Dr. Solon Gonçalves Souza Menezes
Professor of Surgery — FAMED UFU · Robotic Surgery Certification (Intuitive / Albert Einstein Hospital) · Practices at Hospital UMC and Hospital Mater Dei Santa Genoveva, Uberlândia, Brazil · +55 (34) 99341-0915
The hiatus is the opening in the diaphragm through which the esophagus passes from the chest into the abdomen. When this opening widens, part of the stomach rises into the chest: that is a hiatal hernia. In the most common type, the sliding hernia (type I), the junction between esophagus and stomach slides upward; it is usually small, often an incidental finding at endoscopy, and is linked to gastroesophageal reflux. In paraesophageal hernias (types II to IV), the stomach fundus — and sometimes other organs — rises beside the esophagus; they are less frequent, tend to be larger and carry a mechanical risk of their own: incarceration and twisting of the stomach (gastric volvulus).
The first thing to tell anyone who has received this diagnosis is that most hiatal hernias do not need surgery. A small sliding hernia, without symptoms or with reflux well controlled by medication, is treated clinically. Surgery is indicated when there is proven reflux that cannot be controlled (the ACG 2022 guideline specifically lists “large hiatal hernias” among the indications for antireflux surgery), when a paraesophageal hernia causes symptoms — chest pain or heaviness after eating, early fullness, shortness of breath, anemia from small erosions of the lining — or when there are signs of obstruction. The SAGES 2024 guideline also advises checking whether the hernia is really asymptomatic, because anemia, breathlessness and chest pain are often attributed to other causes.
The repair is done through a minimally invasive approach, with five small incisions: the stomach is brought back into the abdomen, the hernia sac is removed, the hiatus is closed with sutures (hiatoplasty) and, in the vast majority of cases, a fundoplication — wrapping the stomach fundus around the esophagus — is added to prevent reflux and help keep the stomach in place. SAGES 2024 recommends routinely performing the fundoplication in this repair: in clinical trials it reduced objective reflux by about 70% (relative risk 0.31), at the cost of more dysphagia early on. The use of reinforcing mesh at the hiatus has no recommendation for or against: in randomized trials, mesh did not reduce recurrence.
Dr. Solon Gonçalves performs hiatal hernia repair by laparoscopy and by robotic surgery, at Hospital UMC and Hospital Mater Dei Santa Genoveva in Uberlândia, Brazil. The meta-analyses published between 2023 and 2026, totaling hundreds of thousands of patients, found no difference in mortality, conversion, recurrence, hospital stay or readmission between the two routes; laparoscopy has a slightly shorter operative time (about 15 minutes) and a lower cost, while some observational studies suggest fewer intraoperative complications with the robot. In large paraesophageal hernias, where the dissection inside the chest is long and delicate, the 3D vision and articulated instruments of robotics are particularly useful — the choice is made case by case, with the patient.
Book a consultationWho has an indication for hiatal hernia surgery.
The indication depends on the type of hernia, the symptoms and objective proof of reflux. Endoscopy, a contrast X-ray of the esophagus, manometry and, in selected cases, pH monitoring and CT scan are part of the assessment.
Reflux that cannot be controlled
Hiatal hernia with proven reflux and persistent symptoms despite medication, severe esophagitis or significant regurgitation: repair of the hernia with fundoplication is an indication for antireflux surgery (ACG 2022).
Symptomatic paraesophageal hernia
Chest pain or pressure after meals, early fullness, vomiting, shortness of breath or anemia from erosions of the lining: these indicate repair, because of the risk of incarceration and gastric volvulus.
Obstruction or incarceration
Intense pain, retching without being able to vomit and inability to pass a tube are signs of emergency — an incarcerated hernia needs immediate surgery.
Hernia without symptoms
In truly asymptomatic hernias there are no studies comparing surgery and observation; SAGES 2024 considers watchful waiting reasonable when the work-up is negative and the patient understands the risk of volvulus. Age alone does not contraindicate surgery.
Laparoscopy and robotics in hiatal hernia: what the evidence shows.
The steps of the operation are the same in both routes — reduction of the stomach, removal of the hernia sac, hiatoplasty and fundoplication. The table gathers the results of the most recent comparative meta-analyses.
| Outcome | Laparoscopy | Robotic surgery |
|---|---|---|
| Mortality, conversion, recurrence, hospital stay and readmission | No difference (13 studies, 205,000 patients, Hernia 2025) | No difference |
| Postoperative complications | No difference in the largest meta-analysis (38 studies, 550,000 patients, RR 0.85) | One observational study suggests fewer complications (OR 0.52) |
| Intraoperative complications | — | Fewer in a meta-analysis of 11 studies (OR 0.41), with no difference in serious complications |
| Operative time | About 15 to 20 minutes shorter | Longer |
| Cost | Lower | About US$ 3,000 more per case |
| Paraesophageal hernias | No superiority demonstrated for either route (10 studies, 186,000 patients) | 3D vision and articulated instruments useful in mediastinal dissection |
On a phone, drag the table sideways to see all the columns.
