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Hiatal hernia

Updated May 31, 2025

What's new

The American Society for Gastrointestinal Endoscopy (ASGE) has published an updated guideline for the diagnosis and management of gastroesophageal reflux disease (GERD), including surgical indications in patients with hiatal hernia. Transoral incisionless fundoplication is suggested for small hiatal hernias (≤2 cm) with Hill grade I or II in patients with chronic or refractory GERD, regurgitation-predominant GERD, chronic PPI use, or a preference to avoid chronic PPI use. The Stretta procedure is suggested for small hiatal hernias with Hill grade I or II when other alternatives are unavailable. Combined hiatal hernia repair is suggested for large hiatal hernias (>2 cm) with Hill grade III or IV. .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of hiatal hernia are prepared by our editorial team based on guidelines from the American Society for Gastrointestinal Endoscopy (ASGE 2025) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES 2024,2013).

Classification and risk stratification

Classification: as per SAGES 2013 guidelines, classify hiatal hernias into the following types:

Situation

Guidance

Type I

Sliding hernias - the GEJ migrates above the diaphragm, the stomach remains in its usual longitudinal alignment and the fundus remains below the GEJ

Type II

Pure paraesophageal hernias - the GEJ remains in its normal anatomic position, but a portion of the fundus herniates through the diaphragmatic hiatus adjacent to the esophagus

Type III

A combination of types I and II, with both the GEJ and the fundus herniating through the hiatus, and the fundus lies above the GEJ

Type IV

Hiatal hernias with the presence of a structure other than stomach (such as the omentum, colon, or small bowel) within the hernial sac

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Diagnostic investigations

Diagnostic strategy: as per SAGES 2013 guidelines, recognize that hiatal hernia can be diagnosed by various modalities. Obtain only investigations that will alter the management.

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Perioperative care

Postoperative care: as per SAGES 2013 guidelines, do not obtain routine postoperative contrast studies in asymptomatic patients after hiatal hernia repair.

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Surgical interventions

Indications for surgery: as per ASGE 2025 guidelines, consider evaluating patients with confirmed GERD and a small hiatal hernia (≤ 2 cm) with Hill grade I or II for transoral incisionless fundoplication as an alternative to chronic medical management if they meet any of the following criteria:

chronic GERD for at least 6 months

chronic PPI use (≥ 6 months) for GERD symptoms

refractory GERD

regurgitation-predominant GERD

preference to avoid long-term PPI use.

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Specific circumstances

Patients undergoing bariatric surgery: as per SAGES 2013 guidelines, repair any hiatal hernia detected during Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric band placement.

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Follow-up and surveillance

Management of recurrent hernia

As per SAGES 2024 guidelines:

Consider converting to Roux-en-Y gastric bypass in selected patients without obesity and with recurrent type II, III, or IV hiatal hernia.

Perform redo hiatal hernia repair and fundoplication in patients with recurrent hiatal hernia after a previous uncomplicated hiatal hernia repair with fundoplication. Consider performing Roux-en-Y gastric bypass in patients with diabetes mellitus, severe esophageal dysmotility, short esophagus, or gastroparesis, patients with previous complicated hiatal hernia repair with fundoplication having poor quality tissue of the fundus, and patients after multiple recurrent hiatal hernia failures by an expert.

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