← Back to Hiatus Hernia & Reflux
Evidence-Based — Combined with 20+ Years of Experience
Dr. Irshad’s TakeHiatus Hernia & Reflux Surgery
K IrshadMD
Who benefits
Reflux that medication can’t control — or a large, symptomatic hiatus (paraesophageal) hernia.
The operation
Keyhole (laparoscopic) repair with a fundoplication — usually a one- to two-night stay.
What I’m fixing
Reduce the hernia, rebuild the diaphragm opening, and rebuild the anti-reflux valve.
What matters most
A tension-free repair and enough esophagus sitting below the diaphragm.
Main trade-off
Early trouble swallowing and gas-bloat — usually settle over a few weeks.
Durability
Hernias can come back over time; careful technique is how I keep that risk low.
Who is a good candidate
Reflux not controlled by medication
Heartburn, regurgitation or a sour taste that persists despite a proper trial of acid-suppressing medication — or that comes straight back whenever the medication is stopped. Surgery rebuilds the anti-reflux barrier itself, which is why it can offer lasting relief where medication only manages the symptom.
You’d rather not take lifelong medication
Some patients get good control on medication but do not want to take it indefinitely — because of side effects, cost, or simply preference. For the right person, a durable surgical repair is a reasonable alternative to decades of daily pills, and we weigh that together.
A large or symptomatic paraesophageal hernia
When a significant portion of the stomach has slipped up into the chest, the symptoms are often subtle — chest pressure or pain after a large meal, feeling full quickly, shortness of breath after eating, gurgling, or trouble swallowing. Many patients quietly change what they eat to cope. These hernias tend to enlarge over time and are the ones where repair is most clearly worthwhile.
Unexplained anemia with a known hernia
Large hernias can cause slow, hidden blood loss from small erosions (Cameron lesions) where the stomach rubs across the diaphragm, showing up as iron-deficiency anemia. When a hernia is present, repairing it usually resolves the anemia, and an exhaustive search for another source is often unnecessary.
Testing confirms the problem
Before recommending surgery I confirm the picture objectively — endoscopy to look at the lining and measure the hernia, a barium swallow to show its size and shape, and, where it will change the plan, pH testing and a motility (manometry) study. Matching the operation to your specific anatomy and swallowing function is what makes the result reliable.
When I watch, wait, or investigate first
A small sliding hernia, well controlled on medication
A small sliding hiatus hernia whose reflux is well managed with medication rarely needs an operation. Here the hernia matters only in relation to the reflux, and if medication is doing the job comfortably, surgery is usually not the better trade.
Symptoms that may not be from reflux
Chest or upper-abdominal symptoms have many causes. If it isn’t clear the trouble is coming from reflux or the hernia, I investigate first rather than operate — a fundoplication only helps when reflux is genuinely the problem.
Weak esophageal motility
If the esophagus squeezes weakly, a full 360-degree wrap can make swallowing difficult. This doesn’t rule out surgery, but it changes it — I tailor the type of fundoplication (often a partial wrap) to your motility so you can still swallow comfortably afterward.
A symptom-free hernia in a high-risk patient
The decision to repair a hernia that isn’t causing symptoms is individualized — weighing the small but real risk of a future emergency against a person’s overall health and surgical risk. This is a conversation, not a reflex.
Significant obesity
A higher body-mass index raises the chance a repair will come apart over time, and in some patients reflux is better addressed as part of a weight-loss operation. Where that applies, I’ll say so honestly and help you find the right path.
How I do the repair
Keyhole approachLaparoscopic
The whole repair is done through a few small incisions with a camera, which means less pain, a shorter stay, and a quicker recovery than open surgery — without compromising the quality of the reconstruction.
Reduce the hernia & remove the sacStep 1
I gently bring the stomach back down into the abdomen and completely remove the hernia sac from the chest. Fully excising the sac is important — it exposes the anatomy clearly and removes tissue that would otherwise pull the repair apart.
Rebuild the diaphragm openingStep 2
I close the widened diaphragm opening (the hiatus) snugly around the esophagus with strong, permanent sutures, reinforced with small buttresses. A closure that is secure but not under excessive tension is the foundation of a durable repair.
Restore esophageal lengthWhen needed
If the esophagus has been pulled up so long that it sits short, I lengthen it (a wedge Collis gastroplasty) so that a healthy segment rests below the diaphragm without tension. Getting the length right is one of the quiet keys to a repair that lasts.
Rebuild the anti-reflux valveFundoplication
I wrap the top of the stomach around the lower esophagus to recreate a one-way valve, choosing a full or partial wrap based on your swallowing function. I also secure the wrap to the diaphragm so it stays where it belongs.
Reduce tension on the repairKey principle
Tension is the main reason repairs fail. I take specific steps to relieve it — opening the lining of the chest to relax the diaphragm, and, for very large defects, a controlled relaxing incision — so the diaphragm comes together without strain.
