On this page
At a glance
- A hiatal hernia means part of the stomach has moved up through the diaphragm into the chest.
- Small sliding hernias are usually managed by treating any reflux they cause.
- Paraesophageal hernias that cause symptoms are generally repaired; those found by chance without symptoms can often be watched.
- Repair is usually done laparoscopically or robotically, and a fundoplication is often added to control reflux.
Types of hiatal hernia
The esophagus passes through an opening in the diaphragm called the hiatus before joining the stomach. When that opening stretches, part of the stomach can move up into the chest. Surgeons usually describe four types:
| Type | What has moved | How it usually behaves |
|---|---|---|
| I — sliding | The junction between the esophagus and stomach slides up through the hiatus | By far the most common. Often small; mainly matters because it can worsen reflux |
| II — paraesophageal | The junction stays in place, but the top of the stomach rolls up beside the esophagus | Less common; can trap or twist the stomach |
| III — mixed | Both the junction and part of the stomach have moved up | The most common form of large “paraesophageal” hernia |
| IV — complex | Another organ, such as the colon or spleen, has also moved into the chest | Least common; usually large |
Types II to IV are often grouped together as paraesophageal hernias. In very large hernias, most of the stomach can sit in the chest — sometimes called an intrathoracic stomach.
Symptoms
Many hiatal hernias cause no symptoms and are found on a CT scan or endoscopy done for another reason. When they do cause symptoms, they can include:
- Heartburn and regurgitation
- Chest pressure or pain after eating, or feeling full after a few bites
- Food sticking or slowly passing
- Shortness of breath, particularly after meals or with exertion, when a large hernia takes up space in the chest
- Iron-deficiency anemia, sometimes from slow bleeding in irritated stomach lining at the level of the diaphragm
Rarely, a paraesophageal hernia can twist (gastric volvulus) or lose its blood supply. That is an emergency — see the urgent-care guidance above.
How a hiatal hernia is evaluated
Planning around a hernia depends on its type and size and on how the esophagus works. Depending on the situation, evaluation may include an upper GI (barium) study to show the anatomy, upper endoscopy to examine the lining, a CT scan, and esophageal manometry to understand swallowing function. When reflux is the main question, pH monitoring can help. Not everyone needs every test.
Which hernias need repair
Small sliding hernias usually don’t need repair on their own. If they contribute to reflux, treatment follows the same path as other GERD — and if anti-reflux surgery is chosen, the hernia is repaired as part of it.
Paraesophageal hernias that cause symptoms are generally repaired, according to long-standing SAGES guidance, because symptoms tend to persist and the risk of complications doesn’t go away.
Paraesophageal hernias without symptoms can often be watched. Decision-analysis research has supported watchful waiting for many people with few or no symptoms, and the 2024 SAGES guideline says watchful waiting is reasonable after discussing the risk of twisting. The same guideline notes that selected people — for example those with evidence of reflux or aspiration, breathing symptoms or reduced exercise tolerance attributable to the hernia, or special circumstances such as an upcoming lung transplant — may reasonably be offered repair.
How repair works
Most repairs are done with minimally invasive surgery — laparoscopic or robotic — through several small incisions. The main steps are to:
- Return the stomach to the abdomen and remove the hernia sac
- Free the esophagus so that a healthy length of it sits below the diaphragm without tension
- Narrow the enlarged hiatus with stitches (and, in selected cases, reinforcement)
- Add a fundoplication — a wrap of the upper stomach — for most patients, to restore a reflux barrier and help hold the stomach in place
Whether to use mesh reinforcement is one of the most debated questions in hernia surgery. The 2024 SAGES guideline reviewed the evidence and did not make a recommendation for or against it, so the decision is individualized.
Hiatal hernia surgery, including reoperative (redo) paraesophageal hernia repair, is among the clinical interests listed in Dr. Speer’s professional profile. If you’ve already had a hernia repair and symptoms have returned, see recurrent reflux and revisional surgery.
Recurrence, honestly
Large hiatal hernias can come back. Imaging studies after repair of large paraesophageal hernias commonly show some degree of recurrence over time, yet many of these recurrences are small and cause few or no symptoms — which is why a recurrence on a scan doesn’t automatically mean another operation. Careful technique, attention to esophageal length, and follow-up are aimed at reducing this risk.
Common questions
Does a hiatal hernia always need surgery?
No. Small sliding hernias rarely need repair on their own, and paraesophageal hernias without symptoms can often be watched; symptomatic paraesophageal hernias are generally repaired.
