Hiatal Hernia Surgery and Repair in Northern Virginia
What hiatal hernias are, and what they mean for patients
Accuracy of the medical content was verified by Dr. Matthew Fitzer, M.D., FACS, FASMBS, a board-certified bariatric surgeon. (He authored most of it.) Read Dr. Fitzer's professional bio
A hiatal hernia occurs when the top of the stomach gets pulled up into the chest. Small hernias sometimes cause heartburn, but that’s about it. They are usually found by accident.
Large hernias also can cause heartburn, but they make other kinds of mischief, too. They cause some people to have food come back up on its own (regurgitation), chest pain, trouble swallowing, or an abnormal feeling of fullness after a few bites of food. Very large hernias occasionally create more serious problems, such as bleeding or blockage of the GI tract.
Dr. Matthew Fitzer repairs these hernias laparoscopically. In other words, he uses either four or five small cuts instead of one big one.
Some patients have their hernia fixed at the same time they get weight-loss surgery.
Obesity and hiatal hernias are two problems that have a lot of overlap. The connection between them is worth understanding, but we'll get into that later. First, we need to talk about the different types of hernias.
What is a hiatal hernia?
Your esophagus connects your mouth to your stomach, which sits in the abdomen. To get to the abdomen, the esophagus must pass through the chest. The barrier between the chest space and the abdominal cavity is your diaphragm muscle. (See the diagram.)
Everybody is born with a small gap in the top of the diaphragm. It’s where the esophagus passes through from one side to the other. The opening is called the esophageal hiatus. It’s why we call hernias in that spot hiatal hernias.
The diaphragm should fit the esophagus snugly at the hiatus. There shouldn’t be much extra room there. If the gap is overly loose or wide, a hiatal hernia is said to exist. Over time, the top of the stomach tends to get sucked up through that gap into the chest.
These hernias come in four distinct types. Types II, III and IV are all called paraesophageal hernias, because part of the stomach moves up into the chest alongside the esophagus.
Type I, “sliding”
Less than an inch or so of the stomach is in the chest. They tend to “slide” in and out of the chest as you breathe. Most hernias are type I. Type I hernias can (but don’t always) cause reflux.
Type II, “paraesophageal”
The esophagus mostly stays put, but part of the stomach rolls into the chest alongside it.
Type III, “mixed”
Both the esophagus and stomach move up into the chest. Most hernias that get to surgery are type III.
Type IV, “giant”
The gap in the diaphragm got so big that other organs — colon, spleen, pancreas, etc. — have been sucked up into the chest with the stomach.
Hiatal hernia symptoms: some familiar, some surprising
The type of hernia is important to surgeons. For one thing, it says a lot about the odds that a hernia could turn into an urgent problem. Sliding hernias may cause heartburn, but they don't cause emergencies. Giant hernias, on the other hand, can cause an emergency. They carry a small risk of causing organs to twist, bleed, and/or obstruct. They need to be treated more urgently.
The familiar ones:
- Heartburn, especially lying down or after a large meal
- Regurgitation — food or acid coming back up, sometimes at night
- Chest pain that can mimic cardiac pain
- Trouble swallowing, or food getting stuck
The ones patients rarely connect to a hernia:
- Early satiety (sometimes getting full after only a few bites)
- Chronic cough (stomach acid inflames the trachea and main bronchi)
- Hoarseness (stomach acid inflames the vocal cords)
- Worsening asthma (stomach acid reflux damages the lungs at night)
- Shortness of breath after eating (when a full stomach keeps the left lung from filling with air)
- Unexplained anemia (when erosions cause minor, intermittent bleeding where the stomach is pinched at the hiatus)
Why hiatal hernias and obesity travel together
People with obesity store fat on the inside of their body as well as the outside. One of the places fat is stored is inside the abdomen. The abdomen only has so much room. When fat accumulates there, it leaves less room for your organs. When the abdomen becomes too crowded, the pressure starts to go up.
