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Reflux and hiatal hernia — the surgical approach
Anti-reflux surgery (fundoplication) is for a patient with proven reflux that is not controlled by drugs or who does not want them; before surgery reflux must be proven by pH monitoring and a motility disorder excluded by manometry, and a symptomatic para-oesophageal hiatal hernia is repaired.
Why it matters in the exam
Questions on reflux in a surgical setting test the threshold conditions for surgery: gastroscopy, ambulatory pH monitoring proving acid in the oesophagus, and manometry excluding achalasia or absent peristalsis — because a full fundoplication on an oesophagus that does not contract causes severe dysphagia. A patient who responds well to PPIs is a good surgical candidate, whereas a patient with no response at all needs work-up for another diagnosis first.
The second part is hiatal hernia: type I (sliding) is the most common and is managed like reflux; type II (para-oesophageal), in which the gastric fundus rises into the chest while the gastro-oesophageal junction stays in place, and types III–IV are dangerous because of incarceration and gastric volvulus. Borchardt's triad — severe pain, unproductive retching and failure to pass a nasogastric tube — demands urgent surgery. Candidates are also asked about side effects of fundoplication: dysphagia and "gas-bloat" syndrome.
Key points
- Before surgery: gastroscopy, pH monitoring and manometry.
- Good candidate: proven reflux responding to PPIs, marked regurgitation or a wish to stop drugs.
- Type I sliding — the most common; type II para-oesophageal — risk of incarceration and volvulus.
- Borchardt's triad — acute gastric volvulus, urgent surgery.
- Side effects: dysphagia and "gas-bloat".
Summary table
| Situation | Features | Treatment |
|---|---|---|
| Hiatal hernia type I (sliding) | The gastro-oesophageal junction rises into the chest; linked to reflux | Treat the reflux; surgery only if fundoplication is indicated |
| Type II hernia (para-oesophageal) | The fundus rises beside the oesophagus; the junction stays in place | Repair when symptomatic; risk of incarceration and volvulus |
| Types III–IV hernia | Mixed, or other organs in the chest (colon, spleen) | Surgical repair when symptomatic |
| Acute gastric volvulus | Borchardt's triad: pain, retching without vomiting, inability to pass a nasogastric tube | Urgent surgery |
| Proven reflux not controlled, or marked regurgitation | pH proves reflux, normal manometry | Laparoscopic fundoplication (Nissen or partial) |
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Sources
- SAGES guidelines for the surgical treatment of gastroesophageal reflux disease, 2021 — Patient selection and choice of fundoplication
- SAGES guidelines for the management of hiatal hernia, 2013 — Paraesophageal hernia repair
- Sabiston Textbook of Surgery, 21st edition (2022) — Esophagus
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.