A hiatal hernia occurs when part of the stomach pushes upward through the diaphragm into the chest cavity. This disrupts the natural barrier that prevents stomach acid from flowing back into the esophagus, causing gastroesophageal reflux disease (GERD). While medication controls symptoms for many patients, surgery is the only treatment that can repair the hernia and rebuild the anti-reflux valve.
Types of Hiatal Hernia
Most common (~95%)
Type I — Sliding
The gastroesophageal junction slides upward through the hiatus. This is the most common type and is closely associated with GERD. Surgery is considered when reflux symptoms are not adequately controlled with medication or the patient prefers a definitive solution over lifelong pills.
Less common but higher risk
Types II–IV — Paraesophageal
Part or all of the stomach herniates alongside the esophagus into the chest. These hernias carry a risk of strangulation (blood supply being cut off) and often require surgical repair regardless of whether reflux symptoms are present, because of the potential for a life-threatening emergency.
Suffering from Chronic Reflux? Here’s What Happens Next
Call us directly
No referral needed unless your insurance requires one. You do not need to see your PCP or gastroenterologist first, and you do not need testing done before your visit. Interpretation services available for all languages at our office and the hospital.
Thorough evaluation
Dr. Kakarla reviews your history, examines you, and orders any necessary tests. He performs his own EGD (upper endoscopy) unless you have an established gastroenterologist.
Clear plan
Based on the workup results, Dr. Kakarla discusses whether surgery is right for you, what to expect, and answers all your questions.
Recognizing the signs
Symptoms of Hiatal Hernia and GERD
Typical Symptoms
- Heartburn — burning sensation behind the breastbone, often worse after meals and when lying down
- Regurgitation — food, liquid, or bile coming back into the throat or mouth. This is the symptom that medication cannot fully address
- Difficulty swallowing (dysphagia) — feeling of food getting stuck, especially with large hiatal hernias
- Chest pain — can mimic heart-related chest pain. Always rule out cardiac causes first
Atypical Symptoms
- Chronic cough — especially at night or after eating
- Hoarseness or sore throat — from acid reaching the vocal cords
- Asthma-like symptoms — wheezing triggered by reflux
- Dental erosion — acid damaging tooth enamel over time
- Sensation of a lump in the throat (globus)
When to seek care
Call our office first if you experience a sudden worsening of symptoms, new difficulty swallowing, or increasing pain — we can often evaluate you quickly and guide you on next steps. If you are experiencing symptoms that feel like a true emergency — severe chest pain, inability to swallow even liquids, or vomiting blood — go to the emergency room or call 911.
Non-surgical options
Conservative Management: When Medication May Be Enough
Not every patient with GERD or a hiatal hernia needs surgery. Many patients manage well with a combination of lifestyle changes and medication. Surgery is considered when conservative measures are not enough — or when you prefer a definitive solution.
Lifestyle Modifications
- Elevate the head of your bed — 6–8 inches using blocks or a wedge pillow (extra pillows alone are not effective)
- Avoid eating 3 hours before bed
- Weight management — excess weight increases abdominal pressure and worsens reflux. For significantly overweight patients, Dr. Kakarla may recommend discussing newer weight-loss medications with your primary care doctor before considering surgery, especially if symptoms are currently manageable
- Avoid trigger foods — fatty/fried foods, chocolate, coffee, alcohol, peppermint, citrus, tomato-based foods, and spicy dishes
- Stop smoking — smoking weakens the lower esophageal sphincter and impairs healing
- Eat smaller, more frequent meals rather than large portions
- Avoid tight-fitting clothing around the waist
Medications
Proton pump inhibitors (PPIs) — omeprazole, pantoprazole, esomeprazole, and similar — are the most effective medications for GERD. They reduce acid production and allow the esophagus to heal. PPIs are generally safe for long-term use; the associations with bone density and kidney function seen in observational studies have not been confirmed in the only large randomized trial. However, PPIs treat the symptom (acid) — not the cause (the hernia and weak valve). They do not stop the physical backflow of stomach contents.
Is Surgery Right for Me?
