Sliding hiatal hernia
The junction of the esophagus and stomach slides above the diaphragm. This is the most common type and is often associated with reflux.
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Reflux & Hiatal Hernia Surgery
Persistent reflux and hiatal hernias require an accurate diagnosis—not just symptom treatment. Michael Orloff, MD, FACS, evaluates the anatomy, esophageal function, prior treatment, and individual goals before recommending surgery.
GERD & Hiatal Hernia
Related conditions, but not the same diagnosis
Gastroesophageal reflux disease, or GERD, occurs when stomach contents repeatedly move backward into the esophagus and cause symptoms or tissue injury. A hiatal hernia occurs when part of the stomach moves through the diaphragm opening where the esophagus passes into the abdomen.
A hiatal hernia can contribute to reflux by changing the normal relationship between the esophagus, diaphragm, and stomach. However, some people have a hiatal hernia without reflux, and many people with GERD do not need surgery.
Why the distinction matters
Successful treatment depends on identifying whether symptoms are truly caused by reflux, understanding the hernia anatomy, and checking how well the esophagus moves food before selecting an operation.
Hiatal Hernia Types
Location and anatomy guide treatment planning
The type, size, symptoms, stomach position, and presence of obstruction or twisting help determine whether observation, medical treatment, or surgery is appropriate.
Paraesophageal hernia
Part of the stomach moves beside the esophagus into the chest while the junction may remain closer to its normal position.
Mixed or complex hernia
Both the stomach junction and a larger portion of stomach may move into the chest. Other organs can occasionally be involved in very large hernias.
Symptoms & Complications
Reflux can present in different ways
Symptoms alone cannot always prove GERD or determine whether a hiatal hernia is responsible. Testing may be needed before surgery.
Typical reflux symptoms
Heartburn, sour or bitter regurgitation, and discomfort that worsens after meals or when lying down.
Swallowing symptoms
Food sticking, painful swallowing, early fullness, post-meal pressure, or difficulty tolerating normal portions.
Throat or respiratory symptoms
Chronic cough, hoarseness, throat clearing, wheezing, or suspected aspiration may have several possible causes.
Potential complications
Esophagitis, bleeding, narrowing, Barrett’s esophagus, anemia, obstruction, or twisting of a paraesophageal hernia.
Preoperative Evaluation
Testing confirms the problem and plans the repair
Not every patient needs every test. The evaluation is tailored to symptoms, prior results, anatomy, and the operation being considered.
Upper endoscopy
Examines the esophagus and stomach for inflammation, narrowing, Barrett’s change, ulceration, or another diagnosis.
Barium esophagram
Shows swallowing, esophageal emptying, hernia anatomy, stomach position, and possible obstruction.
Reflux monitoring
Measures acid or other reflux events and relates them to symptoms, particularly when the diagnosis is uncertain.
Esophageal manometry
Measures esophageal muscle function and lower sphincter pressure to help select an appropriate repair.
Bring prior records when possible: endoscopy and pathology reports, imaging, pH and manometry results, medication history, and prior abdominal or chest operative reports can prevent duplicated testing.
Treatment Before Surgery
Most reflux treatment begins without an operation
Lifestyle changes and medication control symptoms for many patients. Surgery is considered only after the diagnosis and expected benefits are carefully reviewed.
Lifestyle measures
Individual recommendations may include smaller meals, avoiding meals close to bedtime, identifying personal triggers, weight management, tobacco cessation, and elevating the head of the bed.
Acid suppression
Antacids, H2 blockers, or proton pump inhibitors may be used depending on symptom frequency and evidence of esophageal injury. Medication decisions belong with the treating clinician.
Confirm persistent symptoms
Symptoms that continue despite treatment deserve reassessment for adherence, correct dosing, nonacid reflux, motility disorders, functional symptoms, or another diagnosis.
When Surgery Is Considered
Repairing anatomy and strengthening the reflux barrier
Surgery may be discussed for objectively confirmed reflux that remains troublesome, selected medication-dependent patients, reflux complications, or a symptomatic or higher-risk paraesophageal hernia.