Pressure in the belly pushes outward in all directions. One place it pushes is against the edges of the hiatus muscle. Pressure keeps on pushing, all day, year after year. With enough time, it may stretch the opening. High belly pressure is why hiatal hernias tend to develop in patients with obesity. It is also why reflux often improves as weight comes off.
There is a lot of overlap between hiatal hernia repair and bariatric surgery in practice:
- Hiatal hernias are often discovered during bariatric surgery. Some need to be repaired on the spot, especially during a sleeve gastrectomy.
- When reflux after a sleeve is severe, converting to a bypass with hiatal repair at the same time is a reliable and durable solution.
- For severely obese patients with a hiatal hernia and bad reflux, the standard treatment is hiatal hernia repair AND gastric bypass. Hernia repair by itself is extremely prone to failure and recurrence in obese patients.
- For a hiatal hernia that was previously repaired once and came back, gastric bypass is a recognized option. In selected patients, it is a better choice than a redo repair.1
When hiatal and paraesophageal hernia repair is recommended
Not everybody needs hiatal hernia repair. In fact, it is right to say that most hernias should be left alone. Small sliding hernias can usually be managed just fine with medication and lifestyle changes. When it works, it’s the right call.
Repair should at least be a part of the conversation when:
- Reflux persists despite proton pump inhibitor medication which cannot or should not be taken indefinitely.
- Reflux has caused severe damage: esophagitis, stricture, or Barrett’s esophagus.
- The hernia is large.
- The hernia is causing obstruction, bleeding, or anemia.
- Intolerable reflux develops after a sleeve gastrectomy.
How hiatal hernia repair is done
The operation is performed laparoscopically, meaning through small incisions. There are four main steps.
Reduce the hernia. The stomach (and any other organ) is returned to the abdomen.
Cut out the sac. The hernia sac is excised from the chest. Leaving it is a reason hernias recur.
Mobilize the esophagus. The esophagus needs to reach into the abdomen with no tension. (Tension is the enemy of a lasting repair.) If it is stuck in the chest, it must be made un-stuck.
Close the crura. The “crura” are the sides of the hiatus.1 The oversized opening is brought back to normal with sutures. A mesh may be needed to close a huge hernia, but we try to get by without one. The outcomes evidence doesn’t favor either way over the other.1
Fundoplication (a “wrap”). In patients who have not had weight loss surgery, hiatal hernia repair normally includes this step. Fundoplication entails wrapping the fundus around the lower esophagus. Once wrapped, it is permanently sutured into place.
How wraps work is hard to explain without diagrams and/or hand gestures, but they work. They effectively create a one-way valve at the top of the stomach. What you swallow can pass across it into the stomach, but it can’t go the other way.
Current guidelines favor doing a wrap with hiatal hernia repair. That guideline does not, however, apply when the patient has had weight-loss surgery. For bariatric patients, we normally skip it.
Sleeve patients don’t have a fundus anymore. For them, there’s simply nothing to wrap. Bypass patients do have a fundus—sort of. It’s there, but it was separated from the pouch. Wrapping the disconnected fundus of a bypass patient has been tried, but it doesn’t work as well. It provides no real benefit.2
There are three ways to do a wrap, each named for its surgeon inventor. They include the Nissen, the Toupet, and the Dor. They all have different clinical uses.
Nissen fundoplication
A complete 360-degree wrap. The top of the stomach is brought around the back of the esophagus and sewn to itself in front, forming a full collar. It gives the best reflux control of any wrap, and it has the longest track record. Most long-term data on antireflux surgery is Nissen data. We’ve been doing them since the 50’s.3
Reflux control is good, but the trade-off is swallowing. A full wrap is the most prone to causing difficulty swallowing in the early weeks, and maybe longer. It can also cause bloating. Some patients find they can no longer belch or vomit.
These kinds of problems usually fade away within a few months. During those months, the swelling slowly resolves, and the wrap itself softens.
The Nissen is a good operation overall. It is the best choice for severe reflux when the esophagus works normally.
