Surviving after the Hiatus Hernia Surgery as a Singer

Since my last article about my struggle with a Hiatus Hernia, and my two Nissen Fundoplication surgeries to resolve it, I have had so many questions from other people suffering from the same condition. Some were about to get the surgery and were fearful. Others had done the surgery, and had confusing post-surgical symptoms, or wanted to get back to singing as soon as possible.

This article addresses specific concerns that they had, and that others may have about the surgery. If you want to know more about my journey and the details of the surgery, you can find my older article here.

I’ve tried to answer each question personally via email, but I will also pass the knowledge onto everyone who may be going through the same thing.

As I am no doctor, please do not take my advice as gospel. I will answer each question using both the advice of mine (and other) doctors, as well as my own experience as a singer.

Firstly, I’d like to say this: You are not alone. I understand that feeling. The concern that your reflux may never go away without surgery. The anxiety of going through surgery. The desire to make the healing process after surgery much faster. The fear that the surgery could come undone. I know each of those phases. I am here to say that it’s a very small blip in an otherwise very fulfilling life after surgery!

Should I ask anything before/after the surgery?

I would just make sure of these things:

• That your surgeon is known for performing this surgery.
• That you ask for a sedative BEFORE your anaesthetic. This will remove any nervousness you have before you are taken into theatre.
• Ask that you speak to the anaesthetist or surgeon on the day and ask for the smallest intubation tube possible. This is to reduce any inflammation that the breathing tube may cause to your throat post-op (which is usually minor and lasts a day or so).
• Bring a laptop, ipad, iphone, books etc. Make sure it’s a range of material, and not too difficult to read/watch. You may struggle to sleep in hospital, so you’ll want these to pass the time.
• Encourage people to visit you. Those first couple of days in the hospital can be a little lonely, but it’s not too bad with enough reading/viewing material. Note that you may be quite drowsy and not the best at entertaining guests!
• Let the hospital staff know of any allergies or dietary requirements.

How long until I start singing again?

The doctor’s answer:

Around 2-3 months you can return to light singing (5-10 minutes every day-two days). 3-5 for more committed singing (20-30 minutes every couple of days). After then, it’s best to listen to your body, and let it decide what you’re ready for.

My experience:

First Surgery – About a month after surgery I ended up getting recruited for Ralph in HMS Pinafore. I barely gave myself time to recover. After 3-4 weeks I was singing about 10-20 minutes every couple of days. Then once rehearsals started, it would be short bursts of singing, but full song runs for musical and movement rehearsals. My voice was healthy, although I did have to ‘float’ the sound a lot, as I did not have my full lung capacity available. Breathing deep would cause some pain.

I would not recommend that anyone do this, as over-working myself so early on may have contributed to the dilation of the wrap.

Second Surgery – As my voice had been injured from 3-5 months of singing on chronic reflux (after the first surgery came undone), I had no choice but to slowly ease back into singing. I was singing for short periods (5-10 minutes) every couple of days for the first 2-3 months, and that grew to 30 minutes after 3 months. I am a tenor, but I was singing lighter baritone and lower tenor art song repertoire during this period.

I returned to singing exam preparation 7 months after the surgery. Had my first singing exam a year after surgery, and my largest singing exam (60 minutes of singing) 1.5 years after the surgery. From then on, I gradually started to perform in musicals, concerts, soloist roles in masses and opera.

In short, I did not properly return to singing in public for over a year.

Singing Recommendations:

My surgeon’s original advice would be the best to follow. Avoid singing for the first month. You could always spend some time humming, and doing very gentle deep-breathing exercises, but nothing that stretches the diaphragm too far. After 1.5-2 months, gradually introduce 5-10 minute vocalises. They can grow longer with time. 3-5 months you could begin to learn repertoire again, but nothing that demands too much from the body.

Can I return to exercise? And if so, when, and what exercise can I do?

The doctor’s answer:

I did not actually get a lot of information from my doctor about this. I believe this is because a lot of his patients were people with weight-loss surgery, so their exercise regime was focused more on fat loss – consistent, lower impact exercise.

