Specialists from Massachusetts General Hospital’s Gastroesophageal Surgery Program answer your frequently asked questions about hiatal hernias, including symptoms, diagnosis and treatment.

Our surgeons work collaboratively with physicians in the Swallowing and Heartburn Center in the Digestive Healthcare Center to provide advanced diagnostic and treatment options for patients with hiatal hernias.

What is a hiatal hernia?

A hiatal hernia is a condition that occurs when the upper part of the stomach pushes up into the chest through a small opening in the diaphragm, resulting in retention of acid and other contents that can easily back up (reflux or regurgitate) into the esophagus.

Chest X-ray showing a hiatal hernia
A chest X-ray showing a large hiatal hernia with air-fluid level, which suggests that fluid is being retained in the stomach.
What are the different types of hiatal hernias?

There are four types of hiatal hernias. Most hiatal hernias are called type I or “sliding hernias,” where the stomach intermittently slides up into the chest through a small opening in the diaphragm. Sliding hernias are very common, and most don’t require surgery.

Types II, III and IV hiatal hernias are called paraesophageal hernias. They occur when a portion of the stomach pushes up into the chest adjacent to the esophagus. Types II, III and IV hiatal hernias are differentiated by the location of the gastroesophageal junction (the place where the esophagus and stomach meet). Surgical repair of these hernias should be considered when they cause symptoms (see below). 

What can cause a hiatal hernia?

The cause of a hiatal hernia is unknown, but possible triggers include coughing, vomiting, straining while having a bowel movement, sudden physical exertion and pregnancy. Aging, tobacco use and obesity can also contribute to this disorder.

What are the symptoms?

Most of the time, a hiatal hernia does not cause symptoms. Heartburn, belching, nausea, vomiting and regurgitation (backflow of stomach content into the esophagus or throat) are the most common symptoms. They can be present in all four types. More severe symptoms are usually associated with a paraesophageal hernia.

Patients with type IV paraesophageal hernias may have a significant portion of their stomach or other abdominal organs push up into their chest. In severe cases, the stomach or abdominal organs may rotate or twist, causing pain after eating, dry heaves, nausea or difficulty swallowing. When a hiatal hernia causes severe pain or dry heaves, it may be a medical emergency that could require immediate surgery.

How are hiatal hernias diagnosed?

Hiatal hernias cannot be routinely diagnosed during a physical exam. Most often, hiatal hernias are diagnosed on a chest X-ray, computed tomography (CT) scan, upper endoscopy or barium swallow (a test that captures images after the patient has taken barium, an element that helps with X-ray imaging). Many people age 50 and over have small hiatal hernias, but hiatal hernias may affect people of all ages.

How are hiatal hernias treated?

Specific treatment for a hiatal hernia will be determined by your physician. Medication may be prescribed to neutralize stomach acid, decrease acid production or strengthen the lower esophageal sphincter (a muscle that prevents stomach acid from coming up into the esophagus).

If medication is not effective, surgery is a good alternative. If the hiatal hernia is in danger of becoming constricted or strangulated (so that the blood supply is cut off), surgery is needed to repair the hernia.

Are the surgical procedures minimally invasive?

Mass General surgeons pioneered the laparoscopic approach to paraesophageal hernia repair more than two decades ago. The vast majority of paraesophageal hernias continue to be repaired in a minimally invasive manner at Mass General. This technique is most successful when used as the first operation to treat hiatal hernias. Re-operations, however, are more complex. Obtaining the best results requires evaluating each patient and their prior surgery carefully. In some circumstances, a more traditional open operation is the best option if a prior laparoscopic operation has failed.

What is robotic surgery, and is it better than minimally invasive surgery to treat hiatal hernias?

Robotic surgery is a form of minimally invasive surgery where a surgeon sitting at a console away from the patient uses laparoscopic instruments guided by a robotic arm(s) to perform the intended surgical procedure. Mass General surgeons have used robotic surgery for many types of laparoscopic procedures. While this new technology is useful in urologic and some types of colorectal surgery, both our own experience and scientific studies performed so far have failed to show any advantage to robotic surgery in comparison with laparoscopic or minimally invasive surgery for hiatal hernias. In fact, robotic surgery adds complexity, cost, prolonged operating room time and unique complications to hiatal hernia repairs, so we do not recommend this approach.

Is mesh used in hiatal hernia surgery?

Most hiatal hernias can be repaired with your own native muscular tissue of the diaphragm. However, if the muscles of the diaphragm are very weak, a surgical mesh (made of synthetic materials) may be necessary to strengthen the surgical repair.

How do I make an appointment with a specialist?

Patients may request an appointment online, and physicians may refer a patient online, or call 617-724-1020 to speak with a care coordinator of the Gastroesophageal Surgery Program at Mass General. All requests will be triaged the same day, and the patient and referring physician will be called back to schedule an appointment within one business day.

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