Hiatal and Paraesophageal Hernia Repair

A hiatal hernia occurs when the upper stomach (and sometimes other organs) pushes up through the esophageal hiatus — the opening in the diaphragm where the esophagus passes into the abdomen. The most common type (type I, or sliding hernia) is closely linked to gastroesophageal reflux disease (GERD), because the displaced junction and widened hiatus weaken the body's natural antireflux barrier and delay acid clearance, producing heartburn, regurgitation, and the long-term risks of esophagitis, stricture, and Barrett's esophagus (Callaway et al., Clinical Gastroenterology and Hepatology, 2018). Paraesophageal hernias (PEH) (types II–IV) are larger and more serious — a portion of the stomach rolls up alongside the esophagus into the chest, and these can progress to obstruction, bleeding, iron-deficiency anemia, volvulus, and strangulation (Baiu & Lau, JAMA, 2019; Callaway et al., Clinical Gastroenterology and Hepatology, 2018).

Antireflux surgery — most commonly laparoscopic fundoplication with hiatal hernia repair — is the definitive treatment for GERD that is inadequately controlled by, or dependent on, medication, and for anatomically significant or symptomatic hernias (Thrumurthy et al., JAMA, 2026). In randomized trials, fundoplication relieves GERD symptoms in up to 92% of patients, achieves greater than 90% patient satisfaction at 10 years, and controls regurgitation markedly better than medication (Thrumurthy et al., JAMA, 2026; Maret-Ouda et al., JAMA, 2020). It is important to counsel honestly: surgery is highly effective but not a guaranteed lifetime cure — roughly 18% of patients experience symptom recurrence within 10 years, and a small percentage require revision (Thrumurthy et al., JAMA, 2026). The modern operation is minimally invasive, with a short hospital stay and very low mortality (0.1–0.2%), a dramatic improvement over the open surgery of the past (Maret-Ouda et al., JAMA, 2020; Rattner, JOMI, 2024).

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Reflux and hernia symptoms arise from a failure of the gastroesophageal junction (GEJ) barrier — a combination of the lower esophageal sphincter, the diaphragmatic crura, and the acute angle of His — compounded by a widened hiatus that lets the stomach migrate into the chest (Callaway et al., Clinical Gastroenterology and Hepatology, 2018). The operation restores that barrier through three linked maneuvers (Baiu & Lau, JAMA, 2019):

1. Reduction — the stomach (and any other herniated organs) is returned from the chest to its normal position in the abdomen, and the hernia sac is excised.
2. Crural repair (cruroplasty) — the enlarged diaphragm opening is tightened, closing the defect that allowed the hernia, with mesh reinforcement in selected large defects.
3. Fundoplication — the top of the stomach (fundus) is wrapped around the lower esophagus to recreate a competent one-way valve that permits swallowing and belching but prevents acid from refluxing upward (Baiu & Lau, JAMA, 2019).

Because dissecting the hiatus during any hiatal hernia repair disrupts the natural antireflux anatomy, adding a fundoplication is strongly favored — a randomized trial showed hernia repair with fundoplication produced significantly better reflux control, higher satisfaction, and fewer complications than hernia repair alone (Li et al., Scientific Reports, 2019; Callaway et al., Clinical Gastroenterology and Hepatology, 2018).

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• Definitive, durable reflux control — fundoplication relieves GERD symptoms in up to 92% of patients, with greater than 90% satisfaction at 10 years (Thrumurthy et al., JAMA, 2026).

• Freedom from daily medication — in a real-world cohort, more than 80% of patients did not resume antireflux medication after surgery (Katz et al., ACG Clinical Guideline, 2022).

• Superior control of regurgitation vs. medication — surgical patients had far less acid regurgitation (2% vs. 13%) and better reflux-specific quality of life than those on PPIs (Maret-Ouda et al., JAMA, 2020).

• Prevents dangerous hernia complications — repairing a paraesophageal hernia removes the future risk of obstruction, volvulus, and strangulation, complications whose emergency repair carries far higher morbidity and mortality (Crnkovic et al., Journal of the American College of Surgeons, 2026; Baiu & Lau, JAMA, 2019).

• Minimally invasive recovery — laparoscopic/robotic repair means small incisions, less pain, a short (often 1–2 day) hospital stay, faster recovery, fewer complications, and lower mortality than open surgery (Rattner, JOMI, 2024).