My experience:

First surgery – I was back to some casual weight lifting after about 5-6 months. I was never very committed to this however. I did swim a lot though, and this never seemed to have any major impact on me for either surgery.

What I can say, however, is that I took up a part time job in a chiller during my student years. Over the summer break I was lifting heavy boxes of chilled and frozen product every day for long periods of time. I and my surgeon believed this was one of the key reasons why my surgery came undone.

Second surgery – I avoid any heavy lifting, both for exercise and in everyday life. I only ever lift something heavy if someone is helping me. I swim 2-3 times a week and keep active – e.g. hiking, kayaking, walking or scootering to places rather than driving.

Exercise Recommendations:

• A rule of thumb; if you must grunt to lift something, stop immediately and get someone to help you. Your health and happiness are more important than your ego.
• Take up swimming. This is one of the most full-body exercises you can do. It will improve your lung capacity, improve your fitness dramatically, and tone your muscles. If you don’t know how to swim, here’s a secret: I taught myself to swim only 4 years ago!!! The key is to constantly compete with yourself. If you are a new swimmer, getting through 2-3 lengths will still work your body because of how tough it will be.
  For those early days, get a flutter board to learn to kick. Then get a snorkel and some hand and leg flippers to help strengthen and grow your muscles and improve your form. Flippers will also help you bulk up even after you’ve improved!

• In addition to the rest, take up an active lifestyle. Go for longer, brisk walks either by yourself or with friends. Go hiking, go kayak, do Tai-Chi, yoga, or snowboarding. Learn exercises that will work your whole body, while avoiding anything that causes you to consistently lift heavy objects unaided.

The surgery is a lifestyle change, especially for anyone who is into extreme-bulking. I would like to say, however, that I was never an extreme-bulker. If you are determined to take this up post-surgery, I would seek out another bulker who has done the surgery. They will have the best advice for you.

Do symptoms ever come back? Are they meant to?

The doctor’s answer:

It depends on the person. It fails completely for a small portion of people. Some will get minor reflux symptoms, and some will get absolutely no reflux again.

My Experience:

First Surgery – Until it came undone, I had absolutely no reflux.

Second Surgery – While the second one has been longer lasting, I am prone to very minor bouts of reflux. Usually this is only after eating a very big meal (which you should generally avoid doing), or spend a long period of time drinking alcohol in the evenings, or eating sugary things. For example, I recently had about 1-2 weeks worth of on and off symtpoms after the Christmas and New Year break. I do not get ‘silent reflux’ (aka the singer’s nemesis) at night time.

One could argue that if you ever get small bouts of reflux again, you’re probably getting the same symptoms as someone without a hernia who gets occasional reflux. In a sense, you are returning to a level of normality – and minor reflux is probably a signal of something dietary you should change, or your level of stomach HCL (see later sections).

How do I know whether to worry?

Generally, worrying is never a great idea! However, make sure that if you ever get reflux-like symptoms again, you are sure that it is because of reflux. I used to get a ‘cold peppermint in the throat feeling’ when I had bad reflux. I also get this symptom with hay fever, so when I do get this sensation, I’ve learned that it is rarely, if ever a sign of reflux.

Symptoms? Here’s a few ways to determine if your reflux may have returned. Note that these symptoms need to occur repetitively and during the same period of time for any telling signs:

• If you find that when you belch, you are consistently bringing up food.
• If you do any shoulder-standing and you regurgitate consistently, as well as having similar incidents while upright.
• If you find that when you burp, it just feels like a column of air from mouth to gullet, this could mean things are too loose down there.
• Any typical reflux symptoms: Lots of coughing in the morning, burning in the chest, regurgitation, sour taste in the mouth.

Handy test: I find that when everything is doing well, drinking water in the morning (if it’s the first thing you drink) may cause a ‘draining sensation’. You will slightly hear this from around where the stomach is, and you may even feel a very slight vibrating when this happens. While this isn’t a hard and fast test, if you find that drinking just causes things to slosh back up instantly, this could be a sign to get things checked.

