A hiatal hernia occurs when the upper part of the stomach goes up through the opening in the diaphragm that is normally occupied by the esophagus. (The diaphragm is a muscle that separates the chest and the abdomen.)Physicians often use the phrases 'hiatal hernia' and 'esophageal reflux' interchangeably. Esophageal reflux is a clinical diagnosis - it is based on symptoms (heartburn, reflux, and so forth), and is confirmed by testing that evaluates the extent of reflux of gastric juice and acid into the esophagus. A hiatal hernia is a diagnosis of an anatomic change that can only be made by x-r ay studies or upper endoscopy.
....-> This leads to reflux ->
Many patients are told that they have a hiatal hernia when they complain of gastroesophageal reflux symptoms, and are under the impression that the hernia causes pain in their upper abdomen like groin hernias cause pain in the groin area. Occasionally hiatal hernias do cause upper abdominal pain or chest pain, and when they do surgical repair may be needed to prevent strangulation of the stomach. For the most part, however, hiatal hernias weaken the effectiveness of the antireflux barrier and so increase the severity of gastroesophageal reflux disease.

Large or giant hiatal hernias - where a good portion of the stomach is up in the chest - may cause problems not only with reflux but with feelings of getting full early, shortness of breath especially after eating, chest pain, food sticking, painful upper abdominal bloating. They can also cause chronic blood loss leading to anemia. In these instances, if evaluation indicates that these symptoms are likely due to the hiatal hernia, then surgery to repair the hiatal hernia is often indicated. This surgery can often be performed laparoscopically and consists of three parts: (1) Freeing up attachments that kept the stomach up in the chest and getting the stomach back down into the abdomen ; (2) Repairing the opening in the diaphragm by sutures and an onlay patch to reinforce the sutured closure; and (3) Folding the stomach around the lower esophagus to create a bumper which prevents the stomach from riding back up into the chest again, as the stomach no longer has membranes to hold it in the abdomen. (These membranes were stretched out when the hernia developed.) We have repaired over 150 large and/or paraesophageal hiatal hernias, the majority laparoscopically.

Improved Results with Hiatal Hernia Repair. Since 2007 we have been using a biologic patch to reinforce hiatal hernia repairs. This patch allows for a patient's own tissue to grow into the patch as the patch gradually reabsorbs, and this increases the overall strength of the repair considerably. No permanent foreign body is left behind. Studies have shown that the addition of this patch reduces the risk of the hernia reoccuring by over 60%.
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Paraesophageal hernias occur when the stomach slides up beside the esophagus. In these situations the stomach may twist and lose its blood supply or may obstruct. Symptoms often include bloating and chest pain. Surgery may be necessary in these situations to prevent loss of the stomach, and occasionally this surgery needs to be done on an emergency basis. The surgical repair is similar to that described above for large hiatal hernias.

Hiatal hernias associated with GERD - where the hernia's prime role has been to lead to deformation of the antireflux barrier - are repaired at the time of performing a laparoscopic Nissen fundoplication. We are now using an acellular human collagen matrix to reinforce the hiatal hernia repair.

GERD in which there is minimal hiatal hernia. Although up to 90% of patients with GERD have a hiatal hernia, the degree of that hiatal hernia is variable - and in many patients the hiatal hernia is fairly minimal (less than 2cm in height). In this situation endoluminal techniques such as Transoral Intraluminal Fundoplication (Esophyx) may provide excellent relief of symptoms and allow elimination or reduction of chronic medical therapy.