• Sustained quality-of-life gains even in older patients — symptomatic PEH repair in patients over 70 produces quality-of-life improvements sustained beyond 5 years (Merzlikin et al., Surgical Endoscopy, 2017).

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The best candidates have objectively confirmed GERD or an anatomically significant/symptomatic hernia, after a complete foregut workup (Yadlapati et al., AGA Clinical Practice Update, 2022; Thrumurthy et al., JAMA, 2026). Favorable indications include:

• PPI-dependent or PPI-refractory GERD, or a desire to stop lifelong medication, with reflux confirmed by pH monitoring (Maret-Ouda et al., JAMA, 2020).

• Regurgitation-predominant GERD and volume reflux, which respond especially well to surgery and poorly to medication (Yadlapati et al., AGA Clinical Practice Update, 2022).

• Symptomatic hiatal hernia, or any symptomatic type II–IV paraesophageal hernia — including those causing iron-deficiency anemia, chest pain, early satiety, dysphagia, or pulmonary symptoms (Callaway et al., Clinical Gastroenterology and Hepatology, 2018).

• Complications of reflux such as esophagitis, peptic stricture, or Barrett's esophagus (Callaway et al., Clinical Gastroenterology and Hepatology, 2018).

Candidacy requires confirmatory evidence of pathologic GERD, exclusion of achalasia, and assessment of esophageal peristalsis before an invasive antireflux procedure (Yadlapati et al., AGA Clinical Practice Update, 2022). Relative contraindications to standard fundoplication include prior upper-abdominal surgery, BMI over 35, esophageal dysmotility, normal esophageal pH, atypical symptoms, and symptoms unresponsive to PPIs; absolute contraindications include esophageal outlet obstruction, inability to tolerate general anesthesia, and uncorrectable coagulopathy (Thrumurthy et al., JAMA, 2026). In patients with obesity, Roux-en-Y gastric bypass is often the preferred antireflux operation (see GERD/Reflux Considerations) (Yadlapati et al., AGA Clinical Practice Update, 2022).

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The operation is performed under general anesthesia, almost always minimally invasively — laparoscopically or robotically — with open surgery reserved for unusual circumstances (Baiu & Lau, JAMA, 2019; Rattner, JOMI, 2024). Through several small incisions, the surgeon reduces the stomach and any herniated contents back into the abdomen and excises the hernia sac. The esophagus is then mobilized high into the mediastinum to obtain at least 3 cm of tension-free intra-abdominal esophageal length — a step shown to reduce recurrence (Schlottmann et al., JAMA Surgery, 2025). The diaphragmatic crura are reapproximated with nonabsorbable sutures (cruroplasty), with mesh reinforcement added selectively for large defects that cannot be closed without tension (Schlottmann et al., JAMA Surgery, 2025).

The reflux barrier is then reconstructed. A fundoplication is tailored to the patient's esophageal motility: a complete 360° (Nissen) wrap offers robust reflux control for patients with normal peristalsis, while a partial wrap (Toupet 270° posterior or Dor anterior) provides comparable reflux control with less postoperative dysphagia and gas-bloat and is favored when motility is impaired (Maret-Ouda et al., JAMA, 2020; Yadlapati et al., AGA Clinical Practice Update, 2022). As an alternative in appropriate patients — particularly those with a small hernia who wish to preserve the ability to belch and vomit — magnetic sphincter augmentation (the LINX device), a ring of magnetic titanium beads placed around the GEJ, can be used instead of a wrap, combined with crural repair when a hernia is present (Maret-Ouda et al., JAMA, 2020; Yadlapati et al., AGA Clinical Practice Update, 2022). The operation typically takes about 1.5 hours; a Nissen fundoplication is frequently completed with a hospital stay under 24 hours (Andolfi & Fisichella, JOMI).

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Modern laparoscopic antireflux surgery is safe, with short-term mortality of only 0.1–0.2%, but it is not risk-free and must be discussed candidly (Maret-Ouda et al., JAMA, 2020). Potential risks include:

• Dysphagia (difficulty swallowing) — common early and usually transient; some solid-food dysphagia persists in a minority long-term (up to ~11% vs. 5% with medication), and a small number need endoscopic dilation (Maret-Ouda et al., JAMA, 2020; Thrumurthy et al., JAMA, 2026).

• Gas-bloat syndrome, increased flatulence, and reduced ability to belch — more common after complete than partial wraps (up to ~40–46%) (Thrumurthy et al., JAMA, 2026; Maret-Ouda et al., JAMA, 2020).

