Hiatal Hernia Repair After Sleeve Gastrectomy

Sleeve gastrectomy is the most commonly performed weight-loss operation in the world. Its main long-term drawback is gastroesophageal reflux disease (GERD), which affects roughly 20–30% of patients over time (Vosburg et al., American Society for Metabolic and Bariatric Surgery, 2026). Reflux after a sleeve has three main causes: a hiatal hernia with upward migration of the sleeve, narrowing or twisting of the sleeve, and de novo reflux from a weakened lower esophageal sphincter in a high-pressure, tube-shaped stomach (Vosburg et al., American Society for Metabolic and Bariatric Surgery, 2026).

When the top of the sleeve slides up through the diaphragm into the chest, the condition is called intrathoracic sleeve migration (ITSM). Reported rates range from under 1% to more than 45%. The wide range reflects inconsistent definitions and how hard migration is to detect (Aloulou et al., Obesity Surgery, 2024). Migration is very common among patients converted for reflux, and nearly half (48%) of patients converted to bypass for GERD in one series had a migrated sleeve (Crozet et al., Obesity Surgery, 2024). Most cases are chronic. They appear months to years after surgery, with reflux, regurgitation, food intolerance, or trouble swallowing (Aloulou et al., Obesity Surgery, 2024).

Repairing the hernia is only half the decision. The other half is choosing the operation most likely to control your reflux. That can be a hernia repair alone, a hernia repair reinforced with the ligamentum teres, or conversion to Roux-en-Y gastric bypass with hernia repair. The right choice depends on your weight, the condition of your esophagus, and your preferences (Sabry et al., Journal of Laparoendoscopic & Advanced Surgical Techniques, 2022).

Several things allow the sleeve to migrate into the chest. They include dissection of the left crus and angle of His at the original operation, removal of the fat pad and the stomach's natural attachments, negative pressure in the chest, rapid weight loss, and a small hiatal hernia that was present but not repaired at the time of the sleeve (Crozet et al., Obesity Surgery, 2024).

The repair restores the anti-reflux anatomy by:

• Reducing the sleeve and gastroesophageal junction back into the abdomen, restoring enough intra-abdominal esophageal length (Aloulou et al., Obesity Surgery, 2024).

• Closing the diaphragmatic crura (cruroplasty) to rebuild the barrier at the hiatus.

• Fixing the sleeve in place with a gastropexy, a ligamentum teres cardiopexy, or a LINX device. In the cardiopexy, the round ligament of the liver is used as a sling that anchors the gastroesophageal junction below the diaphragm (Mackey et al., Surgical Endoscopy, 2023).

• Reinforcing a weak hiatus with bioabsorbable mesh or a ligamentum teres flap when the crura are thin or under tension (Sabry et al., Journal of Laparoendoscopic & Advanced Surgical Techniques, 2022).

A standard Nissen or Toupet fundoplication usually cannot be done after a sleeve, because the fundus normally used to build the wrap has been removed. That is why the ligamentum teres has become a key tool in these repairs (Dore and Cherng, Journal of Medical Insight, 2024).

• Keeps your sleeve. Patients avoid the long-term risks of a bypass: marginal ulcers, internal hernias, dumping syndrome, and nutritional deficiencies (Dore and Cherng, Journal of Medical Insight, 2024).

• Meaningful reflux relief. In migration patients who are not bypass candidates, posterior cruroplasty alone has achieved up to 72% resolution of reflux and discontinuation of PPIs (Vosburg et al., American Society for Metabolic and Bariatric Surgery, 2026).

• Added benefit from the ligamentum teres. 81% of patients reduced or stopped acid medication at one year after hernia repair with ligamentum teres cardiopexy (Mackey et al., Surgical Endoscopy, 2023). Other series report 80–86.6% improvement or resolution (Dore and Cherng, Journal of Medical Insight, 2024).

• Regurgitation responds especially well. In one cardiopexy series, regurgitation resolved completely and half of patients stopped PPIs (Coisy et al., Journal of Laparoendoscopic & Advanced Surgical Techniques, 2026).

• Lower reoperation rate than conversion. In one series, reoperation was 3.4% after cardiopexy, compared with 6.7% in published conversion-to-bypass data. Hospital stay averaged about 1.3–1.5 days (Dore and Cherng, Journal of Medical Insight, 2024).

• Minimally invasive. The operation is done laparoscopically or robotically.

• Patients with a prior sleeve gastrectomy and a documented hiatal hernia or sleeve migration who have reflux, regurgitation, dysphagia, or food intolerance despite medical therapy (Aloulou et al., Obesity Surgery, 2024; Dore and Cherng, Journal of Medical Insight, 2024).

• Patients with good weight loss who do not want or need more weight loss and want to avoid a bypass (Dore and Cherng, Journal of Medical Insight, 2024).

