first-line care means eating smaller meals, avoiding food within 3 or 4 hours of bed and raising the head end of the bed by 10 to 20cm, with antacids or alginates from a pharmacist and stronger acid-reducing medicines from a GP if needed. A GP will refer you to a specialist if other treatments have not worked and you keep having very bad symptoms.

Operating on someone whose symptoms are controlled does not usually make sense, and a small hernia found by chance rarely needs treatment. Tests before any decision generally include an endoscopy and sometimes a swallow study or pH monitoring, so the surgeon can confirm that reflux is truly the cause of your symptoms.

Pre-assessment covers your health, medicines and fasting rules. Surgeons often ask for weight loss and stopping smoking where relevant, because both can strain the repair. You may be told to stay on a modified diet shortly before the operation, and you should follow whatever your unit writes down.

You will be asleep for the operation. A Hull leaflet says that compression stockings are worn for 5 days afterwards and that most patients stay one night.

Using a camera and fine instruments through about five small cuts, each under 1cm according to the Hull leaflet, the surgeon pulls the stomach back below the diaphragm and stitches the opening snug. Then part of the upper stomach is wrapped around the lower gullet, called a fundoplication, to restore a valve-like barrier against reflux. The leaflet gives 60 to 90 minutes for the keyhole operation.

The degree of wrap can be tailored, a full or a partial wrap, to balance reflux control against swallowing comfort. Large hernias sometimes need mesh to reinforce the repair, which your surgeon will explain if relevant.

The NHS states that there is a chance you may need more surgery. The Hull leaflet lists as uncommon a recurrent hernia or slippage of the wrap, and injury to the lung with air in the chest, and it says conversion to open surgery occurs in fewer than 1 in 100 cases. Delayed stomach emptying and a feeling of food sticking are also mentioned.

Early after surgery most people notice swelling at the wrap that makes swallowing awkward, plus wind and bloating, with difficulty belching. The NHS says bloating, wind and swallowing difficulty can take a few months to improve. Some people vomit less easily afterwards, which is part of how the wrap works.

Diet is staged. The Hull leaflet describes sips first, liquids on day one, small portions eaten slowly and chewed thoroughly, and advises avoiding bread and fizzy drinks for the first 4 to 6 weeks. The NHS says it can be up to 6 weeks before you can eat what you want. Mild pain lasts about a week, and the leaflet gives about 2 weeks before returning to work.

Do not fly for at least 48 hours after keyhole surgery, according to the same leaflet, and do not drive for 48 hours; check your insurance. Call NHS 111 or the ward for fever, repeated vomiting, wound problems or being unable to swallow even liquids. Call 999 for chest pain or breathlessness.

Reflux surgery is performed by upper gastrointestinal surgeons in both settings. The differences lie mainly in waiting time, choice of surgeon and the extent of dietetic follow-up, so ask who sees you if swallowing remains difficult.

• Which tests do I need to confirm that surgery will help?

• Full or partial wrap, and why?

• Will mesh be used?

• What happens if I cannot swallow comfortably after a few weeks?