• Early surgical complications (~4%) — wound infection (~1%), bleeding (~0.9%), and iatrogenic esophageal perforation (~0.9%) (Maret-Ouda et al., JAMA, 2020; Katz et al., ACG Clinical Guideline, 2022).

• Symptom/GERD recurrence — up to ~18–20% within 10 years (Thrumurthy et al., JAMA, 2026; Katz et al., ACG Clinical Guideline, 2022).

• Anatomic hernia recurrence — common after large (>5 cm) hernia repair (reported up to ~48%), though most recurrences are small and asymptomatic (Callaway et al., Clinical Gastroenterology and Hepatology, 2018).

• Device-specific risks of magnetic sphincter augmentation — dysphagia, MRI restriction above 1.5 Tesla, and rare device erosion (~0.3% at 4 years) or removal (~3.9%) (Katz et al., ACG Clinical Guideline, 2022; Fadel et al., International Journal of Surgery, 2024).

• General surgical/anesthetic risks — venous thromboembolism, rare need for reoperation.

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Because the operation is minimally invasive, recovery is relatively quick. Many patients are discharged within 24 hours to 1–2 days (Andolfi & Fisichella, JOMI; Rattner, JOMI, 2024). The most important part of recovery is diet: patients follow a staged progression from clear liquids to full liquids to soft foods over several weeks while the wrap heals and early swelling resolves, which helps manage the normal early dysphagia (Baiu & Lau, JAMA, 2019). Carbonated beverages, bread, and tough meats are typically avoided initially. Early postoperative dysphagia is expected and generally improves over the first several weeks to months as tissue adaptation occurs (Chai et al., Surgical Endoscopy, 2026). Most antireflux medications are stopped at the time of surgery (Andolfi & Fisichella, JOMI). A follow-up visit is usually arranged within the first week or two, with activity restrictions (notably heavy lifting) for several weeks to protect the crural repair.

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The large majority of patients achieve durable, high-quality reflux relief. Randomized and real-world data show symptom relief in up to 92% of patients, greater than 90% satisfaction at 10 years, and more than 80% remaining off antireflux medication long-term (Thrumurthy et al., JAMA, 2026; Katz et al., ACG Clinical Guideline, 2022). At the same time, surgery is not a permanent cure for everyone: roughly 18% experience reflux recurrence within 10 years, about 4–7% undergo reoperation within 9–10 years, and anatomic hernia recurrence (usually small and asymptomatic) is common after large-hernia repair (Thrumurthy et al., JAMA, 2026; Maret-Ouda et al., JAMA, 2020; Callaway et al., Clinical Gastroenterology and Hepatology, 2018). Importantly, quality-of-life benefits tend to persist even when a small anatomic recurrence is present, including in patients over 70 followed beyond 5 years (Merzlikin et al., Surgical Endoscopy, 2017). When GERD does recur, endoscopy and pH monitoring guide whether revision is warranted (Maret-Ouda et al., JAMA, 2020).

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More in Anti-Reflux and Hiatal Hernia Surgery

Related procedures: Gastric Bypass for GERD — The Antireflux Operation of Choice in Obesity, After Sleeve, and for Failed Fundoplication, Ligamentum Teres Cardiopexy for Acid Reflux After Sleeve Gastrectomy, Revisional Foregut & Antireflux Surgery — Fixing Failed Reflux and Hiatal Hernia Repairs, Anti-Reflux Surgery for GERD: Fundoplication, LINX & Hiatal Hernia Repair, Laparoscopic Nissen Fundoplication, Toupet Fundoplication for Acid Reflux & Hiatal Hernia. For an overview of all options, see Foregut Surgery.

Conditions treated: Acid Reflux, Hiatal Hernia & Paraesophageal Hernia, Paraesophageal Hernia, Recurrent Hiatal Hernia, Failed Fundoplication, PPI-Refractory GERD.

Expected Symptom Improvements

The measurable gains after antireflux surgery are in reflux symptoms, medication use, and quality of life rather than metabolic parameters. Patients can expect marked reductions in heartburn and regurgitation, validated improvements in reflux-specific quality-of-life scores, and freedom from daily PPIs in the large majority (Maret-Ouda et al., JAMA, 2020; Katz et al., ACG Clinical Guideline, 2022). Stopping long-term PPIs is itself a goal for patients concerned about the potential risks of chronic acid suppression (Katz et al., ACG Clinical Guideline, 2022).