• Patients with a contraindication to bypass, such as ongoing NSAID use or smoking, which raise the risk of marginal ulcers (Vosburg et al., American Society for Metabolic and Bariatric Surgery, 2026).

• Patients with a smaller hernia and no severe esophageal damage. Simpler revisions fit small hiatal defects without esophagitis, Barrett's esophagus, or stricture. Larger defects or esophageal damage point toward bypass (Sabry et al., Journal of Laparoendoscopic & Advanced Surgical Techniques, 2022).

Conversion to Roux-en-Y gastric bypass with hernia repair is usually the better operation for patients with weight regain or inadequate weight loss, severe erosive esophagitis or Barrett's esophagus, a large hernia, a twisted or narrowed sleeve, or failure of an earlier hernia repair (Vosburg et al., American Society for Metabolic and Bariatric Surgery, 2026; Sabry et al., Journal of Laparoendoscopic & Advanced Surgical Techniques, 2022). An international expert consensus named bypass the predominant surgical solution for reflux after sleeve, regardless of weight status (Kermansaravi et al., Surgical Endoscopy, 2023).

The operation is done under general anesthesia through small incisions, either laparoscopically or robotically. Scar tissue from the original sleeve is carefully released. The hernia sac is removed, and the sleeve and gastroesophageal junction are freed from the chest. At least several centimeters of esophagus are brought back below the diaphragm. In one published technique, at least 4 cm of distal esophagus was reduced into the abdomen (Sabry et al., Journal of Laparoendoscopic & Advanced Surgical Techniques, 2022).

The crura are closed with permanent sutures, and absorbable mesh reinforcement is used selectively (Sabry et al., Journal of Laparoendoscopic & Advanced Surgical Techniques, 2022). When a ligamentum teres cardiopexy is added, the round ligament is freed from the abdominal wall toward the umbilicus. It is then passed behind the esophagus as a partial (about 270-degree) sling and sutured to the gastroesophageal junction to anchor it in the abdomen. Some surgeons moved from a 360-degree to a 270-degree sling after finding the full wrap too tight (Dore and Cherng, Journal of Medical Insight, 2024).

If a "neofundus" (a dilated upper sleeve) is found, a re-sleeve can be done at the same operation (Sabry et al., Journal of Laparoendoscopic & Advanced Surgical Techniques, 2022). If the workup or the findings during surgery favor it, conversion to Roux-en-Y gastric bypass with posterior cruroplasty is done instead (Termine et al., Obesity Surgery, 2021).

• Recurrent migration. Simple suture repairs can fail over time. After crural repair alone, migration reached 22.9% at 18 months, and none of those recurrences appeared before six months (Teshaev et al., Obesity Surgery, 2026). In a five-year study of cruroplasty, migration occurred in 18.4% after simple suture repair and 4.3% with bioabsorbable mesh reinforcement (Boru et al., Journal of Gastrointestinal Surgery, 2020). Large hernias (5 cm or more) had about five times the recurrence risk (36.4% versus 10.3%) (Carrano et al., Obesity Surgery, 2026).

• Persistent reflux. Reflux symptoms, more than anatomic recurrence alone, are the most common reason for repeat intervention (Carrano et al., Obesity Surgery, 2026). Some patients later need conversion to bypass.

• Dysphagia. Mild, temporary swallowing difficulty occurs in roughly 15–19% of cardiopexy patients. It is usually caused by over-tightening of the hiatus rather than the ligament sling itself (Coisy et al., Journal of Laparoendoscopic & Advanced Surgical Techniques, 2026).

• Standard reoperative risks: bleeding, injury to the sleeve, esophagus, or vagus nerves, pleural injury, leaks, and blood clots.

Most patients stay in the hospital one to two nights. Ligamentum teres cardiopexy patients averaged about 1.3–1.5 days (Dore and Cherng, Journal of Medical Insight, 2024). The diet moves from liquids to soft, moist foods over several weeks. Walking starts the same day. Patients avoid heavy lifting and straining for several weeks to protect the hiatal repair. Early mild swallowing discomfort is common and usually settles as swelling goes down.

Most well-selected patients get substantial relief of reflux and regurgitation, and many stop or reduce acid medication (Mackey et al., Surgical Endoscopy, 2023). Even so, only about half of cardiopexy patients with resolved symptoms stop antisecretory medication entirely, and the rest remain on some therapy (Lind et al., Obesity Surgery, 2024). Because recurrence can appear after the first six months, follow-up with endoscopy or imaging is recommended (Teshaev et al., Obesity Surgery, 2026). Long-term data beyond a few years are still limited (Hawasli et al., American Journal of Surgery, 2021).