Hiatal hernia repair
The stomach is returned below the diaphragm, the hernia sac is addressed as appropriate, and the enlarged hiatus is closed with sutures. Mesh is used selectively rather than automatically.
Fundoplication
The upper stomach is wrapped completely or partially around the lower esophagus to reinforce the anti-reflux barrier. Esophageal function helps guide the type of wrap.
Minimally invasive approach
Many repairs can be performed laparoscopically or with robotic assistance through small incisions. Open surgery remains appropriate for selected situations or unexpected findings.
Individualized reconstruction
Large or recurrent hernias may require additional fixation, length assessment, or another reconstruction. Prior surgery, obesity, motility, and overall health influence planning.
The goal is not simply to stop acid. The operation should restore anatomy and improve reflux while preserving comfortable swallowing and the ability to eat. No operation can guarantee permanent symptom relief.
Preparing & Recovering
What patients can generally expect
Instructions vary with the procedure and operative findings. Follow the diet, medication, lifting, wound-care, and follow-up plan given by the surgical team.
Prepare
Review medicines, blood thinners, allergies, diabetes, smoking, anesthesia history, fasting, transportation, and home support.
Operate
Under general anesthesia, the surgeon restores the stomach below the diaphragm and performs the planned reconstruction.
Advance diet
Liquids and soft foods are commonly used while swelling settles. Eat slowly, take small bites, and follow the specific progression provided.
Follow up
Activity increases gradually. Keep postoperative visits and report difficulty swallowing, dehydration, or worsening symptoms.
Temporary swallowing changes
Swelling can make swallowing feel tight early in recovery. Persistent or worsening difficulty requires communication with the surgical team.
Gas and bloating
Reduced ability to belch, abdominal bloating, early fullness, and increased gas may occur after fundoplication and often improve with time.
Gradual activity
Walking is generally encouraged. Driving, work, exercise, and lifting restrictions depend on the repair and individual recovery.
Risks to discuss before surgery
Potential risks include bleeding, infection, blood clots, anesthesia complications, injury to the esophagus, stomach, spleen, liver, bowel, or nearby nerves, difficulty swallowing, gas-bloat symptoms, inability to vomit or belch normally, recurrent reflux, recurrent hernia, and need for another procedure.
Patient Questions
Frequently asked questions
These general answers cannot replace recommendations based on your examination, testing, and medical history.
Does every hiatal hernia require surgery?
No. Many small sliding hiatal hernias are managed by treating reflux symptoms. Surgery is more often considered for a symptomatic large or paraesophageal hernia, complications, or objectively confirmed reflux that warrants operative treatment.
Can reflux be cured permanently with surgery?
Surgery can provide long-term improvement for appropriately selected patients, but no operation guarantees permanent relief. Reflux or a hiatal hernia can recur, and some patients still use acid-reducing medication afterward.
What is a fundoplication?
Fundoplication uses the upper stomach to create a complete or partial wrap around the lower esophagus. This reinforces the anti-reflux barrier and is commonly combined with hiatal hernia repair when a hernia is present.
Why might I need pH testing and manometry?
Reflux monitoring can document abnormal reflux and its relationship to symptoms. Manometry assesses esophageal muscle function and helps exclude important motility disorders before anti-reflux surgery.
Will the operation be robotic or laparoscopic?
Many repairs can be completed through small incisions using laparoscopic or robotic-assisted techniques. The appropriate approach depends on anatomy, prior surgery, complexity, health risks, available equipment, and surgeon judgment.
Why is a special diet needed after surgery?
Swelling near the repaired hiatus can temporarily narrow the passage into the stomach. A staged liquid-to-soft diet, small bites, thorough chewing, and slow eating can help while healing progresses.
What if swallowing becomes difficult after surgery?
Mild temporary tightness can occur, but inability to swallow liquids, repeated vomiting, dehydration, severe pain, or worsening difficulty requires prompt contact with the surgical team or urgent evaluation.
Medical review: Michael Orloff, MD, FACS
General surgeon • Suffolk Surgery PLLC • Last updated September 2026
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This page provides general educational information and does not establish a physician–patient relationship or replace individualized medical advice. For a medical emergency, call 911.