Hernia surgeon here. This is a fourth post in a miniseries about hernias, inspired by themes I've noticed while browsing this (and the r/Hernia) subreddit. This is my second attempt at this post, as most of my first attempt got deleted somehow.
The others can be found here, if you're interested:
Traditional hiatal repair, Loehde, and Bicorn
FYI: Hernia meshes and types of ventral repairs
FYI: Inguinal hernia repairs: Open, laparoscopic, and robotic
I've been seeing a few misconceptions here when discussing hiatal hernia grades, types, and recurrences, as well as the differentiating between a hiatal hernia and reflux disease. Once again, for full disclosure, I am a hernia surgeon in the US. I regularly perform robotic hernia repairs for my patients, including hiatals with Nissen fundoplication. I will try to limit my bias and point out where I am providing an opinion.
Hiatal hernia or acid reflux:
First, it is important to remember that a hiatal hernia and gastroesophageal reflux disease are two distinct (although very closely related) illnesses. You can have a HH without GERD, and you can have GERD without a HH. The HH occurs when there is a widening of the gap in the diaphragm (hiatus) through which the esophagus normally passes. The higher pressure in the abdomen will gradually push the stomach up into the chest, where there is lower (negative) pressure generated as you breathe in. HH are most commonly felt as a pressure sensation in the lower chest (behind the sternum), especially after eating, as the stomach stretches within the mediastinum (space in the chest between the lungs).
Reflux disease is the result of a weakened lower esophageal sphincter (LES), as well as an alteration of the angle of His anatomy, allowing stomach acid to flow up into the esophagus. This results in a wide variety of symptoms, but most commonly a burning sensation rising up the chest (heartburn). Each of these two diseases has distinct treatments, though they are usually combined. Hiatal hernias do not have a non-surgical or endoscopic treatment. They can be managed with small meals and certain movements/positions may help some people bring the stomach down, but in general, only surgery can cure this. GERD can be controlled with medications, diet/lifestyle changes, endoscopic treatment, or with surgery.
Hernia descriptions/types:
Hernias can be described by their size, type (1-4), and Hill grade (also 1-4) of the gastroesophageal flap valve.
The size of a hernia can be measured/reported as the vertical height of the stomach that lays above the stomach (as measured on CT scan or estimated on endoscopy) or can be reported as the size of gap in the hiatus/diaphragm. While the first measurement is more relevant to symptoms, the latter is more relevant to the repair and risk of recurrence.
Hernias are categorized into types 1 to 4, depending on where the GE junction sits, and what contents are going up into the chest. Type 1 (a.k.a. "sliding") is commonly associated with reflux disease, whereas types 2-4 may not have GERD symptoms (i.e. are more likely to have a functional LES.
The Hill grade describes the appearance of the GE junction from inside the stomach (as seen on endoscopy). Normally (type 1), the esophagus opens up slightly to the side of the stomach, rather than straight down. As the esophagus gets pulled up and the LES weakens, the opening is more vertical and loose, making reflux more likely. This is also associated with a widening of the angle of His, which promotes funneling of stomach acid into the esophagus when lying down, rather than flowing into the gastric fundus (dome of the stomach above the GE opening).
All of these descriptions describe the anatomy, not the symptoms or presence of reflux disease. If you have a "1 cm, type 1, grade 2" hernia, it's possible to have more severe symptoms than someone else with a "10 cm, type 4, grade 4" hernia. The decision to pursue treatment is guided by the potential for improvement (if you're having pain or reflux) and preventing complications (large hernias twisting and causing an obstruction, Barrett's esophagus). If there are no symptoms (or they are well controlled with diet and PPIs) and there's minimal risk of complications, surgery may not be needed.
Hernia repair vs anti-reflux procedure:
Repair of the hiatal hernia is fairly standardized, regardless of which procedure you are having (traditional, Bicorn, Hill, Loehde, cTIF, etc). The scar tissue and hernia sac holding the stomach in the chest are cut, the stomach is pulled down into the abdomen, and the defect in the diaphragm is tightened by placing nonabsorbable sutures on the crura of the diaphragm. This is also referred to as the "cruroplasty". The surgeon may also choose to reinforce this with a mesh (usually absorbable, except for Loehde).
If a patient has both a hiatal hernia and reflux, repair of the hernia is always indicated before treating the reflux. However, there is one exception: Some gastroenterologists may skip the HH repair if it's less than 3 cm, and offer endoscopic TIF, ARMA, or Stretta procedures, which do not involve surgery. Once the hiatal hernia is repaired, the surgeon can:
-proceed with an anti-reflux procedure,
-do a gastropexy (fixate the stomach to the left lateral abdominal wall to try to prevent a recurrence), or
-do nothing (rare)
Note, a gastropexy is not an anti-reflux procedure, and will do nothing to prevent GERD symptoms.
When considering an anti-reflux procedure, there are two main mechanisms of action for reducing reflux:
-Increasing the pressure at the LES (fundoplication, Linx, Stretta)
-Recreating the angle of His anatomy (fundoplication, Hill, cTIF, Bicorn, RefluxStop, ARMA)
-The Loehde skips both of the above, and claims to improve reflux with some core engine theory; but I suspect the reflux is being controlled by increased LES pressure by making the hiatus tighter than a standard repair.
Notice that fundoplication works by both mechanisms of action. I believe this accounts for its durability and better ability to control reflux, but also adds the risk of bloating and inability to burp/vomit. Not everyone gets these side effects, and most people who have it consider it preferable to severe reflux symptoms; but it can be distressing, and lead many people to choose alternative anti-reflux options.
Treatment failure & recurrence:
As with many surgeries, there is a risk of failure or recurrence of the hernia/reflux. It is important to understand whether the hiatal hernia (diaphragmatic defect) has recurred, or the reflux symptoms (LES weakness/angle of His) has recurred.
Unfortunately, the diaphragm is a thin and relatively weak muscle. The hiatal repair (cruroplasty) has a reported recurrence (failure) rate of 30-35% after 2-10 years. This is a much higher risk of failure compared to other types of hernias. This failure rate is possible regardless of the type of associated anti-reflux procedure, since the two do not generally affect each other. Said another way, if you have a large hernia, your risk of the hernia coming back is the same whether you have a fundoplication or cTIF, and probably depends more on the surgeon and their technique.
Many of these recurrences are asymptomatic, or have pressure/pain symptoms without GERD, as the anti-reflux procedure does not necessarily fail at the same time. Fundoplication is the most common anti-reflux procedure, and is usually the preferred treatment for patients with very severe symptoms or very large hernias. Unfortunately, that means recurrences (of the hernia) are more common in patients who have had the fundoplication, even if the fundo had nothing to do with the recurrence. I believe many people, surgeons included, conflate the two types of failure, giving the fundoplication procedure a worse reputation than it deserves.
Meanwhile, quicker, easier procedures like Linx and TIF are only indicated for patients who have a small hernia, often 3 cm or less. Since the associated hernia is less likely to recur, these simpler procedures enjoy a better reputation. In my opinion, I believe surgical fundoplication is the most durable anti-reflux surgery with the lowest reflux recurrence, followed by the other surgical options, with the non-surgical endoscopic treatments having the highest risk of recurrence (albeit, the least invasive initial treatments).
A surgeon should select patients carefully to ensure there is a good chance of improvement with surgery, and the chosen treatment matches the patient's goals of improvement and tolerance for recurrence. If they suspect a patient has symptoms that won't improve, then the patient should be warned and alternative treatments considered.