Recovery & what to expect
In hospital
Most patients stay one to two nights. You’ll start on clear liquids and be up and walking the same day or the next morning. Because the surgery is keyhole, the incisions are small and pain is usually well controlled with simple medication.
Your diet for the first few weeks
You’ll go home on a soft or liquid diet and step it up gradually over several weeks as the swelling around the repair settles. Eating slowly, chewing well, and smaller meals make this phase much easier.
Early difficulty swallowing
Some tightness with swallowing in the first weeks is normal — it’s swelling, not a problem with the repair, and it typically eases as things heal. In the small number of patients where it lingers, a simple stretching (dilation) resolves it.
Gas-bloat, and not being able to belch at first
A new valve means air is harder to burp up early on, so some bloating and increased wind is common in the first weeks. It improves as your body adjusts; avoiding carbonated drinks and gulping air helps.
Protecting the repair
The diaphragm repair is tenuous while it heals, so I ask patients to avoid heavy lifting and hard straining for several weeks. Getting back to strenuous activity too soon is one of the avoidable causes of an early recurrence.
Recurrence over time
No hernia repair is permanent in everyone — hernias can recur over the years, more so with very large ones. My technique is aimed squarely at lowering that risk, and most recurrences that do happen are small and don’t need another operation.
In my words
Why tension and length matter more than anything else
The reason hernia repairs come apart is almost always the same: tension. The diaphragm is thin, the tissue is often weak, and a very large opening has to be brought down to a small one. If I simply pull it together and hope, the sutures work against already-fragile tissue and the repair is halfway undone before the patient even leaves the operating room. So I do the opposite — I deliberately relieve tension, restore the length of esophagus below the diaphragm, and only then close and reinforce. That patience is what turns a good-looking repair on the day into a durable one years later.
My view on mesh
Mesh at the hiatus is not like mesh elsewhere in the body. This is a constantly moving area, and permanent synthetic mesh here carries a real risk of eroding into the esophagus or stomach — a serious problem. So I use mesh selectively, for larger defects and weaker tissue, and I use a bioabsorbable mesh that reinforces the tissue and then dissolves. Mesh is never a way to rescue a repair that is under tension — the tension has to be fixed first. It is a reinforcement of a sound repair, not a substitute for one.
The evidence, briefly
~90%+
of patients have good, durable relief of reflux symptoms after fundoplication
Long-term randomized & cohort data2,3
Tension
reducing it — via a pleural window and relaxing incisions — measurably lowers crural-closure force
DeMeester & colleagues1
Selective
bioabsorbable mesh avoids the erosion risk seen with permanent synthetic mesh at the hiatus
Randomized mesh trials1,4
Surgical technique pearls
My repair follows the principles championed by Dr. Steve DeMeester — meticulous sac excision, a tension-free crural closure, and restoring intra-abdominal esophageal length. Below are the specific technical choices I make. Where I differ from that standard approach, it is noted.
Crural closure
Non-absorbable Ethibond placed with the Endo Stitch device, 3–4 sutures, reinforced with PTFE pledgets as buttresses under selected stitches; suture distribution tailored to the defect.
Tension reduction
Routine capnothorax / pleural window to neutralize the diaphragm and offload crural tension; right-sided relaxing incision when needed for large, high-tension defects.
Esophageal lengthening
Wedge Collis gastroplasty when the esophagus is short despite full mobilization — a judgment call, not a fixed cutoff — over a 48 Fr bougie.
Fundoplication
Wrap tailored to esophageal motility (Nissen vs. Toupet), constructed to sit tension-free below the repair.
Fixation & anti-recurrence
Pexy the wrap to both crura (3–4 sutures); occasional anterior gastropexy (stomach to anterior abdominal wall) for added security.
Mesh
Phasix (bioabsorbable), used selectively for larger defects / weak tissue / redos, as a circumferential keyhole fixed with absorbable tacks — never permanent bridging mesh.
A technical summary for referring physicians and interested patients — the operative details behind the plain-language steps above.
This describes my general approach and the current evidence; it is not a promise of a specific outcome. Every patient is different, and the right plan — including whether surgery is appropriate at all — is decided together at a personal consultation.
References
- DeMeester SR. Paraesophageal Hernia — History, Fundamental Concepts, and Adjunct Techniques to Improve Outcomes (International Hernia Collaboration lecture series). 2020.
- Stefanidis D, Hope WW, Kohn GP, et al. SAGES Guidelines for Surgical Treatment of Gastroesophageal Reflux Disease (GERD). Surg Endosc. 2010;24(11):2647–2669.
- Kohn GP, Price RR, DeMeester SR, et al. SAGES Guidelines for the Management of Hiatal Hernia. Surg Endosc. 2013;27(12):4409–4428.
- Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: long-term follow-up of a randomized controlled trial. J Am Coll Surg. 2011;213(4):461–468.