Hiatal hernia surgery is performed to repair the opening in the diaphragm, reducing symptoms like acid reflux, heartburn, and difficulty swallowing. To ensure a smooth recovery and prevent complications, a specific diet is crucial both before and after the procedure. This article provides a comprehensive guide to managing your diet throughout the entire process, including the importance of a pre-operative diet to optimize the surgical field.
Understanding Hiatal Hernia and Surgical Repair
A hiatal hernia occurs when the stomach protrudes through the diaphragm into the esophagus. Hiatal hernia repair involves making a valve around the lower part of the esophagus to prevent reflux. The surgeon uses a laparoscope (a tiny “telescope” attached to a camera) to see a magnified view of your internal organs on a monitor. The surgeon operates through these incisions to repair the hiatal hernia and then to wrap the upper stomach around the lower esophagus to create a "collar" effect. Sometimes a tube is left across the abdominal wall to tether the corrected stomach until healing can occur. The outside incisions are usually closed with dissolvable stitches and surgical glue (Dermabond), which will come off on its own with time.
The Importance of Diet Modification
Diet modification is important because swelling at the gastroesophageal junction is normal after surgery, and you may find that solid foods “get stuck.” This is expected during the first four weeks, which is why a gradual dietary progression is recommended as the swelling subsides. A proper hiatal hernia surgery diet is essential for a smooth recovery and to prevent complications. After undergoing hiatal hernia surgery, patients must follow a specific diet to allow the surgical site to heal, prevent bloating, and avoid acid reflux.
Pre-Operative Diet: Preparing for Surgery
Some surgeons advocate a very low-calorie diet (VLCD; 450-800 kcal/day) or low-calorie diet (LCD; 800-1500 kcal/day) in the preoperative period to "shrink" the liver. A very low-calorie diet (VLCD) or low-calorie diet (LCD) is often used prior to laparoscopic surgery to optimize access to the hiatus. The surgeons in this study felt that operability was improved due to better visualization of the gastro-esophageal junction, and easier retraction of the liver.
The Role of Liver Volume Reduction
Obesity is the main risk factor for the development of non-alcoholic fatty liver disease. Prior to surgery, estimation of a patient’s liver volume may be attempted by clinical examination using the palpation method; however, multiple studies have shown this technique to be inaccurate and potentially misleading. Whilst computed tomography (CT) and magnetic resonance imaging (MRI) remain the gold standard for measuring liver volume, they are expensive, not readily accessible, and carry various contraindications such as radiation exposure (CT) and claustrophobia (MRI). In contrast, ultrasound is non-invasive, non-radiating, fast and inexpensive.
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Study on Low-Calorie Diets and Liver Volume
A study examined liver volume after treatment with an Optifast® VLCD for 6 weeks with magnetic resonance imaging (MRI) and found a 14.7% reduction in mean liver volume. A study was conducted to determine the optimal amount of time on an LCD prior to laparoscopic anti-reflux surgery to achieve maximal liver volume reduction. The study also wanted to use Child’s equation to measure change in liver volume following an LCD, and to assess its accuracy against MRI. Participants scheduled for laparoscopic anti-reflux surgery were recruited between 2018 and 2021. Participants who spoke English; were competent to give consent; were over 18 years old; and had a body mass index (BMI) of > 22 km/m2 were included. Those who had had a prior liver resection or were unable to undergo MRI were excluded. Informed consent was obtained from all individual participants included in the study.
Study Methodology
An experienced dietitian assessed each patient and determined the optimal time on a preoperative LCD. At the outset of the study, each patient underwent body composition analysis with the InBody® 230, liver ultrasound, and liver MRI. Body composition was evaluated with bioelectrical impedance analysis using two different frequencies (20 kHz and 100 kHz) of five body segments (right and left arms, trunk, right and left legs) with an 8-point tactile electrode system. Age, height, and gender were entered into the analyzer, and then weight, body fat mass, segmental fat mass, percent body fat, skeletal muscle mass, segmental lean mass, and total body water were all evaluated. Basal metabolic rate and recommended daily calorie intake was then predicted.
