what size hiatal hernia needs surgery

What Size Hiatal Hernia Needs Surgery

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The hiatal hernia surgery takes into consideration the size and signs of the hernia. If the hiatal hernia is more than 6 cm and is symptomatic, it would require surgical intervention. If not, until the hiatal hernia turns symptomatic it can be treated through medications.

Upon examination, your healthcare provider will find the size, location, and severity of the hiatal hernia and comment on the requirement of surgery.

What Size Hiatal Hernia Needs Surgery

Small-sized hernias remain mostly in the abdominal region and are asymptomatic or show no symptoms.

Medium or moderate-sized hernias are present in the chest cavity, partially most of the time. They are symptomatic but can be managed through medication.

Large-sized hernias are mostly paraesophageal hernias and those that are usually above 6 cm in size. They require surgical intervention, especially if they are symptomatic.

Also, look out for symptoms such as:

  • Extreme abdominal and chest pain
  • Increased nausea and recurrent vomiting
  • Chronic heartburn
  • Severe constipation
  • Bloating of the abdomen
  • Indigestion and loss of appetite

If you encounter any of the above-listed symptoms contact your hernia surgeon immediately and book for surgery. These symptoms may indicate an incarcerated and strangulated hiatal hernia.

Types of Hiatal Hernias

The different types of hernia are determined based on the location of the hernia or how far and how much the contents of the hernia have ascended into the chest cavity.

Your hernia specialist may ask you to undertake a radiographic evaluation such as a barium swallow X-ray or CT scan and endoscopic assessments to determine the size of the hernia.

Hiatal hernias are broadly classified into:

  • Type 1 Hiatal Hernia
  • Type 2 Hiatal Hernia
  • Type 3 Hiatal Hernia
  • Type 4 Hiatal Hernia

Type I Hiatal Hernia:

Type I hiatal hernia is also called a sliding hernia. The lower part of the esophagus and the upper part of the stomach slide up and down through the hiatus in the diaphragm in this scenario.

It causes mild acid reflux and can be addressed through medications and lifestyle changes such as incorporating an appropriate and healthy diet, doing mild exercises, and so on.

Type II Hiatal Hernia:

Type II hiatal hernia is called “rolling hiatal hernia” because the upper part of the stomach rolls into the chest cavity and stays adjacent to the esophagus.

This can cause mild symptoms such as heartburn, nausea, and so on but does not require surgery until it turns symptomatic.

Type III Hiatal Hernia:

Type III hiatal hernia often follows the type II hernia condition. With the widened hiatus due to the rolling up of the stomach to the chest cavity other contents in the abdominal cavity also begin to ascend. Most parts of the stomach and the junction between the stomach and the esophagus stay above the diaphragm in this type.

With increasing symptoms and pain this type of hernia would require surgical intervention.

Type IV Hiatal Hernia:

Type IV hiatal hernia is a very serious condition in which most of the abdominal organs such as the colon, pancreas, spleen, etc. spill into the chest cavity.

Owing to the heightened complications of the scenario this type of hernia requires immediate surgery.

Types of Surgeries To Repair Hiatal Hernia

Hiatal hernia is not much to be worried about with the modern and safe introduction of treatments and surgeries to address the issue.

The surgeries mainly aim to close the hiatus with a special mesh or stitch the top part of the stomach with the lower part of the esophagus to prevent future hiatal hernia.

Hiatal hernia can be repaired through:

  • Open Hernia Surgery
  • Laparoscopic Hernia Surgery
  • Robotic Hernia Surgery

Open Hernia Surgery

It is the traditional method of surgery. The chest or abdominal region is cut open as required and the hernia is treated under direct visualization.

This method requires a longer recovery period.

Laparoscopic Hernia Surgery

This is the latest use of technology to address the process of surgery. This method makes only use of smaller incisions on the abdominal area to treat the hernia. The area under repair is projected on a display in the operating room and surgeons use minimally invasive tools to repair the hernia.

The pain is less severe and the recovery rate is quicker for this surgical procedure.

Patients can go home within the same day most of the time if treated with this procedure.

Robotic Hernia Surgery

Robotic surgery is similar to that of laparoscopic surgery only that the surgeon sits inside a console and operates from within. The area under repair is displayed on a screen.

It also uses smaller and minimal incisions like laparoscopic surgery and promises less pain and a faster recovery rate with fewer post-operation complications.

Factors such as age, lifestyle, risks, degree of severity, etc. determine the decision of surgery to treat hiatal hernia.

Who Should Avoid Hiatal Hernia Surgery?

If you are over 60 years of age and your health condition is adverse toward any surgery, you will have to avoid hiatal hernia surgery.

Also, people with type I hernia with no GERD symptoms and type II hernia with no symptoms can avoid hiatal hernia surgery on consultation with a hernia repair specialist.

What to Expect After Hiatal Hernia Surgery?

You can resume your everyday activities after 4 to 6 weeks of the hiatal hernia surgery. The rate of recovery depends upon your initiatives to change food habits and lifestyles that are kind to your body as well.

You may have to avoid driving until your surgical wounds are healed and you do not have to take painkillers anymore.

Quitting smoking and alcohol will also help in quicker recovery from the surgery.

The possibility of recurrence of hiatal hernia after surgery is very low. A 2019 study states that the recurrence of hiatal hernia after mesh hiatoplasty has a significant reduction.


The need for a hiatal hernia surgery depends upon the size and severity of the state of the hernia.

You have to follow the protocol of your hernia specialist regarding the need for surgery or not after appropriate physical examination and consultation.

The surgical procedure for hiatal hernia has become easier with a faster recovery rate and minimal need for invasion into the body.

If you are looking for the latest hernia treatments and laparoscopic procedures contact your hernia specialist.


1) How serious is a 5 cm hiatal hernia?

A 5 cm-sized hernia will not cause much pain. It can be managed with medication and self-care.

2) What size is a large hiatus hernia?

A large hiatal hernia is usually 6 cm and above. Type III and type IV hernias are considered large hernias with over 30% of the stomach moved upward to the chest.

3) Can you live with a hiatal hernia without surgery?

When the hiatal hernia begins to show symptoms of pain and discomfort and disrupts a healthy body function it should be repaired. If it does not cause any pain and is manageable you can bear it without surgery. Yet always be on the lookout for the hernia to not turn incarcerated or strangulated.

Dr. K. Amilthan MBBS., MS., FMAS., FALS.

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