Hiatus Hernia: Diagnosis & Surgical Treatment

A hiatus hernia occurs when part of your stomach pushes up through the diaphragm into your chest.

Many people live with one for years, but when symptoms become persistent or severe, surgery offers lasting relief.

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1 in 5 Canadians affected

99% Performed laparoscopically

1 night Typical hospital stay

2–4 weeks Return to normal activity

What is a hernia?

Your diaphragm is the dome-shaped muscle that separates your chest from your abdomen.

It has a small opening, the hiatus, through which your esophagus passes to connect to your stomach. Normally, this opening fits snugly around the esophagus.

In a hiatus hernia, the opening becomes enlarged or weakened, allowing part of the stomach (and sometimes surrounding structures) to slide or push upward into the chest cavity. This disrupts the normal anatomy that keeps stomach acid where it belongs.

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Types of Hernias

Type I · Most common

Sliding hiatus hernia

The gastroesophageal junction slides up and down through the hiatus. This accounts for approximately 95% of all hiatus hernias and is strongly associated with GERD and acid reflux symptoms.

Type II–IV

Paraesophageal hernia

Part or all of the stomach herniates alongside, or in place of, the esophagus. Less common but more mechanically significant. Can cause obstruction, volvulus, or strangulation if untreated.

Large hiatus hernias, particularly paraesophageal types, are a focus of Dr. Schofield's practice. He performs laparoscopic paraesophageal hernia repair routinely, including complex re-do cases.

Symptoms

Many hiatus hernias are found incidentally and cause no symptoms.

When symptoms do occur, they vary depending on the type and size of the hernia.

Common symptoms

Heartburn, especially after meals or when lying down
Acid reflux or regurgitation
Chest discomfort or pressure
Difficulty swallowing (dysphagia)
Belching or bloating
Feeling full quickly after eating
Nausea or vomiting

Symptoms suggesting larger hernias

Shortness of breath, especially after eating
Chest pain mistaken for cardiac causes
Anaemia from chronic occult bleeding
Inability to tolerate a full meal
Feeling of food "sticking" in the chest
Recurrent aspiration or respiratory symptoms

How is a hiatus hernia diagnosed?

Gastroscopy (upper endoscopy)

Often the first investigation. This allows direct visualization of the hernia, esophagus, and any associated inflammation or Barrett's changes.

Barium swallow

An X-ray series taken while swallowing contrast dye. This is excellent for characterizing the anatomy and size of the hernia, particularly for paraesophageal types.

CT scan

Provides cross-sectional detail of the hernia content and surrounding structures. Particularly valuable for large or complex hernias before surgical planning.

Esophageal manometry & pH testing

Measures pressures and acid exposure in the esophagus. Guides decisions about whether, and what type of, fundoplication to combine with hernia repair.

Surgical treatment

Not every hiatus hernia needs surgery. Small sliding hernias are often managed with medications and lifestyle changes. Surgery is considered when symptoms are persistent despite medical therapy, when medications carry long-term risks, or when the hernia is large enough to pose mechanical risk regardless of symptoms.

Laparoscopic hiatus hernia repair & fundoplication

The procedure is performed laparoscopically. The herniated stomach is returned to the abdomen, the enlarged hiatus is repaired with sutures (and mesh when appropriate), and a fundoplication, where the top of the stomach is wrapped around the lower esophagus, is added to restore the anti-reflux valve.

4–5 Small incisions (5–10 mm)

45–90 min Typical operative time

90–95% Long-term symptom relief

What happens during surgery

The abdomen is inflated with CO₂ gas to create working space
Herniated stomach and contents are gently reduced back below the diaphragm
The esophageal hiatus is closed with permanent sutures, narrowing the opening
Biologic or synthetic mesh may be used to reinforce the repair for large defects
A fundoplication is fashioned to recreate the anti-reflux mechanism

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Recovery & what to expect

1

Hospital stay

1 night

Most patients are up and walking the day of surgery. A liquid diet is started and you'll be discharged once tolerating fluids and comfortable on oral pain control.

2

First 2 weeks

Soft diet & rest

A graduated soft diet helps the wrap settle in. Temporary bloating and difficulty swallowing are normal during this period as swelling resolves.

3

Weeks 2–4

Return to activity

Most patients return to desk work within 2 weeks and normal daily activity within 4. Heavy lifting and strenuous exertion are restricted for 6 weeks.

4

6–12 weeks

Full recovery

By 6–8 weeks most patients are eating a full diet. The fundoplication typically "softens" over several months, and any temporary swallowing difficulty resolves.

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