Hiatal Hernia in the Obese Patient Undergoing Bariatric Surgery: A Comprehensive Review

Abstract

Hiatal hernia (HH) is frequently encountered in candidates for metabolic and bariatric surgery and closely interacts with gastroesophageal reflux disease (GERD) and procedure selection. This review synthesizes landmark and contemporary evidence (2010–2025) on prevalence and diagnosis of HH in obesity; reflux and Barrett’s outcomes after sleeve gastrectomy (SG) versus Roux-en-Y gastric bypass (RYGB); the impact of concomitant hiatal hernia repair (HHR); the role of mesh and fundoplication variants; outcomes of conversion from SG to RYGB for refractory reflux; and robotic versus laparoscopic approaches. HH is common among bariatric candidates; SG carries a higher risk of postoperative and de novo GERD and a non-trivial prevalence of Barrett’s esophagus, whereas RYGB provides more reliable reflux control. Concomitant HHR at the time of SG mitigates, but does not eliminate, reflux and recurrence risks; bioabsorbable mesh may reduce mid-term recurrence whereas permanent mesh is not routinely favored. SG with fundoplication can improve reflux at the expense of higher complication rates and should be reserved for selected patients in experienced centers. Conversion of SG to RYGB improves reflux in most, but not all, patients. Robotic platforms facilitate complex reconstructions with perioperative outcomes comparable to laparoscopy. Individualized, guideline-informed decision-making and long-term surveillance remain central to optimizing outcomes.