Following body composition analysis, all participants were instructed to consume three VLCD products per day (Optifast® VLCD, Optislim® VLCD, or Proslim Rapid VLCD), a minimum of two liters of low energy fluids, a minimum of two to three cups of low starch vegetables, and one teaspoon of oil. If a participant’s predicted skeletal muscle mass was on the lower side of normal, he/she was also instructed to include an additional entrée meal and, in individual cases, an additional snack, to optimize compliance and stem muscle mass wasting. The additional entrée meal generally consisted of 50-200 g of raw weight lean protein (e.g., lean red meat, chicken breast, fish or eggs) and, in individual cases, 20-40 g of carbohydrate. When a participant’s weight loss consistently fell below 1 kg per week, the dietician adjusted the LCD, either eliminating the additional prescribed protein and/or carbohydrate. Participants were encouraged to include strength and resistance training and/or walking in their daily routine to stem muscle mass wasting. All participants weighed on their first day on an LCD and repeated this weekly.
Two qualified and experienced sonographers performed all liver ultrasounds on the study participants. A Phillips IU22 ultrasound machine (Phillips Healthcare, Bothell, WA, USA) and a 5--1-MHz curved array transducer measured liver volume according to the published protocol. MRIs were performed on a Philips Ingenia 1.5 T MRI machine (Philips Healthcare, Bothell, WA, USA) with a 1.5-Tesla magnet. The MRI extended from just above the liver to just below the liver using a Axial e-THRIVE (T1 FEE 3D single shot) sequence with a 14-s breath hold. The MRI duration was approximately 10 min.
Study Results
Seventeen participants were recruited, 11 males and 6 females. The mean age (SD) was 54 (15.5) years (range 21, 74). Mean height (SD) was 173 cm (11.1 cm) (range 155, 193). The number of weeks on an LCD ranged from 2 to 10 weeks with the mean (SD) length of time at 3.9 (2.3) weeks. The mean (SD) weight of the participants prior to an LCD was 87.6 (11.7) kg with a mean (SD) BMI of 29.3 (3.9). The mean (SD) reduction in MRI estimates of liver volume was 16 (10) % whilst the mean (SD) reduction in ultrasound liver volume was 18 (9) %. The mean (SD) reduction in body fat was 19 (11) % (Table 2). Comparison of the % liver volume loss measured by ultrasound to the % liver volume loss measured by MRI was not statistically significant (P = 0.7). A Cohen’s D of 0.21 showed the difference was relatively small. Comparison of the % volume loss measured by ultrasound to the % body fat loss measured using InBody scales was also not statistically significant (P = 0.8). A Cohen’s D of 0.08 showed that the % body fat loss measured by InBody scales was a comparative measure of % liver volume loss measured by ultrasound.
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All seventeen patients lost liver volume on a low-calorie diet. Notably, 47% of patients peaked their liver volume loss after the first week on an LCD. Twelve per cent achieved their maximal liver volume loss after the second week, and 29% after the third week.
Conclusions from the Study
The study found that 47% of participants lost most of their liver volume after only 1 week of an LCD. In fact, close to 90% of participants achieved maximal liver volume loss in the first 3 weeks of an LCD, suggesting that there is little value to enforcing a longer duration of a preoperative LCD. Participants in the study lost on average 19% of their liver volume by following an LCD for a mean time of 3.9 weeks. This prospective case-controlled study showed that close to 90% of patients achieved maximal liver volume reduction within three weeks on an LCD. In fact, 47% achieved this during the first week on an LCD. As well, the study found that bedside ultrasonography (using Child’s equation) and the InBody® 230 body composition analysis device were both as accurate as the gold standard modality, magnetic resonance imaging (MRI), in the measurement of liver volume. The study demonstrates unequivocally that an LCD is an effective method of reducing liver volume in a non-bariatric patient population. Since the conclusion of the study, a 2-week LCD has been implemented for patients with a BMI < 30 kg/m2.
Specific Instructions Before Surgery
Two days before your hiatal hernia repair, you should start a clear liquid diet. Do not eat or drink anything beginning eight hours prior to your scheduled operation. The reason for the clear liquid diet is to help "shrink" the liver prior to surgery, which improves exposure of your hiatal hernia during the operation. You may be told to stop taking medications the night before your surgery. You will receive instructions from the anesthesiologist at the “work-up.” Refrain from smoking before the operation.
Post-Operative Diet: Promoting Healing and Preventing Complications
After surgery, you will be admitted for 23-hour observation and pain control. You will be discharged home within 23 hours on a full liquid diet. You will stay on a full liquid diet for two weeks, after which you will advance to a soft diet for an additional two weeks. You should return to a regular diet four weeks after surgery.