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Recurrence-Prevention Strategy

Because reflux and hernia recurrence are the central long-term challenges, prevention is built into surgical technique and patient selection rather than postoperative measures. The evidence supports: (1) complete mediastinal esophageal mobilization to achieve ≥3 cm of tension-free intra-abdominal esophagus (Schlottmann et al., JAMA Surgery, 2025); (2) meticulous crural closure, with selective mesh reinforcement for large defects, where several meta-analyses suggest reduced recurrence — though high-quality trials find mesh does not reliably lower recurrence for all hernias, so it is reserved for large or high-tension defects rather than used routinely (Nickel et al., Langenbeck's Archives of Surgery, 2023; Angeramo & Schlottmann, Annals of Surgery, 2022; Salehi et al., Surgical Endoscopy, 2024); (3) adding a fundoplication at hernia repair to restore the reflux barrier (Li et al., Scientific Reports, 2019); (4) tailoring the wrap to esophageal motility to minimize failure and reoperation (Yadlapati et al., AGA Clinical Practice Update, 2022); and (5) weight optimization, since elevated BMI strains the repair (Thrumurthy et al., JAMA, 2026).

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Antireflux and hiatal hernia surgery is Dr. de la Cruz-Muñoz's highest-volume operation, and outcomes in this field are strongly tied to surgeon and center experience — the literature consistently shows that complex foregut and redo repairs achieve the best, most durable results in the hands of experienced, high-volume foregut surgeons (Zahiri et al., Surgical Endoscopy, 2017; Bomio-Pacciorini et al., Langenbeck's Archives of Surgery, 2024). As a board-certified surgeon with extensive expertise in advanced minimally invasive and robotic foregut surgery, Dr. Nestor de la Cruz-Muñoz, MD, FACS, DABOM emphasizes the rigorous preoperative workup the guidelines require (endoscopy, esophageal manometry, and pH monitoring to confirm GERD and exclude achalasia), individualizes the operation to each patient's anatomy and esophageal motility (tailored Nissen vs. partial fundoplication, selective mesh, or magnetic sphincter augmentation), and manages the full spectrum of disease — from routine sliding hernias to giant paraesophageal hernias and complex reoperative repairs (Yadlapati et al., AGA Clinical Practice Update, 2022; Schlottmann et al., JAMA Surgery, 2025). His dual expertise in foregut and bariatric surgery is a distinct advantage for patients with obesity, in whom Roux-en-Y gastric bypass is frequently the superior antireflux solution (Yadlapati et al., AGA Clinical Practice Update, 2022). Patients receive candid counseling about expected benefit, the real rates of dysphagia, gas-bloat, and recurrence, and every available option before proceeding.

Our practice provides bilingual care and supports patients from Miami, Puerto Rico, the Dominican Republic, and Latin America.

Hiatal and paraesophageal hernia repair is a core part of Dr. de la Cruz-Muñoz's foregut practice. Over more than 25 years he has completed over 15,000 minimally invasive procedures, covering complex foregut, hernia, gallbladder, abdominal and bariatric surgery.

Research and Publications

Dr. de la Cruz-Muñoz's published and presented work on this topic includes:

• Jacome F, de la Cruz-Muñoz N. Laparoscopic Type IV hiatal hernia repair. Video presentation, Society of Laparoendoscopic Surgeons, 2012.
• Ribieras AJ, Monzon Canales EJ, Manzur-Pineda K, Cuesta M, Kutlu O, de la Cruz-Muñoz N. Comparison of upper gastrointestinal series and symptom questionnaires with intraoperative diagnosis of hiatal hernia during sleeve gastrectomy. Surgery for Obesity and Related Diseases. 2023.

If you live in or near Miami, our page on hiatal hernia surgery in Miami explains how evaluation and repair are handled at our practice.

This operation is, fundamentally, the surgical treatment of GERD, so reflux considerations drive every decision. Candidacy demands objective confirmation of pathologic acid reflux (pH monitoring), exclusion of achalasia (manometry), and assessment of peristalsis before surgery (Yadlapati et al., AGA Clinical Practice Update, 2022). Choice of operation is reflux- and anatomy-specific: standard fundoplication for non-obese patients with normal motility; partial fundoplication when motility is impaired; magnetic sphincter augmentation for selected patients who prioritize preserved belching and reduced gas-bloat; and, critically, Roux-en-Y gastric bypass as the preferred antireflux operation in patients with obesity, since sleeve gastrectomy can worsen GERD (Yadlapati et al., AGA Clinical Practice Update, 2022; Thrumurthy et al., JAMA, 2026). Magnetic sphincter augmentation also has a role in treating GERD that develops after sleeve gastrectomy, where standard fundoplication is not anatomically feasible (Katz et al., ACG Clinical Guideline, 2022).