Surgery may be a good option if:
- You have proven acid reflux on testing
- Heartburn or regurgitation persists despite medication
- Your symptoms improve on PPIs but return when you stop them
- You have a large hiatal hernia causing mechanical symptoms
- You have a paraesophageal hernia (Types II–IV)
- You want an alternative to lifelong daily medication
Medication may be better for now if:
- Your main symptoms are bloating alone without documented reflux
- Testing does not confirm acid reflux
- Your symptoms are mostly functional or unrelated to reflux
- Throat or cough symptoms exist without clear reflux correlation on pH testing
- Weight loss or lifestyle changes have not yet been fully tried
When Surgery Should Be Considered
- Persistent symptoms despite optimized PPI therapy — you have tried lifestyle changes and maximum-dose medication, and reflux is still affecting your quality of life
- Regurgitation is your primary symptom — PPIs reduce acid but cannot prevent the physical backflow of food, liquid, or bile into your throat. Surgery is the only treatment that addresses this
- Large hiatal hernia — the hernia itself is causing mechanical symptoms (difficulty swallowing, chest pain, early satiety)
- Paraesophageal hernia (Types II–IV) — these often require repair regardless of symptoms due to risk of strangulation
- Complications — Barrett’s esophagus (managed by a gastroenterologist, but surgery may prevent further acid damage), erosive esophagitis, or peptic stricture
- Desire to discontinue long-term medication — especially in younger patients facing decades of daily pills
Anti-reflux surgery works best in patients with documented acid reflux, typical symptoms, and a good response to PPIs. Patients whose symptoms respond well to medication are actually excellent surgical candidates — it confirms the problem is truly acid-related. Dr. Kakarla discusses your options honestly and helps you make the decision that is right for you.
Before surgery is recommended
The Pre-Surgical Workup
Before recommending surgery, a thorough evaluation confirms the diagnosis, characterizes the hernia, and predicts how well you will respond. The workup typically takes 1–2 weeks and includes up to five tests. Our office coordinates scheduling and groups tests when possible to minimize visits. This evaluation ensures surgery is the right solution and helps avoid unnecessary operations:
This comprehensive workup is essential for achieving the best surgical outcome. Not all patients with heartburn have GERD, and not all GERD patients are good surgical candidates. The testing ensures that surgery will address your specific problem.
The procedure
Robotic Hiatal Hernia Repair with Toupet Fundoplication
The surgery has three key steps, performed robotically through 5 small incisions in the upper abdomen. The surgical plan is discussed and decided together with you based on your workup results, anatomy, and goals:
Hiatal Hernia Repair
The stomach is carefully pulled back down below the diaphragm into its normal position. The enlarged opening in the diaphragm (hiatus) is closed with permanent sutures, reinforcing the weakened crura (the muscular pillars of the diaphragm).
Toupet Fundoplication (Partial Wrap)
The upper portion of the stomach (fundus) is wrapped 270 degrees around the back of the lower esophagus, recreating the anti-reflux valve that prevents stomach contents from flowing backward.
Anchoring
The repair is secured to maintain its long-term position and prevent the hernia from recurring.
Why Toupet Over Nissen?
The Nissen fundoplication (complete 360-degree wrap) has been the traditional gold standard. However, for many patients, the Toupet (partial 270-degree posterior wrap) offers excellent reflux control with a lower risk of post-operative swallowing difficulty and gas-bloat syndrome. The partial wrap allows patients to belch and, if necessary, vomit — functions that are sometimes impaired after a complete wrap. Pre-operative manometry helps confirm the esophageal motility pattern and guides the choice of wrap. Dr. Kakarla typically performs the Toupet based on this evidence.
What Surgery May Not Fix
Anti-reflux surgery is most effective for patients with documented acid reflux, typical symptoms (heartburn, regurgitation), and a confirmed response to PPIs. Patients whose primary symptoms are bloating, functional heartburn without documented acid reflux, or isolated extraesophageal symptoms (chronic cough, hoarseness) without a clear reflux correlation may not experience the same benefit. The thorough pre-surgical workup helps identify who will benefit most.