Key Phases of the Hiatal Hernia Surgery Diet
Clear Liquid Diet (First Few Days): Initially, patients are advised to consume clear liquids to avoid putting strain on the esophagus and stomach. Consequently, this phase prevents vomiting and minimizes the risk of irritating the surgical site. Clear liquids ensure hydration and provide essential nutrients without overburdening the digestive system.
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- Water
- Broth
- Gelatin
- Herbal tea (without caffeine)
Clear liquids are important because they reduce the risk of swelling and keep the patient hydrated. Additionally, it is essential to sip liquids slowly and avoid drinking large amounts at once to prevent bloating. Hydration plays a vital role in keeping the body functioning properly and aiding in bowel movements. It is commonly recommended for bariatric surgery patients to aim for at least 64 ounces (about 1.9 liters) of fluids per day. Bariatric surgery patients should be vigilant about signs of dehydration, including dark urine, dizziness, rapid heart rate, and dry mouth. Pay attention to your body's signals. If you're thirsty, drink water. Early Post-Op Stage: This often involves sipping water throughout the day, starting with small amounts and gradually increasing as tolerated.
Full Liquid Diet (Up to One Week): Gradually, the liquid diet expands to include more nutrient-rich fluids that provide additional energy and sustenance. As patients transition to this stage, they can slowly adjust to slightly thicker liquids and semi-solid options.
- Smooth soups
- Milk
- Yogurt
- Seedless jam
- Cottage cheese
Full liquid diets introduce more variety, which helps patients feel more satisfied and nourished. However, it is critical to avoid carbonated beverages and acidic foods at this stage, as they can trigger acid reflux and discomfort. Furthermore, frequent meals consisting of small portions can help avoid overwhelming the stomach.
Soft and Bland Foods (Weeks 2-3): At this point, patients are encouraged to eat bland foods that are easy to chew and swallow. This phase is important because these foods prevent irritation to the surgical site and reduce the risk of trouble swallowing.
- Mashed potatoes
- Scrambled eggs
- Applesauce
- Fish
- Well-cooked vegetables
Soft foods are gentle on the digestive system and minimize the chances of constipation. Therefore, it is recommended to avoid raw vegetables, tough meats, and fried foods during this phase. Introducing soft vegetables and lean proteins gradually ensures a smooth transition back to regular eating habits.
Eating Habits to Follow Post-Surgery
- Eat smaller, frequent meals to prevent bloating and acid reflux. Eat frequently (5-6 times a day) but do not overeat: stop once you feel full! Do not try to always finish everything on your plate.
- Eat slowly and chew thoroughly to aid digestion and prevent difficulty swallowing. Put your fork down between the bites. Enjoy chewing and tasting food in your mouth, pay attention to what you are eating and do not get distracted by TV or cell phone. Focus on your meal.
- Avoid large meals that could put pressure on the surgical site.
- Drink liquids between meals rather than during to avoid swelling. Stop drinking 30 minutes before you eat and do not drink again until 30 minutes after you eat. This will be a requirement following your surgical procedure and needs to become a lifetime habit.
- Avoid lying down immediately after eating to prevent acid reflux.
- Think about your stomach as a colander (strainer), or a funnel. If you only put liquid in the colander/funnel it’s going to go straight through, but if you only put solid/soft food in that colander, it will drain through slowly. If you end up mixing water with the food, it thins it, allowing the food to go through the colander/funnel faster (or your stomach faster). By doing this, you won’t feel as full, allowing you to eat more during your meals and you’ll become hungry sooner, which all equates to consuming more food and more calories throughout the day. And after surgery you will want to fill up your limited stomach space with protein and nutritious food first, and drink later, thus, developing this habit now will become very useful in the future.
Foods to Avoid During Recovery
To promote healing and prevent complications, certain foods must be avoided.
- Fried foods
- Acidic foods (like citrus fruits)
- Carbonated beverages
- Tough meats
- Raw vegetables
- Caffeine
- Spicy foods
Avoiding foods irritating the digestive tract helps speed up recovery and reduces the risk of setbacks.
Preventing Constipation and Bloating
To avoid constipation, patients should incorporate fiber-rich foods once their care team approves. Since constipation can lead to increased pressure on the surgical site, it may delay healing. Drinking plenty of water and keeping track of bowel movements ensures the digestive system functions smoothly.
- Brown rice
- Fresh fruits (without seeds)
- Cooked vegetables
General Nutritional Advice
- Skipping a meal means you will be so hungry at the next meal that you are likely to overeat.
