Hiatal Hernia and Gastric Sleeve Surgery

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Hiatal Hernia and Gastric Sleeve Surgery

A hiatal hernia means the top of the stomach has slid up through the opening in the diaphragm into the chest. It is common in people with obesity and matters for a gastric sleeve because it can worsen acid reflux. When one is found before or during sleeve surgery, published guidance favors repairing it in the same operation. A hernia can also appear or return years later.

What a hiatal hernia is

The diaphragm is the sheet of muscle that separates the chest from the abdomen. The esophagus (swallowing tube) passes through a gap in it called the hiatus, and normally the whole stomach sits below. In a hiatal hernia the gap is loose and part of the stomach rides up through it.

The diaphragm helps keep acid in the stomach. When the junction between the esophagus and stomach slips above it, that barrier is weaker and reflux becomes more likely. Many small hernias cause no symptoms at all and are found only when someone has an endoscopy or X-ray for another reason.

A 2023 systematic review in the Journal of Clinical Medicine (Castagneto-Gissey and colleagues) cites an estimate that about 40% of people with severe obesity have some degree of hiatal hernia.

Found before surgery

Part of preparing for a sleeve can be finding out whether you have reflux, esophagitis (inflammation of the esophagus lining) or a hernia, because the answer can change which operation suits you. A hernia may show on an upper endoscopy, where a thin camera is passed through the mouth under sedation, or on an upper GI X-ray taken while you swallow contrast. Ask the office which tests would be part of your work-up, and see tests before gastric sleeve surgery.

A hernia on its own does not rule out a sleeve. What matters more is how much reflux you have and what the esophagus looks like. Surgeons across the United States weigh this: an analysis of the national MBSAQIP registry for 2015 to 2018 (Naeem and colleagues, Obesity Surgery, 2020) found that people with reflux before surgery were increasingly likely to have a gastric bypass instead of a sleeve. Our bypass versus sleeve comparison explains that choice.

Found during surgery

Hernias are sometimes missed on tests and discovered once the surgeon is looking at the area directly. The Castagneto-Gissey review notes that most high-volume sleeve surgeons advise actively looking for a hiatal hernia during the operation and fixing it. A 2021 meta-analysis in Obesity Surgery (Chen and colleagues) likewise describes repair as recommended when a hernia is found during a sleeve. Ask Dr. Davtyan how a hernia found during your operation would be handled.

What the repair involves

The surgeon brings the stomach and lower esophagus back down into the abdomen and tightens the opening in the diaphragm with stitches. In a laparoscopic operation this is done through the small incisions used for the sleeve.

What the evidence shows

The Chen meta-analysis pooled 18 studies and 937 patients who had a sleeve with hernia repair:

Reflux went into remission in 68.0% of those who had it beforehand.
New reflux developed in 12%.
The hernia came back in 11%.

Sleeve plus repair gave better reflux remission than a sleeve alone, but the rate of new reflux was not significantly different. The picture is not settled. A subgroup analysis in the Castagneto-Gissey review, based on two studies, favored a sleeve alone for reflux remission. In plain terms, repair may help, and it does not remove the sleeve's own tendency toward reflux.

Does repair add risk?

Slightly, in the short term. A matched analysis of 101,902 MBSAQIP patients (Janik and colleagues, Surgery for Obesity and Related Diseases, 2020) compared sleeve with hernia repair against sleeve alone. The risk of death within 30 days was the same in both groups (0.02%). Readmission was somewhat more frequent with repair (4.01% versus 2.96%), as was reoperation (1.10% versus 0.77%).

Found after surgery

A hernia can form, enlarge or return after a sleeve. In the Finnish SLEEVEPASS trial (JAMA Surgery, 2022), a hiatal hernia was recorded at endoscopy in 57 of 91 sleeve patients (63%) ten years after surgery. The Castagneto-Gissey review also describes the top of the sleeve itself migrating up into the chest, citing a rate of about 7%.

The usual clue is reflux: heartburn, regurgitation when you bend or lie down, a night-time cough, or food that seems to pause low in the chest. An upper GI X-ray and an endoscopy show whether a hernia is present and whether there is also a narrowing or twist in the sleeve.

Treatment follows the symptoms. Mild reflux is managed with eating changes and acid-reducing medicine, as described on our acid reflux after gastric sleeve page. If symptoms are severe or the esophagus is being damaged, surgery is considered. That may be a hernia repair alone or, more often when reflux is the main issue, a conversion to gastric bypass with the hernia repaired at the same time. Ask the office whether these operations are available through the practice.

When to call

Go to an emergency room or call 911 if

You have severe chest or upper abdominal pain, with or without retching that brings nothing up
You cannot swallow liquids or keep them down
You are vomiting blood or passing black stools
You have chest pain with shortness of breath or sweating

Call the office if

Heartburn or regurgitation is new, or is breaking through your medicine
Food sticks low in the chest
You wake at night coughing or with a sour taste

Frequently asked questions

Can I have a hiatal hernia and not know it?

Yes. Small hernias often cause no symptoms and are found only on an endoscopy or X-ray. That is one reason surgeons may examine the upper stomach before and during bariatric surgery. Having no heartburn does not prove there is no hernia, and having a hernia does not mean you will have heartburn.

Will repairing my hernia during the sleeve cure my heartburn?

It may improve the odds but is not a promise. In the Chen meta-analysis, reflux went into remission in 68.0% of patients who had a sleeve with hernia repair, which means roughly a third still had symptoms. If your reflux is severe before surgery, ask whether a gastric bypass would be a better fit.

Is mesh used to repair a hiatal hernia during a sleeve?

In the Castagneto-Gissey review, authors favored permanent stitches to tighten the opening, and large openings were sometimes also reinforced with biologic mesh. Two studies comparing stitches alone with mesh showed no statistically significant difference in reflux remission. That is limited evidence. Ask your surgeon what would be planned in your case.

Does lifting or straining cause a hernia to come back?

The studies cited here do not measure the effect of lifting, so we cannot give you a figure. Hernias do come back after repair: 11% in the Chen meta-analysis. Surgeons commonly set activity limits after surgery, so follow the ones you are given; see returning to work and driving after a sleeve.

Talk with Dr. Davtyan in Rancho Cucamonga

Dr. David G. Davtyan, MD, FACS, FICS, FASMBS, is a bariatric surgeon at Davtyan Medical Weight Loss & Wellness, 8330 Red Oak Street, Suite 201, Rancho Cucamonga, CA 91730. If you have reflux or a known hernia, mention it when you call. Call 909-355-2525 or toll free 877-9-BE-SLIM (877-923-7546), or use the contact page. The first consultation is complimentary, and Hablamos Español. Start from the Rancho Cucamonga gastric sleeve guide for other topics.

Hiatal Hernia and Gastric Sleeve Surgery

Hiatal Hernia and Gastric Sleeve Surgery

What a hiatal hernia is

Found before surgery

Found during surgery

What the repair involves

What the evidence shows

Does repair add risk?

Found after surgery

When to call

Go to an emergency room or call 911 if

Call the office if

Frequently asked questions

Can I have a hiatal hernia and not know it?

Will repairing my hernia during the sleeve cure my heartburn?

Is mesh used to repair a hiatal hernia during a sleeve?

Does lifting or straining cause a hernia to come back?

Talk with Dr. Davtyan in Rancho Cucamonga

Sources

More in the Gastric Sleeve in Rancho Cucamonga guide

Understanding the sleeve

Weighing your options

Getting care in Rancho Cucamonga

Adult BMI Calculator

Beverly Hills

Glendale

Rancho Cucamonga

South Coast Lap-Band

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