Hiatal Hernia Surgery and Repair
When the stomach slides into the chest, and what it takes to put it back
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 your stomach is pushed or pulled out of the abdomen and up into the chest. Small hernias tend to be symptom-free and are typically found by accident.
The larger ones can cause problems. They are best known for giving people heartburn, but they can make other kinds of mischief. 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. Once in a great while, a hiatal hernia can turn into an emergency, by bleeding or twisting and blocking the GI tract.
Dr. Matthew Fitzer repairs these hernias laparoscopically, meaning with small cuts. Some patients have their hernia fixed at the same time they get weight-loss surgery. Obesity and hiatal hernias are two problems that often travel together, and the reason is worth understanding.
So what is a hiatal hernia, anyway?
Your esophagus connects your mouth to your stomach, which sits in the abdomen. To get there, it must pass through an opening in the diaphragm muscle. That opening is called the hiatus, hence the “hiatal hernia.”
The diaphragm is supposed to fit the esophagus snugly at the hiatus. If the gap is overly wide, a hiatal hernia is said to exist. Over time, the top of the stomach tends to get sucked up through the hiatus into the chest.
These hernias come in four distinct types:
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.
Symptoms, familiar and surprising
The type of hernia matters quite a bit to surgeons. For one thing, it says a lot about the odds that a hernia will suddenly turn into an urgent problem. A sliding hernia may or may not give you heartburn, but you can trust it not to cause any kind of emergency. Giant hernias, in contrast, carry a risk of causing organs to twist, bleed, and/or obstruct. They need to be taken care of without delay.
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
Obese people accumulate fat on the inside of the body as well as the outside. One of the places fat accumulates is within the abdominal cavity. The abdomen only has so much room, so fat accumulation there tends to raise the pressure. That pressure pushes against the edges of the hiatus muscle all day every day, year after year. Over time, it can 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 sometimes discovered during bariatric surgery. Some hernias need to be repaired at the same sitting, especially during a sleeve gastrectomy.
- When reflux after a sleeve is intolerable, converting to a gastric bypass — with the hiatus repaired at the same time — is the solution that provides the most reliable and durable relief.
- For severely obese patients with a hiatal hernia and severe reflux symptoms, the standard recommendation is laparoscopic hiatal hernia repair AND simultaneous gastric bypass. Hernia repair by itself in the obese is extremely prone to failure and recurrence.
- For a hiatal hernia that has already been repaired once and come back, gastric bypass is a recognized option in selected patients rather than repeating the same repair.1
When 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 needs to enter 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 the repair is done
The operation is performed laparoscopically, meaning through small incisions. There are four main steps.
Reduce the hernia. The stomach, and anything else that has migrated, is brought back down into the abdomen.
Cut out the sac. The hernia sac is dissected out of the chest. Leaving it behind is a common reason hernias recur.
Mobilize the esophagus. You have to have enough esophageal length so that it reaches into the abdomen with no tension. (Tension is the enemy of a lasting repair.)
Close the crura. By the “crura,” we mean the sides of the hiatus. The oversized opening is brought back to normal with sutures. Sometimes a mesh is required to close a really large opening, but we usually get by without one. The current SAGES panel reviewed the evidence and declined to make a recommendation either way.1
Fundoplication. In some cases, we do an extra reflux-preventing maneuver, called a fundoplication. It entails “wrapping” the top of the stomach around the esophagus. It’s a bit complicated, but it creates a one-way (forward) valve for the stomach contents.
Current guidelines suggest routinely adding a fundoplication to a hiatal hernia repair, though they grade the certainty of that evidence as low.1 The common versions (Dr. Fitzer has performed them all):
- Nissen — a complete 360-degree wrap. The strongest reflux control, with the most swallowing side effects.
- Toupet — a partial 270-degree posterior wrap. Slightly less reflux control, fewer swallowing problems.
- Dor — a 180-degree anterior wrap, used in specific situations.
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 it: across 18 studies and 937 patients, sleeve gastrectomy combined with hiatal hernia repair produced GERD remission in about 68% of patients, and 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 symptoms resolve completely and 76% came off acid-suppressing medication.3
Repair is not a guarantee of no reflux. In the same analysis, roughly 12% of patients developed new reflux they did not have before, and about 11% had the hernia recur.2
The practical consequences? If you are considering a sleeve and you already have reflux with or without a known hernia, it means some extra conversation should be had about the operation you choose. Sometimes the answer is a sleeve with the hernia repaired. Other times, a bypass is the right answer.
Reflux after a 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.
A hernia that came back after one repair may benefit from re-repair, but sometimes simple conversion to a gastric bypass is the right answer. The gastric bypass remains the most reliable anti-reflux operation available to patients who have already had bariatric surgery. Read more about sleeve revision surgery and managing weight regain after bariatric surgery.
Recovery
- 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 the outcome we strive to avoid. The hiatus is a moving part — it works with every breath and every swallow — and repairs can loosen over time, particularly in large hernias and in patients with higher intra-abdominal pressure.
Other uncommon risks: difficulty swallowing after a wrap, inability to belch or vomit, bloating, injury to the esophagus or stomach, and the general risks of anesthesia.
Insurance and cost
Hiatal hernia repair for documented symptoms is generally covered as a medically necessary operation — the pathway is different from bariatric surgery, and usually less onerous. Where it is performed at the same time as a weight-loss operation, the coverage question follows the bariatric operation. The self-pay price is identical to sleeve gastrectomy.
Serving patients across Virginia
Our offices are in Northern Virginia, serving Herndon, Reston, Fairfax, Loudoun, Arlington, Alexandria, and the Washington, D.C. area. Patients also come to Dr. Fitzer from Richmond, Charlottesville, Fredericksburg, Newport News, Norfolk, Virginia Beach, and Suffolk — telehealth consults are available for patients traveling from those areas.
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, and it usually should be. A hernia found during a sleeve or bypass is repaired at the same operation. Repairing it improves the odds that reflux resolves rather than worsens.
- I had a sleeve and now I have terrible reflux. Is a hernia the cause?
- Maybe. Often, yes — either one that was never repaired or one that has come back. It takes imaging and usually an endoscopy to tell. If the sleeve itself is driving the reflux, converting to a gastric bypass is generally the most reliable fix.
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 September 2026.
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
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