More Guaranteed ways to know:

• Get your throat checked by an ENT. They will see whether your pharynx and larynx are being affected by any reflux. If you’re getting only lower esophageal reflux, then it should look fine.
• Get a pH test. This is a rod that goes down your esophagus (through the nose). It detects any incidents of reflux.
• Barium Swallow. This is where you swallow a liquid that expands your stomach for anomalies to be detected using X-rays.
• Where a camera goes down your esophagus – This is the best way of knowing for sure.

Is having a second operation depressing?

It is somewhat depressing when you realise you need a repair or a re-do, but on the other hand, it’s another excuse for a long-deserved break, and you know what to expect. Normally the second surgery is FAR less painful. I don’t think I had to take many painkillers at all!

If my symptoms do flare up again, is there a way to stop or reduce them?

In situations like my own, where I occasionally have small bouts of reflux, I like to go on a regiment of Betaine HCL and Stomach enzymes. These are incredible and it works better than Apple Cider vinegar in my opinion! The Lower Esophageal sphincter closes when there’s enough acid in the stomach. There are many of us, including myself, with low HCL. This has been known to cause H.Pylori infections, which can cause reflux.

Simply take 2-3 tablets (I take 2) of Betaine HCL about a minute BEFORE eating a meal. Take 2-3 enzyme tablets too. You can find them on Amazon (see below), and they should last you a long time. Note that most of the reviews for any Betaine HCL are highly positive, and mention a complete end to GERD!

Betaine HCL – (Usually around $10-15)

I also recommend taking a small swing of pure aloe vera juice before and after meals. I tend to do this for smaller meals, as I only take HCL before big meals.

As I have pointed out in a previous article, you can use slippery elm for healing the esophagus from these incidents. I find the lozenges really nice to chew if I ever sing after a meal (which happens!) and I want to reduce the symptoms during singing.  Note that this won’t remove the reflux entirely, but will help coat the esophagus to aid in healing.

Slippery Elm Lozenges ($30-40)

Did you follow a recovery diet? Are there any diets I can follow if I don’t do the surgery/If I do the surgery and I get reflux?

After the surgery, it’s simple. You will be having smoothies (avoid seeds for 2-3 weeks), yogurt, scrambled eggs, vitamin supplements and anything else that isn’t too hard to chew up. Your wrap will be swollen for the first few weeks, so any food that goes down there will trickle into the stomach very slowly. It will be quite painful, but not unbearably so.

If you don’t want to do the surgery, or, like, me, you get rare reflux symptoms due to an indulgence period, then I would follow the diet below during a flare up – then gradually add in things you want to eat after 2-3 weeks. It was recommended to me by a dietician, and it works for me every time.

Firstly, you ideally want to take Betaine HCL and diegestive enzymes before each of the larger meals.

Focus on a very balanced, but plain diet. Make a selection from the lists below.

Breakfast:

• Weetbix (NZ or Aus) or any kind of low-sugar, high fibre cereal. The more plain the better
• Milk (of your choice)
• Yogurt
• Some honey to sweeten your breakfast
• Eggs

Lunch:

• Natural Almonds
• Chia seeds in milk (sweetened with honey. Reduce honey over time as you get used to the flavour)
• Banana (not too ripe, not too early)
• A smoothie with linseed – use the banana in this, and don’t drink too fast

Dinner:

• Boiled/steamed carrots, broccoli, cauliflower
• Coleslaw with no mayonnaise
• Some lime and lemon juice, salt and pepper to season the above
• Fish fried in a small amount of high-burning point oil (rice bran). Make sure there are no bones
• If you are vegetarian, then use tofu or haloumi
• If you cannot stand fish, then you could use some chicken, but ideally you want the healthy fats from fish

Things to note:

• You may wish to take some iron supplements, especially if you’re used to eating lots of red meat.
• VERY IMPORTANT: Chew your food down to a very fine mash in your mouth. I know that sounds disgusting, but it is exactly how food needs to be processed. If you are not doing so, you are likely gulping things down and they will cause havoc in your stomach.
• Also avoid drinking during a meal. Try to be well hydrated throughout the day.
• I would also suggest periods of cutting out gluten and/or dairy to eliminate the possibility of intolerance or Celiac. I am Celiac after 26 years of not knowing!

