Hello, Goff25. I 'm sorry to hear about your predicament. While I cannot give you individualized medical advice, I can discuss some of the general principles around hiatal hernia repair and I hope you will find those helpful. They may inform your decisions and help focus future discussions with medical care providers.
A long reply follows below; TL,DR Summary: Find a surgeon who understands the importance of weightlifting and seek care from them.
As you know, a hiatal hernia describes the malposition of the gastroesophageal junction. The GEJ normally sits well below the diaphragm, but when a hiatal hernia forms that junction slides up into the lower portion of the chest and pulls the upper portionof the stomach up with it, out of its normal position. This can result in problems with swallowing solids. More commonly it results in severe acid reflux symptoms. Medications to reduce the amount of acid secreted by the stomach can help control the reflux symptoms but will do nothing to fix the problem with swallowing solids, which occurs because the portion of stomach that is out of position creates an antechamber, sort of shaped like an hourglass but with a much smaller upper portion, that can fill with food but still has a relatively small exit into the main body of the stomach. Once that chamber is full it creates a lot of discomfort, that will not abate until the patient either regurgitates or the solids managed to slip into the main chamber of the stomach.
Not all hiatal hernia require repair. Those that are asymptomatic and small can be observed. Once the hernia contains more than 1/3 of the total stomach volume it should be repaired whether symptoms are present or not. In between a hernia that size and a smaller one is a gray zone that Requires a lot of discussion between the patient and surgeon with regard to expectations For treatment outcomes. It comes down to degree of symptoms and other comorbidities and overall patient willingness to accept the possible consequences of surgery. for example, people who want surgery because they don’t want to take acid expressing medication’s should understand that only a small portion of patients are ever able to completely discontinue their medication’s after the surgery. Most people will still require acid suppression for long-term control of gastritis or ulcer disease. Lifestyle changes are needed after a hiatal hernia repair, such as avoidance of carbonated beverages and significant reduction or abstinence from alcohol.
A hiatal hernia can be caused by several factors, often multiple are present in the same patient. Obesity is the number one cause, with the excess weight of a large abdomen continuously pushing up on the stomach, the surrounding connective tissues slowly stretch over time, leading to pushing the stomach up into the posterior part of the chest just like squeezing a tube of toothpaste. Genetics certainly plays a role, particularly in the degree of flexibility in an individuals connective tissues, which can predispose to forming All kinds of hernias more easily. People who routinely engage in a Valsalva maneuver will experience Increased abdominalpressures and over time Such pressures could theoretically contribute to developing a hiatal hernia. This is why some surgeons may say that weightlifting is a relative contraindication to hiatal hernia repair. However, it is absolutely possible to do a durable and lasting repair in an obese patient with continuous high abdominal pressures and a well done repair should similarly be durable in a weightlifter once it has had adequate time to heal postoperatively. It is imperative with all hernia repairs that an adequate postoperative window is observed where there is no heavy lifting and every effort is made to avoid constipation, severe coughing, or other activities that will create large amounts of intra-abdominal pressure that strain the healing tissues. I know that Dr. Feigenbaum and Dr. Baraki assert the general prescription of a 4 to 6 week window without heavy lifting is arbitrary but the surgical community would disagree. wound healing is a complex process and discussing it is beyond the scope of this reply, but it marches along in an orderly and sequential fashion. Every wound goes through a series of successional steps from hemostasis to inflammation to matrix proliferation and then ultimately to wound remodeling. in the final remodeling phase the initial fibrin matrix is slowly replaced by collagen fibers and other tissue components to give the healed wound strength and function. While remodeling can take months to fully complete, the wound achieves a reasonable amount of strength and durability by about four weeks postoperatively in the average person with decent nutrition and normal tissue quality. I advise patients to avoid any abdominal muscle straining for at least four weeks after surgery and in someone who engages in powerlifting or bodybuilding it might be reasonable to consider an even longer break before returning to maximal effort lifting.
when patients are searching for a medical provider to assist them in achieving their health goals, several factors need to be considered, not least of which is whether the patient’s and provider’s goals and philosophy of care are aligned. The modern medical system talks a lot about patient noncompliance But often fails to take into account whether the directions and recommendations being given are in alignment with the patient’s world-view, capabilitie, and personal care goals. Ultimately, each patient is individually responsible for their own healthcare outcomes. Finding a care provider who will acknowledge that and help the patient achieve their stated goals leads to more individualized success. Patients should, of course, feel comfortable discussing their hobbies and lifestyle choices with their doctor, but if the doctor is not supportive of those choices then sometimes it might be necessary to search for another provider who is more educated about those topics and comfortable with them. For any weightlifters out there who are having a hard time finding a surgeon who will fix their hernia, plan a vacation to Bar Harbor, Maine and come see me.
If you are dealing with a hiatal hernia (and you’re not in a small rural community where all of your work up is likely to be done by a General Surgeon), your evaluation and care will likely be split between several providers. The evaluation will start with a referral from your primary care provider and the initial starting point will likely be GI (a.k.a. gastroenterology), who may recommend an EGD (fiber optic camera endoscopy of the esophagus and stomach and proximal small bowel), possibly with placement of a temporary probe in the lower esophagus to monitor pH levels for a couple days. Hiatal hernia is not the only cause of dysphasia to solids and an EGD helps to rule out things like scar tissue or stenosis in the esophagus, which can be treated with stretching the lower esophagus to improve swallowing and thus help a patient avoid surgery sometimes. Discoordinated smooth muscle contraction is also a problem in some instances and a test called manometry may also be warranted at the discretion of the doctor doing the evaluation. This is more commonly a concern in older patients or those with long-standing diabetes. The GI doc may give a patient recommendations, or advise that surgery is not a good option, but ultimately only the surgeon can tell a patient whether or not they are a good candidate for fundoplication, which is the preferred manner of fixing a hiatal hernia, typically in conjunction with tightening of the diaphragmatic crura. There are several types of fundoplication but by far the most common is a Nissan fundoplication, which can be done with minimally invasive techniques (laparoscopic or robotic) and patients are be on their feet almost immediately after surgery with very little functional downtime. Patients have every right to seek the opinion of additional providers if they are not comfortable with the advice and recommendations being given by a provider. In the end, the patient is the master of their own ship and needs to be the one directing the care decisions, with the advice and input of providers whom they trust.
If a patient is diagnosed with an umbilical, incisional, inguinal, or other hernia, none of the tests used with hiatal hernia are necessary and the primary care provider will refer patients directly to a General Surgeon for the repair. If the diagnosis was made on physical exam alone, some kind of imaging such as an ultrasound or a CT scan may be needed to further investigate the contents of the hernia, but that is not necessary in all cases. smoking cessation is strongly recommended for anyone considering a hernia repair, for myriad obvious general health reasons, but also specifically because chronic coughing is one of the most common causes of repair failure. For obese patients, weight loss is strongly recommended prior to hernia repair. Obesity causes increased problems with anesthesia and with healing from hernia repair. Incisional hernias (a hernia that occurs when an incision made for a different operative purpose does not heal well or tears back open during the postoperative course) are far more common in obese patients than in those of normal body weight, due to the constant tension on the abdominal wall caused by the obesity as well as impaired insulin sensitivity, which increases the risk of wound infections, another common cause of postoperative hernias. High protein intake in the perioperative period is very important to optimize wound healing and surgical recovery.
I hope you find this information useful. Nothing in the information provided above constitutes establishment of a patient/physician relationship and nothing above is intended as individualized care advice for a specific patient.
Lift heavy, live long.
Dr. Dougherty