Long-Term Benefits and Tradeoffs
What most patients gain:
- Significant reduction or elimination of heartburn and regurgitation
- Freedom from daily reflux medication
- Improved sleep — no more waking up with acid in your throat
- Improved quality of life and confidence with eating
Possible tradeoffs to be aware of:
- You may need to eat more slowly and chew more carefully long-term
- Occasional bloating, especially in the first few months
- Some foods may feel different early on (most normalize by 8–10 weeks)
- A small number of patients may still need low-dose medication
- A small number may develop recurrence over years
The robotic advantage
Why Robotic Hiatal Hernia Surgery?
The hiatus is one of the most technically demanding areas in abdominal surgery — deep, narrow, and surrounded by critical structures including the esophagus, aorta, and vagus nerves. This is where robotic surgery provides its greatest advantage:
- 3D magnified visualization — critical for identifying the crura, esophagus, and vagus nerves in the deep, narrow hiatal space
- Wristed instruments — enable precise suturing of the crura and construction of a symmetric fundoplication wrap in the confined hiatal space, where the additional degrees of freedom improve accuracy over standard laparoscopic instruments
- Less tissue disruption — meticulous dissection means less bruising, less blood loss, and faster healing of the delicate esophageal tissues
- Precise wrap construction — the ability to suture with robotic wristed instruments allows a more consistent, reproducible wrap — important for avoiding a too-tight or too-loose fundoplication
- Tremor filtration — filters natural hand tremor for sub-millimeter precision near the esophagus and aorta
- Ideal for revision surgery — Dr. Kakarla performs redo fundoplications for patients with failed prior wraps from other surgeons, where the robotic platform’s precision is especially valuable in scarred tissue
Your surgeon
Why Dr. Kakarla?
- 2,500+ robotic procedures — among the highest volume in the region, well beyond the learning curve
- Surgical experience across three continents — this international breadth has refined Dr. Kakarla’s approach, allowing him to draw on a wider range of techniques than surgeons trained in a single system
- Performs his own EGD — Dr. Kakarla conducts the endoscopic evaluation himself (unless you have an established GI doctor), ensuring continuity from diagnosis through surgery
- Fellowship-trained in minimally invasive and robotic surgery at the University of Illinois at Chicago
- Board certified by the American Board of Surgery
- Revision fundoplication — accepts patients with failed prior wraps from other surgeons for redo surgery
- Tailored approach — wrap type (Toupet vs. Nissen) is selected based on your manometry results and anatomy, not a one-size-fits-all protocol
Your surgical location
Where Your Surgery Happens
Unlike inguinal hernia or gallbladder surgery, hiatal hernia repair with fundoplication requires an overnight hospital stay for monitoring and a next-morning esophagogram before you begin eating.
Surgery & overnight stay
Northside Hospital Gwinnett
1000 Medical Center Blvd
Lawrenceville, GA 30046
Dr. Kakarla performs all hiatal hernia repairs at Northside Hospital Gwinnett exclusively.
Consultation & follow-up
Gwinnett Robotic & Hernia Surgery
631 Professional Drive, Suite 300
Lawrenceville, GA 30046
Phone: (770) 962-9977
Hours: Mon–Thu 7 am–4:30 pm · Fri 7–11 am
Ready to schedule an evaluation? Same-day and next-day appointments available.
Before your procedure
Preparing for Surgery
You will receive a phone call from the hospital 1–2 days before your procedure with your specific arrival time and final instructions.
Optimizing Your Health
- Stop smoking — at least 2–4 weeks before surgery. Smoking impairs healing and worsens reflux.
- Stay active — walking and light exercise help you recover faster.
- High-protein diet — protein is essential for tissue repair.
- Weight management — for significantly overweight patients, Dr. Kakarla may recommend discussing weight-loss options with your PCP first, especially if symptoms are currently manageable.
The Night Before
- No solid food after midnight. Clear liquids may be permitted up to 2 hours before — the hospital will confirm.
- Medications: Dr. Kakarla will specify which to take and which to hold.
