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Primary Hiatus Hernia Repair Surgery

Definition- Elective/Urgent/Emergency surgery to correct a primary symptom * +/- associated secondary symptoms ** of a large hiatus hernia (>1/3 of stomach in chest or GOJ >5 cm from hiatus, includes intra-thoracic stomach). These hernias are para-oesophageal in nature and are classified as type III and type IV (very rare type II). They are associated with medium and large hiatal defects. This classification of surgery does not include type I and II smaller hiatus hernias repaired as part of an anti-reflux procedure or large hiatus hernias repaired for a primary indication of reflux

* Primary Symptom

Episode of emergency volvulus/post-prandial chest pain/shortness of breath/nausea and weight loss/dysphagia and weight loss /iron deficiency anaemia (other causes excluded)/major respiratory aspiration event

** Secondary Symptom

Reflux/dyspepsia/post-prandial chest pain/shortness of breath/nausea/dysphagia/weight loss/iron deficiency anaemia (other causes excluded)/minor aspiration respiratory events


There is no universally accepted standard of classification of this disease, BBUGSS proposes the following classification to allow uniformity








Type III (Large)

Displacement of GOJ >5cm above diaphragmatic hiatus or >1/3 of stomach volume within chest on CT/contrast study    






Type III Intra-Thoracic Stomach  

Pylorus at, or above level of diaphragmatic hiatus, or if within the abdomen < 5cm distance from diaphragmatic hiatus 








Type IV

Another organ above the level of the diaphragmatic hiatus, small/large bowel, pancreas, spleen (not inclusive of omentum)                
















Type II (Large)

>1/3 of stomach volume above level of the hiatus with the GOJ remaining at or below level of diaphragmatic hiatus (RARE)             


It is recommended patients should have pre-operative OGD and cross-sectional imaging for surgical planning and exclusion of synchronous pathology

Smaller hiatus hernias (<1/3 of stomach in chest or ≤ 5 cm migration of GOJ from hiatus), are unlikely to cause symptoms as described above and repair out side the context of an anti-reflux procedure only to be performed after careful consideration (discussion at hiatal MDT)

As minimum, pass complex/equivocal patients through a hiatal MDT* prior to surgery, best practice to discuss all elective patients prior to surgery

Enter data into a registry to audit outcomes

Laparoscopic conversion to open (elective) < 5%

Elective Morbidity < 15%

Elective Mortality < 2%


Emergency Morbidity <20%

Emergency Mortality < 10%

Type III Giant.png
Type III Intra-Thoracic Stomach.png
Type IV.png




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