If these symptoms are not letting up after this diet, and you’ve had the surgery, it’s time to check in with the surgeon to see if anything has occurred.

Is the operation anything to fear? Will I be in a lot of pain?

The surgery is not overly scary. I recommend calling ahead and asking that you are given a sedative before having the anaesthetic. Why? Because people are generally most anxious BEFORE a surgery.

Where might you experience pain? And why shouldn’t you worry?

Stomach: This will feel like you have bad gas and indigestion. The reason why is because you actually do! During the surgery, your stomach will have been expanded using gas to make the surgery easier. Furthermore, your new wrap will make any air you swallow more difficult to get out. While this is quite scary for people at first, the issue does go away as the inflammation decreases.

There are two main ways to combat this:

1. Go on small walks around the hospital and your neighbourhood (when you’re home) to move the gas through.
2. Before you swallow food and drink, blow any excess air out your nose or mouth. You can blow it out your nose by mothing any ‘air pockets’ in your mouth to the back of the throat and letting it go into your pharynx as if you are about to gulp some water

Timeframe: This pain is more on-going for 1-2 days after the surgery, and on-and-off for 1-2 weeks.

Neck: You may get intense neck pain after a few days. You will possibly think that this has something to do with lying in a hospital bed. This pain comes from your diaphragm. Like when you get ‘the stitch’ while running, you may get some similar pain in the neck.

To reduce this pain, I mostly relied on painkillers, and taking slow, relaxing breaths. This is one you must simply wait out. A good excuse for Netflix!

Timeframe: This pain tends to occur 2-5 days after surgery and dies down after 1-2 weeks.

Diaphragm: As part of the surgery involves stabling the hole in the diaphragm, breathing may cause some discomfort. For most people who are not singers, this will probably feel like something that will just reduce over time. For singers, a twinge of pain may remain whenever they try to inhale deeply even after a month or so. Therefore I recommend waiting for at least 1.5-3 months before any consistent singing practice.

Timeframe: Pain during normal breathing isn’t too intense, and lasts about 1-2 weeks. If you’re a singer, you may get a twinge during deep breathing even 2-3 months after surgery. Don’t be alarmed by this, but keep singing to a minimum

Esophageal pain/burning: If you had really bad reflux before the surgery, your esophagus now has time to heal. As a result, you will likely feel some discomfort in the esophagus and may even think your reflux is back. It’s highly unlikely that your reflux is back. Rather, think back on whenever you damage your skin. The greatest amount of pain often occurs after the damage – this is because the pain is being caused by inflammation. Inflammation is your body’s way of getting more nutrition to a site for healing!

Timeframe: For me, this lasted 2-3 months after, but was only really noticeable if I thought too much about it.

While I have mentioned a number of pain sources, it does NOT feel unbearable or strange. My surgeon referred to the stomach and oesophagus as ‘dumb organs’, because any pain they cause can be confused for other things. You will mostly feel sensations similar to a sharp stitch, bad indigestion/gas and reflux after the surgery, nothing strange or foreign. It is uncomfortable, but not so uncomfortable that you can’t spend a week planted on a couch watching your favourite shows!

It is never as bad as it seems

I have gone through what could possibly be considered some of the worst-case scenarios short of having Barrett’s esophagus and any permanent vocal damage. I can whole-heartedly say that nothing is ever as bad as I made it out to be. Going through one surgery, let alone two, is definitely an emotional journey, but it is doable by anyone. If I can do it, then so can you. Hopefully this article will have cleared up a number of concerns people have going into and coming out of this surgery, particularly when singer, and even non-singer experiences are not well documented.

If you’re going through this now, please do not be afraid to reach out to me as others have done.

With Love

Michael O’Connor