- Do not wait until next day, or Monday or next month to go back to the right course. Resume your healthy diet with the very next meal.
- Do not be obsessed with counting calories, because 100 calories coming from soda or chips are not the same as 100 calories coming from broccoli or almonds. Focus on healthy food choices and portion control (as will be explained further). What we eat is more important than how much we eat.
- Have a glass of water when you think you feel hungry. The feelings of thirst and hunger are very similar (the same part of your brain is responsible for interpreting hunger and thirst signals, which can result in mixed signals). If you have a glass of water and still feel hungry, then you are really hungry. Otherwise, the feeling will go away.
- If you drink a lot of water you might lack potassium, which might cause leg or toes cramps (especially after work outs). To maintain proper levels of potassium, take Potassium Chloride 500 mg a day in pills (if needed), or add foods rich in potassium to your diet (example: spinach, tomatoes, broccoli, Brussel sprouts, champignon mushrooms, pickles or pickle juice, avocadoes, and apricots.
Artificial Sweeteners and Added Sugars
It goes without saying that added sugar is to be avoided, however, artificial sweeteners should also be avoided as much as possible. Extreme and unnatural sweetness encourages sugar cravings and sugar dependence. Non-nutritive sweeteners are far more potent than table sugar and high-fructose corn syrup. A miniscule amount produces a sweet taste comparable to that of sugar, without comparable calories. Overstimulation of sugar receptors from frequent use of these hyper-intense sweeteners may limit tolerance for more complex tastes. That means people who routinely use artificial sweeteners may start to find less intensely sweet foods, such as fruit, less appealing and unsweet foods, such as vegetables, downright unpalatable. Also keep in mind that artificial sweeteners (especially when used after surgery) often cause stomachache, diarrhea, and gas.
Long-Term Lifestyle Changes Following Hiatal Hernia Repair
This procedure is designed to be an anti-reflux surgery, and most patients will be unable to belch to relieve gastric air after the operation.
Other Considerations
- Cook your own food. Avoid all types of fast food, even if seems to be a healthy salad or other type of healthy food, they often contain added sugar (especially premade salad dressings), taste enhancing chemicals and trans fats.
- Clean up your refrigerator and pantry, remove all bad foods to avoid unnecessary temptation. Think ahead what you are going to have for breakfast, lunch, and dinner and shop and cook accordingly. If possible, always bring your own lunch box to work with healthy foods. Use your own thermos with hot coffee or tea to avoid temptation to buy a beverage loaded with sugar and cream. Always give preference to low-processed or non-processed food.
- Solid protein derived from such sources as eggs, poultry, lean meat, low-fat cheese, fish, and seafood, mushrooms, etc., will satisfy you much more than any type of liquid meal substitutes or protein shakes. You will have enough time to get tired of shakes during the 3-day liquid pre-op diet stage as well as during the first 3 weeks of the post-op diet when you will have no other choice but to stick to fluids. Enjoy solid food while you can, it will remain in your stomach longer to get digested and will provide the feeling of fulness much longer than liquid meals.
Common Post-Surgery Symptoms and How to Manage Them
Patients may experience difficulty swallowing or trouble swallowing during the first few weeks. This is normal and can be managed by sticking to softer foods. However, if symptoms persist, consult your surgeon’s office. Monitoring any signs of pain or swelling and reporting unusual symptoms to healthcare providers is essential.
Other Pre-Operative Procedures and Considerations
Barium Swallow or Upper GI x-ray is performed to characterize a hiatal hernia’s size and position. Upper GI Endoscopy, also known as EGD, is a visual exam of the upper GI tract using a small lighted fiberoptic scope. It is performed so that the lining of the esophagus and the stomach can be seen and evaluated prior to the operation. It is most often performed on an outpatient basis and you will be given a throat anesthetic and intravenous sedation in order for the exam to be performed comfortably. You will not be allowed to eat or drink anything past midnight prior to your procedure. Patients are required to have a responsible person to drive them home.
A 24-hour pH test actually measures the amount of time stomach acid is splashing into the esophagus and how high the acid goes up into the esophagus. It usually requires placing a small thin catheter into the esophagus that is connected to a computer and wearing the tube for 24 hours. A computer analysis is performed and the surgeon is given a report. Esophageal manometry is a study performed by placing a small thin catheter and measuring the pressure within the esophagus. Bloodwork, EKG, and Chest x-ray are part of a pre-operative “work-up.” Some or all of these may need to be performed prior to your operation depending on your age and overall physical health.