Toupet fundoplication
A partial 270-degree posterior wrap. The stomach is passed around the back of the esophagus like a Nissen—but not all the way. The collar covers three-quarters of the esophagus rather than going the full circuit. Reflux control is less robust than a Nissen, but only a little. The relevant clinical studies have shown that the difference in reflux control is small.
The benefit of the Toupet is better swallowing. There is less early swallowing trouble, less bloating, and better belching. It’s the preferred wrap when testing shows the esophagus does not squeeze normally. It’s also used for patients who already have some kind of swallowing issue. It is now the most performed partial wrap.
Dor fundoplication
A 180-degree anterior wrap. The stomach is simply laid over the front of the esophagus. No part of the stomach is passed behind it. The Dor is the gentlest option. It is unlikely to give a patient swallowing problems, but it is the weakest at reflux control.
Its uses are pretty specific. For instance, it is usually done as part of a myotomy, which is an operation for achalasia. It is also a fallback maneuver when the back of the esophagus is not safe to move.
An alternative to a wrap: magnetic sphincter augmentation (LINX)
The LINX device is a ring of magnetic beads. It is placed around the lower esophagus, where it hopefully will prevent reflux.
The idea behind it is this: The esophagus is very strong. It pushes food to the stomach with high pressure, much higher than the pressures that drive reflux in the opposite direction. The force of swallowing is enough to make the beads release each other, so food can pass into the stomach.
Once food is past the LINX, however, it’s stuck. It can’t go backwards. Pressure spikes within the abdomen4 are low compared with esophageal pressures. They are too weak to re-open the beads.
Patients researching reflux surgery almost always run into it, so it is worth understanding who can get it. The LINX is not for everybody. It is only right for a specific kind of patient.
The idea LINX candidate has reflux that responds well to medication. Their esophagus needs to work normally. They can have at most a small hiatal hernia. (Hiatal hernias are a problem for the LINX.)
A large hernia, a badly damaged esophagus, or previous stomach surgery all recommend against it. It is also a poor fit after a sleeve gastrectomy. Reflux improvement is mediocre in sleeve patients. For them, repairing the hernia — often with conversion to a gastric bypass — is a much more reliable solution.
Hiatal hernia repair during weight-loss surgery
When a hiatal hernia is found during a sleeve gastrectomy, it should usually be repaired then and there. The data support doing so. Across 18 studies and 937 patients, sleeve gastrectomy combined with hiatal hernia repair produced GERD remission in about 68% of patients. It was meaningfully better than sleeve alone at resolving reflux (odds ratio 2.97).2
A single-center series with nearly four years of follow-up found about 69% of patients had their reflux resolve completely. Even more were able to get off PPIs.3
Repair does not guarantee a reflux-free life. In the same analysis, roughly 12% of patients developed new reflux they didn’t have before. Another 11% had the hernia (and reflux) recur.2
The takeaway? If you are considering a sleeve and you already have reflux, some extra time should be spent going over operation choice. That advice applies regardless of hiatal hernia status. Sometimes the answer is a sleeve with the hernia repaired. Sometimes a bypass is the right answer.
Hiatal hernia and reflux after a gastric sleeve
If you had a sleeve gastrectomy and reflux has become a major issue, a hiatal hernia may be the problem. If so, repairing it has the potential to provide lasting relief.
Diagnosing a hiatal hernia can be done with an upper GI contrast study, which is a five-minute x-ray. Sometimes upper endoscopy (a scope through the mouth) is also needed. pH testing is needed occasionally.
When hiatal hernias come back: recurrent hernias
We want hiatal hernia repairs to last forever, but some will eventually come back. The medical journals put the rate somewhere between 10 and 50%--an unhelpfully broad range.5
If your hiatal hernia comes back, it doesn’t mean the repair wasn’t done right. It can happen even after a flawless repair performed by an expert. Dr. Fitzer has done close to 1,000 such repairs, which is a much, much larger experience than average. He also got formal fellowship training in hiatal hernia repair. Despite these sterling credentials, he still gets recurrences now and again.
