What is a hiatal hernia?
A hiatal hernia is the protrusion of part of the stomach —and, less often, other abdominal organs— into the chest through a widened esophageal hiatus of the diaphragm. The diaphragm is the muscle separating the chest from the abdominal cavity.
It is closely linked with gastroesophageal reflux, because displacement of the gastroesophageal junction disrupts the normal anti-reflux mechanism.
How common is it?
It is very common and its incidence rises with age. Predisposing factors include obesity, raised intra-abdominal pressure, ligament laxity and heredity.
The vast majority are small, sliding (type I) hernias that often remain asymptomatic and are found incidentally on endoscopy or imaging.
How does it present?
When it does cause trouble, the most common symptoms are:
- Retrosternal burning (heartburn) and acid reflux.
- Regurgitation of food or fluid, especially lying down or after meals.
- Dysphagia (difficulty swallowing) and a sense of food "sticking".
- Epigastric or chest pain, belching, bloating.
- In large or paraesophageal hernias: early satiety, breathlessness after meals, chronic anemia (from Cameron erosions).
How is it diagnosed?
Work-up combines endoscopy with functional and imaging studies as needed:
- Gastroscopy (upper GI endoscopy): confirms the hernia, assesses any esophagitis and excludes other pathology.
- Barium esophagogram: demonstrates the size and type of hernia.
- High-resolution manometry and 24-hour pH monitoring: pre-operatively, to assess motility and reflux.
- CT scan: for large or paraesophageal hernias, for precise mapping.
How is it classified?
Four anatomical types are described, and they guide management:
- Type I — Sliding: the most common (>95%). The gastroesophageal junction slides above the diaphragm.
- Type II — Paraesophageal (pure): the fundus rises alongside the esophagus while the junction stays in place.
- Type III — Mixed: a combination of types I and II.
- Type IV: other organs (e.g. colon, spleen) also herniate into the chest.
Types II–IV (paraesophageal) carry a higher risk of complications and more often require surgery.
Modern treatment options
Not every hiatal hernia needs surgery. Management is individualised based on type, symptoms and complications. The goal is symptom control and prevention of complications while preserving normal function.
Laparoscopic hiatal repair & fundoplication
The modern minimally invasive operation of choice: reduction of the stomach into the abdomen, closure of the widened hiatus and creation of an anti-reflux wrap (fundoplication). Indicated for refractory reflux or a symptomatic hernia.
Conservative management
For asymptomatic or mild type I hernias: lifestyle changes (weight loss, avoiding late meals, head-of-bed elevation) and medication to control acid.
Paraesophageal hernia repair
Type II–IV hernias often require surgery when symptomatic or complicated, sometimes with reinforcing material (mesh) to reduce recurrence. Acute volvulus requires emergency treatment.
Robotic approach
For complex, large or recurrent hernias, the robotic platform offers enhanced precision around the esophageal hiatus and facilitates fine suturing.
Frequently asked questions
Does a hiatal hernia always need surgery?
No. Small, asymptomatic type I hernias are usually just monitored. Surgery is offered for refractory reflux, large or paraesophageal hernias and when complications occur.
What is the relationship with gastroesophageal reflux?
A hiatal hernia disrupts the anti-reflux mechanism and promotes reflux. That is why surgical repair is often combined with a fundoplication.
Will I need mesh?
Not always. In large paraesophageal hernias, reinforcing material may be used to reduce recurrence; the decision is individualised.
Can it come back?
There is a small chance of recurrence, particularly with large hernias. Good technique, weight control and avoiding heavy abdominal straining reduce the risk.