Diaphragmatic hernia (hiatus hernia): treatment options and surgical procedures

What are the treatment options for a diaphragmatic hernia?

1. General

Below mentioned measurements are known to have relieving effects. In mild heartburn cases even an effective treatment  of  is possible:

  • Weight reduction in cases of overweight
  • Abdication of late meals
  • Sleeping with an elevated bed-head
  • Consumption of only small amounts of alcohol
  • Non-smoking
  • Avoiding coffee
  • Avoiding chocolate
  • Avoiding greasy foods

2. Medicinal

There is no medicine that prevents the reflux of stomach contents into the esophagus. Existing drugs merely make sure that there is no acid in the fluid. These drugs follow two basic approaches: binding the existing acid or reducing the production of acid.
If an esophagitis, an inflammation of the esophagus, has been diagnosed, a drug therapy is strongly advised.

Risks and side effects of drug treatment

In the short term, treatment with proton pump inhibitors is the therapy of choice. If, however, it becomes apparent after several attempts to omit the proton pump inhibitor, that long-term drug therapy is necessary, it must be borne in mind that this is a purely symptomatic therapy with side effects.
First, this treatment does not change the reflux of food into the esophagus. Secondly, there is no acid available in the stomach for digestion. This means that the treatment creates another pathological condition.

Gastric acid is an important component of our immune system. It is the first barrier responsible for the destruction of harmful bacteria and parasites that may enter with food.
The reduction of the acid barrier of the stomach can result in a moderate to significantly increased risk of gastrointestinal infections, such as bacterial small intestine malocclusions, bacterial diarrhoea, infections with Salmonella, Campylobacter, Clostridium difficile and parasites (e.g. Giardia lamblia). Extraintestinal infections are characterized by a moderately increased risk of outpatient pneumonia.
The marginal influence of PPI on the absorption of vitamin B12, vitamin C and iron plays no role in clinical routine.
After years of PPI therapy, multiple pseudopolyps are often found in the stomach. If taken for decades, the development of osteoporosis may be possible.

3. Surgical

Surgical reflux therapies have one major benefit: The cause of the disorders is eliminated. Minimally invasive surgery enables treatment with a minimal impact on the body. The surgery itself is divided into two steps: 

  1. Correction of the hiatal hernia
  2. Formation of a valve mechanism at the lower end of the esophagus that will eliminate further reflux.

The operation is carried out laparoscopically, which means that no abdominal incision is necessary. The surgical instruments are inserted into the surgical area through five cuts measuring in between 5 and 12 millimeters length, and steered via the monitor.

What are the conventional surgical procedures?

Early surgical interventions to prevent acid reflux into the oesophagus used the upper part of the stomach to form a 360° cuff around the oesophagus.

This method was first used by Rudolf Nissen in New York around 1950. It effectively prevented acid reflux but caused adverse effects such as difficulties with vomiting and burping in the long run. The procedure was modified often as a result. Techniques like e.g. Toupet and Dor developed.

Toupet only placed a 180° cuff dorsally (behind) of the oesophagus. Dor placed a 180° cuff ventrally (in front) of the oesophagus. Rossetti refined his teacher Nissen's procedure and did not always cut the short stomach vessels (vasa brevia) to the spleen. He formed the cuff using the front wall of the stomach.

All of these procedures (Nissen, Rossetti, Toupet, Dor) effectively prevented acid reflux. Adverse effects (difficulty in swallowing, feeling full, inability to vomit and expel air) were, however, impossible to avoid. The stomach cuff does not match the original anatomy.

Even procedures using silicone rings, such as the Angelchick prosthesis, could not persist in the long run. Foreign bodies like these often shifted in position and could migrate into the stomach. A similar procedure has been explored again recently: the magnetic ring.

What alternatives are there?

Diaphragmatic hernia treated with the Bicorn method
Schematic of the Bicorn method according to the drain maier

We use the Bicorn method of Dr. Bernd Ablaßmaier for surgical intervention. The original, now-distorted anatomy of the stomach is restored, and the diaphragm is narrowed in again.