What to expect before and after surgery.
Preoperative preparation
The assessment includes upper endoscopy, a contrast X-ray of the esophagus (which shows the size and type of the hernia), esophageal manometry — which guides the choice between total and partial fundoplication — and, when reflux is not yet documented, pH monitoring off medication. CT scan is useful in large hernias. Blood tests, a cardiology assessment in older patients and an anesthetic assessment complete the preparation; fasting, suspension of anticoagulants under guidance and smoking cessation are advised.
Recovery and postoperative care
The hospital stay is usually 1 to 3 days, longer in large paraesophageal hernias. The diet starts liquid and progresses to soft and solid over a few weeks; difficulty swallowing at the beginning is expected and tends to improve. Shoulder pain from the gas and chest discomfort in the first days are common. Work without effort is resumed in 1 to 2 weeks; physical effort and lifting, generally after 4 to 6 weeks, to protect the hiatal repair. Follow-up matters: some large hernias recur anatomically over the years, even when the symptoms remain controlled.
Risks and recurrence, with the published numbers.
In addition to the risks of any abdominal surgery, hiatal hernia repair has two points the patient needs to know: the dysphagia of the first weeks and the possibility of long-term anatomical recurrence.
- Hernia recurrence — in large paraesophageal hernias, the long-term follow-up of a randomized trial (median 58 months) found radiological recurrence in 54% to 59% of patients; even so, symptom relief and improvement in quality of life were lasting, and few recurrences need further surgery. In small hernias, recurrence is much less frequent.
- Dysphagia — frequent and transient in the first weeks; the added fundoplication increases early dysphagia (relative risk 2.08 in observational studies), in exchange for much less reflux.
- Bloating and difficulty belching — effects of the new valve, smaller with partial fundoplication.
- Surgical complications — perforation of the esophagus or stomach, bleeding, injury to the spleen or the pleura (pneumothorax) during the dissection in the chest: rare, more likely in large hernias and reoperations.
- Reinforcing mesh — when used, there is a rare risk of erosion; in randomized trials there was no erosion in 270 patients, but there was also no reduction in recurrence — which is why it is not used routinely.
- General risks — anesthesia, venous thrombosis and infection, with low frequency.
Common questions about this procedure.
Does every hiatal hernia need surgery?+
No. Most are small, sliding hernias, and are treated clinically — with medication for reflux and lifestyle changes. Surgery is indicated when reflux cannot be controlled despite treatment, when the hernia is paraesophageal and causes symptoms, or when there are signs of obstruction. Hernias without symptoms can be observed, as long as the work-up confirms they really are asymptomatic.
Can a hiatal hernia be cured? Can it go away on its own?+
The hernia does not disappear on its own, because the widened hiatus does not close spontaneously; what can be controlled are the symptoms. Surgery repairs the hernia, but, in large hernias, some recur anatomically over the years — even so, symptom relief is usually lasting.
Can a hiatal hernia turn into cancer?+
The hiatal hernia itself is not cancer and does not turn into cancer. What deserves attention is the chronic reflux that accompanies it: it can cause esophagitis and Barrett's esophagus, a condition that raises the risk of esophageal cancer and needs endoscopic surveillance. Controlling reflux — with medication or surgery — is the way to protect the esophagus.
What happens if a hiatal hernia is not treated?+
It depends on the type. In the sliding hernia, the problem is untreated reflux, with esophagitis and its consequences. In the paraesophageal hernia, the herniated stomach can incarcerate or twist (gastric volvulus), a surgical emergency — which is why symptomatic paraesophageal hernias are operated on electively, before that happens.
What is the risk of hiatal hernia surgery?+
It is a safe minimally invasive surgery, with very low mortality and rare major complications. The most frequent points are transient dysphagia and bloating and, in the long term, anatomical recurrence in large hernias. The numbers are in the risks section of this page.
What is the stomach like after surgery?+
The stomach returns to the abdomen and stays below the diaphragm; the hiatus is closed with sutures and the stomach fundus forms a valve around the esophagus. The capacity of the stomach does not change, but in the first weeks the valve is swollen, which is why the diet is progressive.
