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The anatomy matters, but so do your symptoms.
- A hiatal hernia occurs when part of the stomach moves through the diaphragm into the chest.
- Not every hernia requires surgery. Symptoms, hernia type, and overall health guide the discussion.
- When repair is appropriate, the operation is tailored to the anatomy and the individual patient.
What is a hiatal hernia?
The diaphragm separates the chest from the abdomen. The esophagus passes through an opening in it called the hiatus before joining the stomach. A hiatal hernia occurs when part of the stomach moves upward through that opening.
The position of the junction between the esophagus and stomach, and which structures have moved into the chest, determine the type of hernia.
How do sliding and paraesophageal hernias differ?
| Type | What moves above the diaphragm? |
|---|---|
| Type I: sliding | The junction between the esophagus and stomach moves above the hiatus. This is by far the most common hiatal hernia type. |
| Type II: paraesophageal | The upper stomach moves alongside the esophagus while the junction remains in its usual position. |
| Type III: mixed | Both the junction and part of the stomach move above the diaphragm. This is the most common paraesophageal type. |
| Type IV | Another organ or abdominal structure, such as colon, small bowel, spleen, or fatty tissue, also moves through the opening. |
Types II, III, and IV are grouped as paraesophageal hernias. They may cause obstruction, twisting of the stomach (volvulus), or bleeding.
What symptoms or findings lead to evaluation?
Symptoms may include reflux, difficulty swallowing, pain or fullness after meals, or shortness of breath. Some patients have anemia associated with irritation or lesions at the hernia, called Cameron lesions.
A large hiatal hernia can also cause symptoms beyond reflux. When much of the stomach sits in the chest, it can press on the lungs and limit the space available for them to expand, contributing to shortness of breath.[5] In some patients, the stomach presses on the back of the heart, particularly the left atrium, and can interfere with the heart’s filling and blood flow. This can contribute to breathlessness or reduced exercise tolerance.[6] These symptoms still need evaluation because other heart and lung conditions can cause similar problems.
- CT and barium esophagram
- Help define the hernia’s anatomy and show the position of the stomach. A barium esophagram is an X-ray study performed while swallowing contrast.
- Upper endoscopy
- Examines the esophagus and stomach and is an essential part of the evaluation.
- Selected additional tests
- Manometry and reflux testing are used selectively. Lung function tests or an echocardiogram may be considered when relevant to the clinical assessment.
The workup helps connect symptoms to the hernia and provides information needed to plan treatment.
Does every paraesophageal hernia need surgery?
No. A paraesophageal hernia without symptoms is not automatically an indication for repair. The discussion takes account of age, overall fitness, hernia size, and the person’s preferences.
Repair may be considered when the hernia causes symptoms, anemia, or other complications. A hernia causing obstruction or volvulus may require urgent repair. Emergency surgery carries higher risk than an elective operation, especially in older patients, but this does not make surgery the right choice for every asymptomatic hernia.
What does repair involve?
Hiatal hernia repair generally has three main components:
Complete and partial wraps
A Nissen fundoplication is a complete, 360-degree wrap. Toupet and Dor fundoplications are partial wraps, placed behind or in front of the esophagus, respectively.
A fundoplication is commonly included to help control reflux after hernia repair. The choice of wrap balances reflux control with swallowing function.[2]
The operation is individualized. In selected patients, a gastropexy—securing the stomach in the abdomen—may be used instead of a fundoplication.
A Collis gastroplasty, a procedure to create additional length, is rarely needed when the esophagus still cannot sit adequately below the diaphragm. This is an uncommon additional step, rather than a routine part of repair.
Is mesh always needed?
No. Dr. Servais generally uses sutures alone and reserves mesh for exceptional circumstances. His approach emphasizes returning the stomach to the abdomen, obtaining adequate esophageal length, and closing the hiatus without excessive tension.
Mesh can be used to reinforce a closure, but the evidence is not a simple “always” or “never.” The 2024 SAGES guidance makes no recommendation for or against mesh because the evidence is of low certainty.[2]
Several randomized trials did not show a lasting reduction in hernia recurrence with mesh at longer follow-up. Some reported more swallowing difficulty or chest pain. Potential mesh complications include erosion into the esophagus or stomach, narrowing, and dense scar tissue that can make another operation more difficult.
Evidence behind the options
The Oelschlager trial found an early recurrence benefit with biologic mesh that was not maintained at approximately five years. The Watson and Analatos trials did not demonstrate a long-term recurrence advantage for the mesh strategies studied. These findings inform the discussion; they do not establish one approach for every patient.[3,4]
The evidence remains uncertain, and the choice is individualized to the repair.
Planning ahead
Recovery after hernia repair
Recovery depends on the extent of the repair, whether an antireflux procedure is included, and your overall health. Ask how eating and swallowing may change during recovery and what follow-up will be needed.
Before you go home, ask about
- Eating and drinking: the recommended diet, hydration, and when to advance foods.
- Medicines: pain control and which usual medicines to resume or continue.
- Activity and help at home: walking, lifting, work, driving, and whether you will need assistance.
- Follow-up: when to be seen, which symptoms should prompt a call, and how to reach the team.
Your care team will provide instructions for your procedure and health needs. The information here is a planning checklist, not a postoperative protocol.
Questions to bring to your consultation
- What type of hernia do I have, and which of my symptoms might it explain?
- Is observation reasonable, or is there a specific reason to recommend repair?
- What tests are needed to understand the anatomy and my operative risk?
- Would repair include a fundoplication, gastropexy, or another additional step?
- Would you use mesh in my case, and what are the reasons and tradeoffs?
Source & further reading
About this guide
Patient education based on teaching materials by Elliot Servais, MD, FACS, and the references below. This information supports a discussion with your care team and does not determine an individual treatment plan.
Patient resources, references & image credits
Patient resources
- SAGES. Anti-Reflux (GERD) Surgery. Patient information, including hiatal hernia repair.
Research, clinical guidance & lectures
- Daly S, et al. SAGES guidelines for the surgical treatment of hiatal hernias. Surgical Endoscopy. 2024;38:4765–4775. Read the full guideline.
- Oelschlager BK, et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial. Annals of Surgery. 2006;244:481–490. Long-term follow-up from the randomized trial. Journal of the American College of Surgeons. 2011;213:461–468.
- Watson DI, et al. Five-year follow-up of a randomized controlled trial of very large hiatus hernia repair with sutures versus absorbable versus nonabsorbable mesh. Annals of Surgery. 2020;272:241–247. Analatos A, et al. Hiatal hernia repair with tension-free mesh or crural sutures alone: 13-year follow-up of a randomized clinical trial. JAMA Surgery. 2024;159:11–18.
- Paraesophageal hernia repair with laparoscopic Toupet fundoplication: impact on pulmonary function, respiratory symptoms and quality of life. Surgical Endoscopy. 2022.
- Naoum C, et al. Left atrial compression and the mechanism of exercise impairment in patients with a large hiatal hernia. Journal of the American College of Cardiology. 2011;58:1624–1634.
Image credits
The anatomy and hiatal suture repair illustrations are reproduced from Dr. Servais’s teaching presentation.
Fundoplication comparison illustration supplied by Dr. Servais.
Updated October 4, 2026. This guide is general information; your care team can explain which recommendations apply to you.