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For persistent or recurrent reflux, dysphagia, or hernia after a prior repair, options are individualized and begin with re-evaluation (endoscopy, pH/impedance testing, barium study, and manometry) to define the cause (Maret-Ouda et al., JAMA, 2020). Options include:

• Redo hiatal hernia repair and refashioning of the fundoplication — in experienced high-volume hands, redo repairs achieve quality-of-life improvements comparable to primary surgery (Zahiri et al., Surgical Endoscopy, 2017).

• Conversion to Roux-en-Y gastric bypass — a powerful salvage antireflux option, especially in patients with obesity or multiple failed wraps (Yadlapati et al., AGA Clinical Practice Update, 2022).

• Magnetic sphincter augmentation or endoscopic therapies in carefully selected recurrence patterns (Katz et al., ACG Clinical Guideline, 2022).

• Endoscopic dilation for persistent postoperative dysphagia from a tight wrap or stricture (Katz et al., ACG Clinical Guideline, 2022).

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Antireflux and hiatal/paraesophageal hernia repair is generally covered as a medically necessary treatment for a documented disease. Payers typically expect documentation of objectively confirmed GERD and/or a symptomatic or anatomically significant hernia and the supporting workup — endoscopy, esophageal manometry, pH monitoring, and often a barium esophagram — along with a trial of or dependence on medical therapy (Yadlapati et al., AGA Clinical Practice Update, 2022; Thrumurthy et al., JAMA, 2026). Specific coverage, documentation, coding, and any pre-authorization requirements should be confirmed with each individual plan.

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• Upper endoscopy to assess mucosa, exclude malignancy, and document esophagitis, stricture, or Barrett's esophagus (Maret-Ouda et al., JAMA, 2020).

• Esophageal high-resolution manometry to confirm normal peristalsis and exclude achalasia, which guides the choice of complete vs. partial wrap (Maret-Ouda et al., JAMA, 2020; Yadlapati et al., AGA Clinical Practice Update, 2022).

• Ambulatory pH (± impedance) monitoring to objectively confirm pathologic reflux (Yadlapati et al., AGA Clinical Practice Update, 2022).

• Barium esophagram to characterize anatomy, hernia type and size (Andolfi & Fisichella, JOMI).

• Weight optimization counseling in patients with elevated BMI, and consideration of a bariatric-antireflux approach where appropriate (Thrumurthy et al., JAMA, 2026; Yadlapati et al., AGA Clinical Practice Update, 2022).

• Standard pre-anesthesia evaluation and fasting per the care team.

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Diet is advanced in stages — clear liquids, then full liquids, then soft/pureed foods, then a regular diet — over several weeks as the wrap heals and early swelling resolves (Baiu & Lau, JAMA, 2019). Patients are counseled to eat small, frequent, well-chewed meals; to prioritize protein and hydration; and to temporarily avoid carbonated beverages, bread, tough meats, and other foods that commonly cause early dysphagia. Early difficulty swallowing is expected and typically improves over the first weeks to months (Chai et al., Surgical Endoscopy, 2026). Persistent inability to swallow should prompt evaluation.

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Nutrition During Healing

Because reflux surgery temporarily restricts diet to a staged liquid-to-soft progression, the short-term nutritional focus is maintaining adequate protein, hydration, and calories while the wrap heals, so that lean muscle is preserved during the weeks of limited intake (Baiu & Lau, JAMA, 2019).

With minimally invasive repair there are no large incisions, and light activity such as walking is encouraged within days to reduce clot risk and speed recovery (Rattner, JOMI, 2024). Heavy lifting and strenuous straining are restricted for several weeks to protect the crural repair and reduce early recurrence risk. Patients then return progressively to full aerobic activity and, later, resistance training as cleared by the surgeon, with longer-term exercise supporting the weight management that helps protect the repair.

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Hiatal and paraesophageal hernia patients traveling internationally should plan approximately one week in Miami. Large paraesophageal hernias can cause sudden obstruction, so patients with severe symptoms should be evaluated promptly at home and should not delay. Records and CT images can be reviewed virtually to plan surgery.