More in Sleeve Gastrectomy Revisions

Related procedures: Gastric Sleeve Stricture Management, Sleeve Gastrectomy to Roux-en-Y Gastric Bypass Conversion, Sleeve Gastrectomy to SADI-S Conversion, Sleeve Gastrectomy to Duodenal Switch Conversion, Sleeve to OAGB Conversion, Sleeve Gastrectomy to Magnetic Duodeno-Ileostomy Conversion. Related primary operations: Sleeve Gastrectomy. For an overview of all options, see Revisional Bariatric Surgery.

Conditions treated: Reflux After Sleeve Gastrectomy, Acid Reflux, Hiatal Hernia & Paraesophageal Hernia, Recurrent Hiatal Hernia, Dysphagia.

Reflux after a sleeve sits where two specialties meet: advanced foregut surgery and revisional bariatric surgery. Dr. Nestor de la Cruz-Muñoz, MD, FACS, DABOM, has built his career in both fields. Antireflux and hiatal hernia surgery is the most common operation in his practice. He has performed and revised sleeve gastrectomies and gastric bypasses for decades. He is a board-certified surgeon and a diplomate of the American Board of Obesity Medicine, and he served for 10 years as a fellowship program director, teaching surgeons the reoperative foregut and bariatric techniques these cases require.

What sets his approach apart is offering the full menu and matching it to you. Some patients are best served by a reinforced hiatal hernia repair with ligamentum teres cardiopexy that keeps their sleeve. Others are better served by conversion to Roux-en-Y gastric bypass, which he considers the procedure of choice for patients with weight regain, severe esophagitis or Barrett's esophagus, or failed prior repairs. For selected patients with proven normal esophageal function, LINX is another option. Every plan starts with a complete workup: endoscopy, contrast imaging, CT, manometry, and pH testing. The goal is a durable repair the first time.

Dr. de la Cruz-Muñoz has been performing bariatric surgery for over 25 years and has completed more than 9,000 bariatric operations — a volume few surgeons reach.

Research and Publications

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

• 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.
• Monzon Canales EJ, Ribieras AJ, de la Cruz-Muñoz N. Prospective long-term outcomes in patients undergoing laparoscopic sleeve gastrectomy with and without hiatal hernia repair. ASMBS Annual Meeting, 2024 (Surgery for Obesity and Related Diseases 20(6):S117).
• Invited lecture: “Weight Regain and GERD after Sleeve Gastrectomy.” ASMBS Annual Meeting, Washington, D.C., 2025.

After a sleeve, reflux can come from the hernia, the shape of the sleeve (twist, narrowing, or a dilated upper pouch), or a weak sphincter (Vosburg et al., American Society for Metabolic and Bariatric Surgery, 2026). Patients whose sleeve is kinked or twisted may respond better to hernia repair and gastropexy than patients with a widely open gastroesophageal junction (Rapolti et al., Journal of Laparoendoscopic & Advanced Surgical Techniques, 2024). Conversion to gastric bypass remains the most effective treatment, with 60–100% symptom resolution, and only 20–40% of patients need PPIs afterward (Vosburg et al., American Society for Metabolic and Bariatric Surgery, 2026). That said, one large center found objective improvement in only 45.3% of converted patients. Meeting ACG diagnostic criteria for GERD before surgery predicted success (Cymbal et al., Surgery for Obesity and Related Diseases, 2026). LINX after sleeve improved reflux scores and reduced daily PPI use from 97.4% to 25.3%, with 0.9% erosion. It requires proven normal esophageal motility on manometry (Vosburg et al., American Society for Metabolic and Bariatric Surgery, 2026).

Options include a redo reinforced cruroplasty with mesh or a ligamentum teres flap (Boru et al., Journal of Gastrointestinal Surgery, 2020), a re-sleeve for a neofundus, conversion to Roux-en-Y gastric bypass with posterior cruroplasty, which resolved symptoms in 86.7% of migration patients in one series (Termine et al., Obesity Surgery, 2021), one-anastomosis gastric bypass in select patients (Aloulou et al., Obesity Surgery, 2024), and LINX for patients with normal esophageal function.

Most insurers cover hiatal hernia repair when symptoms and hernia are confirmed by imaging or endoscopy. Requirements may include prior trial of proton pump inhibitors.

Upper endoscopy, a contrast swallow study, and CT (ideally with 3D reconstruction), plus high-resolution manometry and pH testing (Crozet et al., Obesity Surgery, 2024). Patients also need nutrition labs, must stop smoking and avoid NSAIDs, and need optimization of other medical conditions.

Nutrition progresses from liquids to soft foods. Protein goals and vitamin supplementation are maintained.

Early walking begins immediately. Light activity continues through week 2. Resistance training begins at week 4–6.

Patients traveling for hiatal hernia repair after a sleeve should, if possible, complete reflux testing (pH monitoring and endoscopy) at home before the trip. Those results help decide in advance whether a repair alone or a conversion to bypass is best. Plan on approximately one week in Miami.