The pre-operative “work-up” also means that you will need to spend time being interviewed by the anesthesiologist and having a complete physical examination by a resident physician. This is done during a clinic visit. You will be called by a Pre-Care nurse the night before your surgery. The afternoon before your surgery (or the Friday before if you are scheduled for surgery on Monday), a Pre-Care nurse will call to tell you what time you should arrive for surgery. If you will not be at home or if it is difficult for the nurse to call you, then you may call (919) 966-2273 between 3pm and 6pm to find out what time to be at the hospital the day of your surgery.
What to Expect on the Day of Surgery
You should arrive at Pre-Care at the time given you. Your family may be with you while you are being prepared for the operation as well as with you in the operating room holding area. In Pre-Care you will be prepared for surgery. This means changing into a hospital gown, obtaining your vital signs and being interviewed by a nurse. You then will be taken into the operating room holding area where you will meet the anesthesiologist and again more questions may be asked. In the Ambulatory Procedure Care area you will be prepared for surgery. This means changing into a hospital gown, obtaining your vital signs and being interviewed by a nurse. You then will be taken into the operating room holding area where you will meet the anesthesiologist and again more questions may be asked. The operation lasts from 2 to 4 hours (average 3 hours). Immediately after the operation, you will be taken into the Post Anesthesia Care Unit, (PACU), or recovery room, for approximately 1 to 2 hours. You will be watched closely until you are awake and then you will be transferred to a hospital room. The length of time you will be away from your family may be 6 or 7 hours.
Post-Operative Care
- Intravenous line (IV) for fluids and pain medication. You will be in control of your pain medicine by receiving Patient Controlled Analgesia or a “PCA” following the operation. This means that a computerized pump will be attached to your IV line, and you will be in control of your pain medicine by pushing a button to give yourself pain medicine as needed. There will be limits to the amount you can get, but it will be enough to keep you comfortable. As with any type of surgery, it is reasonable to expect some amount of pain.
- Nasogastric tube (NG) a small tube that goes through the nose and into your stomach,to prevent nausea.
- The hospital stay after this operation is usually 2 days. During this time you are monitored closely by the nursing staff.
- You will be kept on a clear liquid diet the day of surgery.
- After your surgery, you will be allowed a full liquid diet.
- You should avoid driving for at least 5 days following surgery.
- Avoid lifting anything heavier than 20 to 25 pounds.
- Keep incisions open to air.
Potential Outcomes and Considerations
The operation lasts from 2 to 4 hours (average 3 hours). Immediately after the operation, you will be taken into the Post Anesthesia Care Unit, (PACU), or recovery room, for approximately 1 to 2 hours. You will be watched closely until you are awake and then you will be transferred to a hospital room. The length of time you will be away from your family may be 6 or 7 hours. Intravenous line (IV) for fluids and pain medication. You will be in control of your pain medicine by receiving Patient Controlled Analgesia or a “PCA” following the operation. This means that a computerized pump will be attached to your IV line, and you will be in control of your pain medicine by pushing a button to give yourself pain medicine as needed. There will be limits to the amount you can get, but it will be enough to keep you comfortable. As with any type of surgery, it is reasonable to expect some amount of pain. Nasogastric tube (NG) a small tube that goes through the nose and into your stomach,to prevent nausea. The hospital stay after this operation is usually 2 days. During this time you are monitored closely by the nursing staff. the stomach. into your chest. suppressing medications may no longer be needed. meaning you will be asleep throughout the entire surgery. access to the affected organs (Figure 1). as needed. post-operatively. Diet: You will be kept on a clear liquid diet the day of surgery. after your surgery, you will be allowed a full liquid diet. surgery. Avoid lifting anything heavier than 20 to 25 pounds. Driving: You should avoid driving for at least 5 days following surgery. Dermabond. This glue will come off on its own with time. open to air. for anti-reflux surgery. in the abdomen. degrees or 270 degrees, around the esophagus. dysphagia (difficulty swallowing). Also, the return of symptoms is possible. the likelihood of developing chronic dysphagia is less than 5%. Results vary depending on your exact symptoms and other factors. satisfied with the results of their surgery. Torquati A, Houston HL, Holzman MD, Sharp KW, Richards WO. fundoplication: 5-year follow-up.