Hiatal hernia surgery repositions your stomach back below the diaphragm and tightens the opening (hiatus) where your esophagus passes through. Most procedures also include wrapping part of the stomach around the lower esophagus to create a new anti-reflux valve, preventing acid from flowing backward. The surgery is most commonly performed laparoscopically through a few small incisions and typically requires just one night in the hospital.
Why Surgery Is Recommended
Not every hiatal hernia needs surgical repair. Surgery becomes an option when symptoms are severe or when medications haven’t provided adequate relief. The clearest reasons for repair include severe heartburn, significant inflammation of the esophagus from chronic acid reflux, narrowing of the esophagus (called a stricture), and repeated lung infections caused by inhaling stomach acid.
Some hiatal hernias cause symptoms that don’t obviously point to the stomach. Shortness of breath, exercise intolerance, chest pain, and anemia are all surprisingly common. One study of 270 patients undergoing hiatal hernia repair found that anemia was present in 24 to 57% of patients, shortness of breath in 21 to 67%, and chest pain in 40 to 60%. SAGES guidelines emphasize that when these symptoms can’t be explained by another condition, patients should be offered surgical repair.
Large hiatal hernias also carry a risk of gastric volvulus, a dangerous twisting of the stomach that can cut off blood supply. Surgeons can’t reliably predict which patients will develop this complication, though pre-existing rotation of the stomach is considered a warning sign.
Pre-Operative Testing
Before surgery, you’ll go through a few diagnostic tests to map how your esophagus is functioning. A 24-hour pH test measures how much stomach acid is reaching your esophagus and how high it travels. This involves wearing a thin catheter threaded into your esophagus and connected to a portable computer for a full day. Esophageal manometry is another test where a catheter measures the pressures inside your esophagus, telling the surgeon how well your anti-reflux valve works and how effectively your esophagus pushes food into the stomach. The manometry results directly influence which type of surgery you’ll get.
Types of Fundoplication
The core of hiatal hernia surgery is a procedure called fundoplication, where the upper portion of the stomach is wrapped around the lower esophagus to reinforce the valve that keeps acid down. The two main types differ in how far the wrap goes around.
A Nissen fundoplication creates a full 360-degree wrap. It’s the stronger option and is typically chosen when manometry shows your lower esophageal valve is weak. A Toupet fundoplication wraps the stomach only 270 degrees, leaving a gap. This partial wrap is preferred when the esophagus has motility problems or the valve still has reasonable pressure, since a full wrap in those cases could make swallowing difficult. Both procedures also include closing the widened opening in the diaphragm and fully mobilizing the stomach’s upper portion.
Open, Laparoscopic, and Robotic Approaches
Traditionally, hiatal hernia repair required open surgery with one large abdominal incision. Most repairs today are done laparoscopically or robotically, using three or four small incisions instead. Both minimally invasive approaches offer faster recovery and less post-operative pain than open surgery.
The practical difference between laparoscopic and robotic surgery comes down to what the surgeon sees. Laparoscopic instruments provide a two-dimensional image of the surgical field, while robotic systems give the surgeon three-dimensional visualization from a seated console. The surgeon controls the robotic instruments remotely, and the enhanced depth perception can be particularly helpful when working in the tight space around the diaphragm and esophagus.
When Mesh Is Used
For larger hernias, surgeons may reinforce the repair with mesh in addition to stitches. The evidence for this is meaningful: one randomized study comparing stitches alone to stitches reinforced with a small piece of mesh found recurrence rates of 26% versus 8% at one year. Both synthetic mesh (made from manufactured materials) and biologic mesh (derived from animal tissue) have been shown to lower recurrence compared to stitches alone.
Mesh isn’t without trade-offs, though. Difficulty swallowing tends to be more common in the early months after mesh-reinforced repairs, even with biologic mesh, though it generally evens out by one year. The bigger concern is that if a reoperation is ever needed, previous mesh makes the surgery significantly more complex. Reoperation rates are low overall (roughly 2 to 4%), but they’re notably higher when mesh was used in the original repair, about 9% compared to 2% without mesh. A case series of 28 patients with mesh-related complications described erosion, dense scar tissue, and esophageal narrowing, with nearly a third ultimately needing removal of part of the esophagus.
Recovery and Diet After Surgery
Most patients go home the day after surgery. You’ll need to avoid heavy lifting and twisting movements for at least six weeks to protect the repair while your diaphragm heals.
Diet progression follows a careful timeline. You’ll start with clear liquids once you’re awake and not nauseated. If those go down well, you’ll move to a soft or pureed diet before leaving the hospital. Plan on eating this way for at least two weeks. At your two-week follow-up, if swallowing feels comfortable, your surgeon will guide you through a gradual return to normal foods. If you’re still having some difficulty swallowing at that point, you may stay on the pureed diet for up to six weeks total. This is normal and doesn’t mean something went wrong; the tissues around the wrap need time for swelling to resolve.
Potential Side Effects
The most common side effects after fundoplication are temporary difficulty swallowing and increased bloating. Early swallowing trouble is largely caused by tissue swelling at the surgical site and typically resolves within the first few weeks. Increased gas and bloating are also common initially because the tighter valve makes it harder to belch.
In about 10% of patients who have a Nissen (full wrap) fundoplication, persistent difficulty swallowing and gas-bloat syndrome continue beyond the initial recovery period. For those who don’t improve, conversion from a Nissen to a Toupet (partial wrap) is a recognized option. This is one reason the pre-operative manometry matters so much: choosing the right wrap from the start reduces the likelihood of these problems.
Long-Term Success and Recurrence
Hiatal hernia repair is effective for most patients, but recurrence is a real possibility. Reported recurrence rates vary widely depending on hernia size, surgical technique, and how long patients are followed. One single-center series of 50 patients treated with minimally invasive fundoplication found a recurrence rate of 18%, which the authors noted was on the higher end of published literature. Mesh reinforcement lowers but doesn’t eliminate this risk. In studies using stitches alone, recurrences tend to accumulate steadily over time without plateauing, while mesh-related recurrences that do occur tend to appear earlier in the post-operative period.
Recurrence doesn’t always mean a second surgery is needed. Some recurrences are small and cause no symptoms. When symptoms do return, a repeat evaluation with pH testing and manometry helps determine whether reoperation is warranted.