Several factors bear on the odds of failure. Among them are the size of the hernia, obesity, and the length of the esophagus. Of those factors, obesity is the only one we can try to proactively correct.
Admittedly, 10 to 50% sounds like a lot of recurrences. Keep in mind that most are small, technical recurrences that do not require another repair. Studies tend to count minor (less than an inch) upward migrations of the stomach found on surveillance imaging. We don’t normally do surveillance testing on asymptomatic patients. It’s only done in clinical studies. They tend to try extremely hard to find recurrences.
Some recurrences entail a more complete failure of the repair. They may be accompanied by return of pre-surgery symptoms or new, worse ones. These are the hernias we consider repairing again. Dr. Fitzer is highly experienced with redo hiatal hernia surgery.
We tend to think a little longer and harder before recommending a second or third repair to a patient. They are almost always feasible, but they entail more risk.
For one thing, repeat operations take longer. Scar tissue from the prior repair tends to stick the liver, stomach, and diaphragm together. Those organs must be manually separated from each other before the repair can begin. It’s work we didn’t have to do the first time around, and it adds operative time. The longer the surgery is, the more likely certain complications (e.g., blood clots) become.
A hernia that came back after one repair may benefit from re-repair. In some cases, conversion to a gastric bypass is the better answer. The gastric bypass remains the most reliable anti-reflux operation available. It works for people who have had weight loss surgery and those who haven’t. Read more about it under sleeve revision surgery and managing weight regain after bariatric surgery.
Recovery after hiatal hernia surgery
Most patients go home the same day a hiatal hernia is repaired, or after one night if weight-loss surgery was done at the same time. People are ready to return to desk work in about a week, but there is no heavy lifting for four weeks. Your diet after surgery is liquids only for the first week. It then moves in stages through soft food to a normal diet over the next four weeks.
- Most patients go home the same day of hiatal hernia repair, from the recovery room.
- If you had bariatric surgery during the same operation, you can plan to spend one night in the hospital.
- You begin a staged diet right away: liquids, then soft foods, then a gradual return to normal over several weeks.
- No heavy lifting for 4 weeks.
- People typically can return to desk work after one week. Physical workers have a longer recovery.
- Some difficulty swallowing in the first weeks is expected. Be patient!
Risks and honest expectations
Recurrence is what we strive to avoid. The hiatus is a moving part — it works with every breath and every swallow — and repairs can loosen over time. We know recurrence happens more with large hernias and in patients with high intra-abdominal pressure.
Other uncommon risks: swallowing trouble, inability to belch or vomit, bloating, and injury to the esophagus or stomach. Also, there are the various risks of general anesthesia.
Insurance and cost
Hiatal hernia repair for symptoms is generally covered as medically necessary. The approval pathway is different from, and less onerous than, the one for bariatric surgery. When hernia repair is to be performed at the same time as a weight-loss operation, the coverage question follows the bariatric operation. The self-pay price is the same as sleeve gastrectomy.
Hiatal hernia surgery for patients across Virginia
Laparoscopic hiatal hernia repair is usually an ambulatory procedure at INOVA Fair Oaks Hospital in Fairfax. When it's done at the same time as a sleeve or bypass, it doesn't affect the one-night stay for bariatric surgery. Many patients are referred by their gastroenterologist or primary care physician. We accept referrals from across Virginia, including Richmond, Fredericksburg and Hampton Roads. Telehealth first visits are available.
Patients also come to Dr. Fitzer from Richmond, Charlottesville, Fredericksburg, Newport News, Norfolk, Virginia Beach, and Suffolk.
Hiatal hernia repair is often done at the same time as gastric sleeve surgery in Northern Virginia or gastric bypass in Northern Virginia.
Frequently asked questions
- Does a hiatal hernia always need surgery?
No. Most are small, cause few symptoms, and are managed with medication and changes to how and when you eat. Surgery is for hernias causing symptoms that medication does not control, or hernias large enough to pose a risk on their own.