Does hiatal hernia surgery make you lose weight?+
That is not the goal. There may be temporary weight loss because of the liquid and soft diet of the first weeks, which stabilizes afterwards. In patients with obesity, the indicated surgery may be gastric bypass, which treats reflux, the hernia and excess weight at the same time.
How long do the surgery and the hospital stay take?+
Between one and three hours, depending on the size of the hernia, under general anesthesia; the hospital stay is 1 to 3 days. Large paraesophageal hernias require a longer dissection inside the chest.
How long is the recovery and the sick leave?+
Work without physical effort in 1 to 2 weeks; effort and lifting after 4 to 6 weeks. The progressive diet in the first weeks is part of the treatment. Sick leave is defined individually.
Is the surgery done with a laser? Laparoscopic or robotic?+
There is no laser hiatal hernia surgery. The repair is done by laparoscopy or with the surgical robot, through the same five small incisions; both routes have equivalent results in the meta-analyses, and robotics is chosen in selected cases, such as large hernias and reoperations.
Is mesh needed in a hiatal hernia?+
Not routinely. The SAGES 2024 guideline makes no recommendation for or against: in randomized trials mesh did not reduce recurrence, although observational studies suggest some benefit. It may be considered in very large or recurrent hernias, case by case.
Do you operate through the SUS, the Brazilian public health system?+
I do operate through the SUS. I am a Professor of Surgery at the School of Medicine of the Federal University of Uberlândia and I operate on patients at the university hospital, HC-UFU. The route, however, does not go through my private practice: to be operated on through the SUS you must go to the health post or Basic Health Unit nearest your home, be assessed by a doctor and, if surgery is indicated, be placed in your municipality's regulation queue. The surgeon does not choose who gets operated on through the SUS — the queue is followed strictly, according to SUS rules.
Hospital facilities in Uberlândia, Brazil.
Hospital Mater Dei Santa Genoveva
Av. Vasconcelos Costa, 967 — Martins, Uberlândia-MG
Open in Google Maps →Content reviewed by Dr. Solon Gonçalves Souza Menezes — CRM-MG 79366, RQE 60355 (GI Surgery), RQE 44656 (General Surgery). Professor of Surgery at FAMED-UFU and Supervisor of the General Surgery Medical Residency Program at HC-UFU. ORCID. Last reviewed: October/2026.
- Daly S, Kumar SS, Collings AT, et al. SAGES guidelines for the surgical treatment of hiatal hernias. Surg Endosc. 2024;38(9):4765-4775. doi:10.1007/s00464-024-11092-3
- Hanna NM, Kumar SS, Collings AT, et al. Management of symptomatic, asymptomatic, and recurrent hiatal hernia: a systematic review and meta-analysis. Surg Endosc. 2024;38(6):2917-2938. doi:10.1007/s00464-024-10816-9
- Katz PO, Dunbar KB, Schnoll-Sussman FH, et al. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2022;117(1):27-56. doi:10.14309/ajg.0000000000001538
- Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: long-term follow-up from a multicenter, prospective, randomized trial. J Am Coll Surg. 2011;213(4):461-468. doi:10.1016/j.jamcollsurg.2011.05.017
- AlFataftah S, Hammadeh BM, Yaghi G, et al. Safety and efficacy of robotic versus laparoscopic hiatal hernia repair: a systematic review and meta-analysis of perioperative outcomes. Hernia. 2025;29(1):305. doi:10.1007/s10029-025-03484-8
- Xiao X, Zhang C, Li H, et al. Robotic-assisted versus laparoscopic esophageal hiatal hernia and anti-reflux surgery: a comprehensive systematic review and meta-analysis. Hernia. 2026;30(1). doi:10.1007/s10029-026-03770-z
- Mathys A, Vanommeslaeghe H, Van Nieuwenhove Y, et al. A systematic review and meta-analysis: robotic versus laparoscopic hiatal hernia repair, is there a difference in Clavien Dindo score? Acta Chir Belg. 2026;126(2):33-42. doi:10.1080/00015458.2025.2611452
- Symeonidou E, Gkoutziotis I, Petras P, et al. Robotic-assisted versus laparoscopic paraesophageal hernia repair: a systematic review and meta-analysis. J Minim Invasive Surg. 2023;26(3):134-145. doi:10.7602/jmis.2023.26.3.134
- Gonçalves-Costa D, Barbosa JP, Quesado R, et al. Robotic surgery versus laparoscopic surgery for anti-reflux and hiatal hernia surgery: a short-term outcomes and cost systematic literature review and meta-analysis. Langenbecks Arch Surg. 2024;409(1):175. doi:10.1007/s00423-024-03368-y