Whether repair makes sense depends on three things: the type and size of the hernia, the symptoms it is causing, and your overall health and preferences.
- A small sliding hernia found on an endoscopy is common and often needs nothing, or only reflux treatment.
- A paraesophageal hernia causing chest pressure, early fullness, trouble swallowing, breathlessness, or anemia is usually repaired.
- A paraesophageal hernia found by chance, with no symptoms, can often be monitored. It’s worth knowing the warning signs of twisting — sudden severe chest or upper-abdominal pain with retching — so you can get care quickly if they occur.
Some people are surprised to learn that symptoms they had accepted as normal, like getting full quickly or becoming winded after meals, can come from a large hernia. A careful history is part of deciding.
Can a large hiatal hernia cause shortness of breath or anemia?
Yes. A large hernia can take up space in the chest and make breathing harder, and irritation of the stomach lining at the diaphragm can cause slow bleeding and iron-deficiency anemia.
When a large part of the stomach sits in the chest, it can press on the lungs and heart, especially after a meal when the stomach is full. People describe getting winded climbing stairs, needing to sit up after eating, or feeling their heart race.
Anemia can come from small erosions or ulcers where the stomach is pinched by the diaphragm (sometimes called Cameron lesions). They may bleed slowly without any visible blood. Unexplained iron deficiency in someone with a large hernia is worth discussing with your clinician, because other causes of bleeding also need to be considered.
These symptoms have other possible causes — heart and lung conditions among them — so they’re evaluated carefully rather than assumed to be from the hernia.
Is mesh used in hiatal hernia repair?
Sometimes. Evidence is mixed, and the 2024 SAGES guideline made no recommendation for or against mesh, so the choice is individualized.
Surgeons close the enlarged hiatus with stitches. Mesh — synthetic or biologic material — can be used to reinforce that closure, particularly in large hernias. Some studies have suggested fewer early recurrences with mesh; others have not shown lasting benefit, and mesh placed near the esophagus carries its own rare but serious risks.
If mesh is being considered for your repair, it’s reasonable to ask what type would be used, why, and what the alternatives are.
Why is a fundoplication often added to hernia repair?
Repairing a hernia disturbs the natural reflux barrier, and a fundoplication restores it; it can also help anchor the stomach below the diaphragm.
To repair a hiatal hernia, the surgeon has to free the junction between the esophagus and the stomach. That dissection can leave people prone to reflux, even if they didn’t have much reflux before. A fundoplication — wrapping the upper part of the stomach around the lower esophagus — rebuilds the valve.
The 2024 SAGES guideline suggests that adding a fundoplication to the repair of paraesophageal hernias may be beneficial. The type of wrap — complete (Nissen) or partial (such as Toupet) — is chosen based on swallowing function and other factors. See Nissen and Toupet fundoplication.
What should patients understand about recovery and follow-up?
Most minimally invasive repairs involve a short hospital stay, a few weeks on a soft diet while swelling settles, and follow-up to check swallowing, reflux, and the repair.
Every surgical team gives its own instructions, and yours should always take priority over general information. That said, some themes are common after hiatal hernia repair and fundoplication:
- Swallowing is often tight at first. Swelling around the repair can make solid food stick for several weeks, which is why a liquid-to-soft diet is typically advanced gradually.
- Gas and bloating are common early on and usually improve.
- Activity can generally increase over a few weeks, with limits on heavy lifting for a period set by your surgeon.
- Follow-up checks how you are swallowing, whether reflux symptoms have settled, and, when needed, the anatomy of the repair.
Call your surgical team promptly for fever, worsening pain, trouble keeping liquids down, or any sudden change. Longer term, it’s worth knowing that small recurrences are not unusual after large hernia repair and don’t always need treatment.
Sources
- Daly S, et al. SAGES guidelines for the surgical treatment of hiatal hernias. Surg Endosc. 2024;38(9):4765–4775.
- Kohn GP, et al. Guidelines for the management of hiatal hernia. Surg Endosc. 2013;27(12):4409–4428.
- Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal hernias — operation or observation? Ann Surg. 2002;236(4):492–500.
- Oelschlager BK, et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair — long-term follow-up from a multicenter, prospective, randomized trial. J Am Coll Surg. 2011;213(4):461–468.
- Katz PO, et al. ACG Clinical Guideline for the Diagnosis and Management of GERD. Am J Gastroenterol. 2022;117(1):27–56.
This page is general education. It can’t account for your history, test results, or other conditions, so please discuss your situation with your own clinician.