Hiatal Hernia Surgery and Repair in Northern Virginia
What a hiatal hernia is, and what it means for you
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
Obesity is an important risk factor for developing a hiatal hernia, and both are often diagnosed in the same patient. The two problems are so closely intertwined that surgery for one usually requires a decision about how to handle the other. To understand the connection between them, it will help to review the basics of hiatal hernia anatomy.
What is a hiatal hernia?
Your esophagus connects your mouth to your stomach, which sits in the abdomen. To get down to the stomach, the esophagus must pass through the chest.
The last barrier between the chest and the abdominal space is the diaphragm, which is a muscle. It looks like a dome-shaped piece of roast beef. (See the diagram.)
We're all born a small hole at the top of the diaphragm. It's where the esophagus goes through it. The opening is called the esophageal “hiatus,” which is why we call these “hiatal” hernias.
The diaphragm is meant to fit the esophagus snugly at the hiatus. There shouldn’t be extra room. When the hiatus is too wide, the extra space there is a hiatal hernia. Over time, the top of the stomach tends to get pushed up through it into the chest.
These hernias come in four types.
Type I, “sliding”
These are the small ones. Less than an inch or so of the stomach is in the chest. It tends 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”
Another kind of paraesophageal hernia. Both the esophagus and stomach move up into the chest. Sometimes it's hard to tell if a hernia is type II or III. Most hernias that get to surgery are type III.
Type IV, “giant”
Another paraesophageal hernia. The gap in the diaphragm is so big that another organ — colon, spleen, pancreas, etc. — got sucked up into the chest with the stomach.
The type of hernia is important to surgeons. It tells them, for instance, the likelihood that a hernia will cause an urgent problem. It also tells them (generally) what symptoms can be expected.
Small hernias tend to be symptom-free, though they sometimes lead to reflux or heartburn. Many of them are found unintentionally on imaging that was done for another purpose.
Large hernias cause heartburn as well, and they sometimes make other kinds of mischief. For instance, they sometimes cause food to 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 are known to occasionally create life-threatening problems, such as bleeding or blockage of the GI tract.
Hiatal hernia symptoms: common and rare
The common 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 rare ones:
- Early satiety (getting full after a few bites)
- Chronic cough (stomach acid inflames the airways)
- Hoarseness (stomach acid inflames the vocal cords)
- Worsening asthma (stomach acid causes bronchspasm)
- Shortness of breath after eating (a full stomach in a big hernia leaves no room for air to come in)
- Unexplained anemia (erosions cause bleeding where the stomach is pinched at the hiatus)
How hiatal hernias and obesity are linked
Obesity raises the pressure inside the abdomen.
People with obesity store fat inside their body as well as on the outside. One place fat builds up is in the abdomen, where there isn't much extra space. When enough fat accumulates there, the pressure starts to rise. (A round, protruding belly is a sure sign of high pressure in the abdomen.)
High abdominal pressure tends to widen the hiatus
The defining feature of pressure is that it pushes outward against its container in all directions. (Think of a balloon. Wherever you poke it, it pushes back against your finger.)
When pressure builds up in the abdomen, it pushes outward on the edges of the hiatus. Given time, that stretching force will widen the hiatus. A hiatal hernia results.
Obesity and hiatal hernia overlap in other ways
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 the most reliable way to get complete, lasting relief.
- When an obese patient has severe reflux due to a hiatal hernia, the standard of care is to perform hiatal hernia repair and gastric bypass. Hernia repair alone is not advised in that situation. The failure rate is too high.
- For a hiatal hernia that was previously repaired and came back, gastric bypass offers better outcomes than a redo hiatal repair for many patients.1
When repair is recommended
Not everybody needs their hiatal hernia repaired. In fact, most are best left alone. Repair becomes part of the conversation when:
- Reflux persists despite anti-reflux medication.
- Long-term medication is not an option.
- 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, 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 one 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.
About wraps and fundoplication
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. We normally skip it in bariatric patients, for good reason.
For one thing, 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, but that's a subject for another day.
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 shows that doing so makes post-op reflux much less likely.2,3
Hernia repair doesn't guarantee a reflux-free life after a sleeve. In one meta-analysis, 12% of patients who had the combined operation developed new reflux they didn’t have before. Another 11% had the hernia (and reflux) recur later.2
The takeaway? If you are considering a sleeve and you already have reflux, you may want to consider a bypass instead. That advice applies regardless of hiatal hernia status. A sleeve with hernia repair often works out fine, but not always. You might be left holding the bag, heartburn-wise. 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 every repair to last forever, but some hernias eventually come back. The medical journals put the rate somewhere between 10 and 50%—an unhelpfully broad range.3
If your hiatal hernia comes back, it doesn’t mean your repair wasn’t a good one. Even master surgeons have repairs fail now and then.
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 high. 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.
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 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. There is still the usual one-night stay for patients who get a sleeve or bypass at the same time.
Many patients are referred by their gastroenterologist or primary care physician. We see referrals from across Virginia, including Richmond, Fredericksburg and Hampton Roads. Telehealth first visits are available.
Patients also come to see Dr. Fitzer from Richmond, Charlottesville, Fredericksburg, Newport News, Norfolk, Virginia Beach, and Suffolk. Come talk to us!
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 when symptoms aren't controlled by medication or for hernias large enough to pose a risk if they remain unrepaired.
- Will hiatal hernia repair cure my heartburn?
Hopefully! It does for a lot of people, but it cannot be guaranteed. Usually, repair will at least improve reflux substantially. Many patients can stop medication entirely.
- Can a hiatal hernia come back?
Alas, 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. If medications don't control it, converting to a gastric bypass is a reliable way to solve the problem.
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
Heartburn, regurgitation, and hiatal hernias can complicate your life and your weight-loss surgery plans. A good surgeon can quickly figure out what's going on and what the options are. Ready to talk? Request a consultation online or call (703) 709-9771.
Last updated November 3, 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. ↩
- 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