- Will hiatal hernia repair cure my heartburn?
Usually it improves it substantially, and many patients stop acid medication entirely. It is not a guarantee, and a small number of patients develop reflux they did not have before.
- Can a hiatal hernia come back?
Yes. The hiatus moves with every breath, and repairs can loosen over time. Recurrence is more likely with large hernias. When a repair fails, a second repair is possible, and in selected patients conversion to a gastric bypass is the more durable answer.
- Can my hiatal hernia be fixed during weight-loss surgery?
Yes. If a hernia found during a sleeve or bypass deserves repair, it is normally done then and there, at the same operation. Repair of a hernia found during sleeve surgery lowers the odds the patient will have heartburn down the road.
- I had a sleeve and now I have terrible reflux. Is a hernia the cause?
Often it is, but not always. Some people develop reflux after their sleeve with no hiatal hernia present. Imaging can tell us what is going on most of the time. Now and then we need upper endoscopy to tell.
If there is no hiatal hernia, the sleeve itself is driving the reflux. Heartburn symptoms can usually be suppressed by medication. When medications don't work, converting to a gastric bypass is a reliable way to solve the problem.
- Can I get a LINX device instead of a fundoplication?
For some patients with reflux, yes — LINX is a magnetic ring placed around the lower esophagus, and it suits patients with a small hernia or none, a normally functioning esophagus, and no prior stomach surgery. It is a poor choice after a sleeve gastrectomy, because reflux after a sleeve comes from pressure inside a narrow stomach rather than from a weak valve. Repairing the hiatal hernia, often with conversion to a gastric bypass, is the more reliable answer for those patients.
Related pages
- Gastric sleeve revision — when reflux after a sleeve means the operation itself needs a second look.
- Sleeve gastrectomy — the first-time weight-loss operation hernias are most often found during.
- Gastric bypass — the most reliable anti-reflux operation.
- Managing weight regain after bariatric surgery — what to do when weight returns after a prior operation.
- Insurance coverage — what plans ask for before approving surgery.
Take the next step
If heartburn, regurgitation, or a known hiatal hernia is complicating your life — or your weight-loss surgery plans — a workup will show exactly what is going on. Ready to talk? Request a consultation online or call (703) 709-9771.
Written and medically reviewed by Dr. Matthew Fitzer, MD, FACS. Last updated October 2026.
Notes
- The word “crura” is the plural form of “crus.” Crus is actually the Latin word for “leg.” When you look at a picture of the crura, it kind of makes sense. The crura are muscular, long, and straight—like legs. Also, there’s a right one and a left one, and they meet at the top. Hence, the “legs” of your diaphragm. ↩
- The physics behind it is not complex, but it’s hard to explain without a diagram. Ask Dr. Fitzer about it if you meet him. He’ll be delighted to sketch it out for you. ↩
- Dr. Rudolph Nissen was a very serious-looking gentleman. ↩
- Caused by coughing, for instance. ↩
- The big variance between studies is due to differences in study design. Study designers must define what counts as a recurrent hernia. Some came up with loose definitions. Others were strict. Also, studies apply very different levels of effort to hunting for recurrences. ↩
Medical references
- Daly S, Kumar SS, Collings AT, et al. SAGES guidelines for the surgical treatment of hiatal hernias. Surg Endosc. 2024;38(9):4765–4775. doi:10.1007/s00464-024-11092-3
- Chen W, Feng J, Wang C, et al. Effect of concomitant laparoscopic sleeve gastrectomy and hiatal hernia repair on gastroesophageal reflux disease in patients with obesity: a systematic review and meta-analysis. Obes Surg. 2021;31(9):3905–3918. doi:10.1007/s11695-021-05545-0
- Kumar A, Madhav JV, Singla V, Monga S, Aggarwal S. Concomitant hiatal hernia repair with sleeve gastrectomy: impact on gastroesophageal reflux? Surg Laparosc Endosc Percutan Tech. 2023;33(5):435–439. doi:10.1097/SLE.0000000000001216
Last updated: