Written by Konstantinos M. Konstantinidis, MD, PhD, FACS, Adjunct Professor of Surgery, Ohio State University, USA, President, Greek Chapter of American College of Surgeons, Scientific Director, Director of General, Bariatric, Laparoscopic and Robotic Surgery Department, Athens Medical Center, Athens Medical Group
What is a Diaphragmatic Hernia?
Diaphragmatic hernia is one of the causes of Gastroesophageal Reflux Disease or GERD.
At the lower part of the esophagus there is a circular muscular layer, called Lower Esophageal Sphincter (LES). In normal individuals, the diaphragm helps the Lower Esophageal Sphincter to remain constantly in contraction, preventing gastroesophageal reflux of the stomach’s liquids into the esophagus, and it only relaxes during swallowing. Indiaphragmatic hernia, the diaphragm’s esophageal chiasm is larger than normal, and it allows the displacement of the esophagus towards the chest, thus cancelling its sphincter mechanism and allowing gastroesophageal reflux of stomach fluids (GERD).
Gastroesophageal reflux disease (GERD) is the flow of stomach contents into the esophagus or pharynx. GER Disease is characterised by recurrent episodes of gastroesophageal reflux and it is a chronic disease. When it starts, it usually lasts forever. Therefore, treatment of Gastroesophageal reflux should be taken for long periods or continuously, according to some specialists.
People with more than 2-3 gastroesophageal reflux episodes per week are considered to suffer from Gastroesophageal Reflux Disease (GERD). Heartburn is the most common symptom of gastroesophageal reflux, characterised by burning or pressure sensation in the middle of the chest, often reflecting towards the pharynx. Other symptoms include:
- Acidic taste sensation in the pharynx
- Dysphagia (difficulty in swallowing)
- Persistent laryngitis and hoarseness
- Persistent sore throat
- Chronic cough, especially at night
- Asthma
- Recurrent respiratory infections
- Worsening of teeth conditions
What are the complications of Gastroesophageal Reflux?
Chronic gastroesophageal reflux of stomach acid towards lower esophagus may cause:
- Esophagitis
- Ulcers in the lower esophagus
- Narrowing of the esophagus
- Chronic bleeding
- Laryngitis - Aspiration pneumonia
- Metaplasia of the esophageal epithelium (Barrett's esophagus)
- Carcinogenesis
Risk Factors for Gastroesophageal Reflux
- Foods such as fried and fatty foods, spices, chocolate, soft drinks, coffee, alcohol, acidic juices
- Smoking
- Obesity
- Chronic increased intra-abdominal pressure (chronic cough, constipation)
- Stress, because it enhances gastric secretions’ acidity
- Pregnancy
How is Gastroesophageal Reflux Disease treated?
Treatment of GERD includes three treatment phases:
- Conservative treatment of GERD
A combination of changes in dietary habits, including the following:
Weight loss is recommended to ALL patients.
- Avoid foods that aggravate gastroesophageal reflux.
- Do not lie down immediately after taking the meal.
- Raise the head during sleep.
- Take small meals in the evening.
- Avoid smoking and stress
- Oral medication
If gastroesophageal reflux symptoms persist, despite changes in lifestyle, medication is required to neutralise stomach acid and reduce the amount of acid produced in the stomach. A series of formulations are effective in the treatment of gastric secretions’ acidity. Simple antacids, histamine receptor blockers (H2Blockers), and Proton Pump Inhibitors (PPIs) are the most popular medications.
- Surgical operation (enhancement of the sphincter mechanism of the esophagus)
Surgical correction of diaphragmatic hernia is very effective in treating the symptoms of Gastroesophageal Reflux. Furthermore, it protects from GERD complications, and it is the only way of preventing cancer in the esophagus (adenocarcinoma).
The following are included among the advantages of surgical operation:
- Eliminates the use of medications.
- Stops gastroesophageal reflux and heartburn.
- Stops chronic cough and chronic laryngitis.
- Allows normal sleep.
- Allows the consumption of “forbidden” foods and alcohol.
- Allows physical exercise.
Which methods are used for diaphragmatic hernia repair?
- Open Surgery
The open surgery for hernia repair is a very traumatic surgery, because the surgeon is forced to make a large cross section in the upper part abdomen in order to reach the diaphragm. Postoperative pain is managed with strong painkillers, which often keep the patient sedated. Therefore, the patient cannot be mobilised quickly and extension of the hospitalisation is required.
- Laparoscopic Nissen fundoplication
Since 1991, our team in Athens Medical Centre performs the laparoscopic technique for diaphragmatic hernia repair, with better results and fewer complications. For the laparoscopic procedure 4-5 small incisions (5 mm) to the skin are required, with no muscle cross section. The advantages of laparoscopy are:
- Less blood loss
- Less postoperative pain
- Faster return to solid diet
- Shorter hospitalisation
- Faster recovery
- Minimisation of postoperative complications associated with trauma (suppuration, cleavage, hernia, chronic pain)
- Elimination of postoperative adhesions
- Optimal cosmetic outcome Studies, as well as our extensive experience with hundreds of patients, have shown that patients with gastroesophageal reflux are completely free, or show marked improvement, of gastroesophageal reflux symptoms, immediately after surgery.
- Robotic Nissen Fundoplication
Robotic fundoplication is the most modern evolution of laparoscopy, and in Greece it is performed since 2006 by our team in cases of gastroesophageal reflux. With the robotic method, micro-incisions of 5-8 mm are again performed, but the surgical field is now stable and the surgeon has great freedom. The risk of converting a surger to an open surgery is less than 1%, while the procedure is performed with ease even in overweight patients and those with sizeable diaphragmatic hernias. Nissen Robotic retains all the advantages of laparoscopic and additionally offers:
- Three-dimensional colour and stable optical high-resolution image (HD 1080p), which gives a feeling as if the surgeon’s eyes and hands are within the patient's body.
- Absolute instruments’ flexibility and precision of movements to the millimeter, and elimination of natural hand tremor through an electronic filter.
- Minimisation of the surgeon’s physical fatigue (who performs the surgery sitting at the console) especially in long surgeries.
- Conversion to open surgery is less likely.
- Excellent recognition and conservation of very important vagal nerve (nerves paring technique) as well as their branches, the injury of which may cause normal food digestion disturbances.
- Accurate identification and preparation of vessels towards the stomach, the liver or the spleen, which are at short distance from the surgical operation field.
- Ability to easily operate even extremely obese persons (Body Mass Index > 60) due to robotic instruments’ stability against increased intra-abdominal and wall pressures.
- Possibility of extensive lysis of adhesions. The accuracy of the surgeon’s movements with the aid of robotic instruments protects the integrity of the esophagus, which usually adheres to the liver and stomach.
- Possibility to perform intra-abdominal suturing with great ergonomics.
- Creation of a “loose” fundoplication. Excessive tension on the suture of the fundoplication of the stomach may cause postoperative complications such as vomiting and dysphagia.
- Through the use of the sophisticated pneumoperitoneum system “Air-Seal” available from our team, the operation is performed at much lower intra-abdominal pressures (8-10 mmHg). This detail is substantial, because lower pressures minimise cardiopulmonary system distress, making surgery safer for patients with increased body weight, as well as those with cardiovascular diseases. Moreover, the lower the pressure within the abdomen during surgery, the lower the postoperative pain for the patient.
- Specialised robotic instruments, such as “VesselSealer”, allow safe ligation of vessels, such as the short gastric arteries towards the spleen. Vesselsealer is an articulated robotic disposable instrument able to ligate and separate tissues and vessels with absolute precision, even in hard to reach spots.
How will I be after surgery?
Most patients feel well and they move out of bed within a few hours. Mobilisation reduces the risk of deep venous thrombosis, and it is thus pursued as soon as the patient feels that he can stand on his feet. Some common symptoms after surgery include dizziness, weakness, abdominal pain and neck discomfort, most of which recede within the first 12 hours. Hospitalisation with the robotic method is reduced to 24 hours. On leaving, the patient already feels comfortable, moves and eats safely. At the same time a prescription is also given, especially for a painkiller and dietary guidelines. No medications for gastroesophageal reflux are required, such antacids and PPIs. Return to daily activities, provided that weight lifting is avoided, is achieved in just a few days.