- Blood thinners and antiplatelet medications: If you take any blood-thinning or antiplatelet medication, you will receive specific stop and restart instructions from our office. Common medications and typical guidance:
- Warfarin (Coumadin) — typically stopped 5 days before surgery; INR checked the day before. Bridging with injectable blood thinner may be needed for high-risk patients — confirm the plan with your cardiologist
- Eliquis (apixaban), Xarelto (rivaroxaban), Pradaxa (dabigatran), Savaysa — typically stopped 1–3 days before surgery depending on kidney function and bleeding risk. No bridging needed
- Plavix (clopidogrel) — stopped 5–7 days before; Brilinta (ticagrelor) — stopped 3–5 days before; Effient (prasugrel) — stopped 7 days before
- Aspirin — may be continued or stopped depending on why you take it. If prescribed for a prior heart attack, stent, or stroke, it may be continued. If taken for general prevention only, it is usually stopped 5–7 days before
- GLP-1 medications (Ozempic, Wegovy, Mounjaro, etc.): Current hospital protocol requires stopping one week before surgery and a liquid-only diet the day before. This is especially important for hiatal hernia patients because GLP-1 medications delay gastric emptying. Inform our office when scheduling.
- No need to shave the surgical area.
What to Bring and Wear
Bring with you
- Photo ID and insurance card
- List of current medications
- Overnight essentials (you will stay one night)
- Phone and charger
Wear / plan for
- Loose, comfortable clothing (elastic waist)
- Slip-on shoes
- Leave jewelry and valuables at home
- No contact lenses — wear glasses
Transportation
You may drive yourself to the hospital, but you must have someone to drive you home the next day and stay with you for the first night at home.
Work Paperwork
If you need employer documentation (work excuse, FMLA, disability forms), let the office know. Paperwork can be completed before surgery or at your post-operative visit.
The day of your procedure
What Happens on Surgery Day
About general anesthesia
Grogginess, mild nausea, and foggy thinking are normal for the rest of the day. Do not drive, operate machinery, or make important decisions for 24 hours after discharge.
The most important part of your recovery
Post-Surgery Diet Progression
What Is Normal After Surgery
The following experiences are common and expected in the first few weeks. They are not complications — they are part of normal healing:
- Swallowing feels tight — this is post-operative swelling around the wrap, not a problem with the repair. It improves over 2–4 weeks
- Feeling full quickly — the wrap reduces stomach capacity temporarily. Small meals help
- Belching less than before — the new valve is doing its job. Some bloating or pressure is normal as your body adjusts
- Upper abdominal bloating or pressure — common and improves over weeks
- Shoulder pain — from carbon dioxide gas used during surgery. Walking helps. Resolves within 48 hours
- Fatigue — especially in the first week. Naps are normal
- Mild weight loss — expected during the liquid and pureed phases. This is temporary and usually stabilizes once you return to a normal diet
When swallowing is concerning: A sense of tightness or slow passage of food is normal for 2–4 weeks. Inability to keep liquids down, repeated vomiting or dry heaving, or worsening difficulty swallowing should prompt a call to our office.
Although the incisions are small, the repair is deep inside the diaphragm and the wrap needs time to heal and scar into place. That is why the diet and activity restrictions are more important — and longer — than after many other minimally invasive surgeries like gallbladder removal or inguinal hernia repair.
The diet after fundoplication is critically important. Eating the wrong foods too soon can stretch or disrupt the repair. Follow the diet progression carefully.
Essential Diet Rules (All Phases)
- Eat small portions — use a side plate, not a dinner plate
- Chew thoroughly — take small bites and chew until the food is smooth before swallowing
- Eat slowly — meals should take at least 20–30 minutes
- No carbonated beverages for 6–8 weeks (the gas can stretch the wrap)
- No straws — they introduce air into the stomach
- Sit upright while eating and for at least 30 minutes after
- Do not lie down within 3 hours of eating
- Stay hydrated — sip water throughout the day between meals
- If food gets stuck, stop eating, relax, sip warm water. If it doesn’t pass, go back to liquids for 24 hours
Some temporary weight loss during the pureed diet phase is normal. Focus on protein intake (protein shakes, yogurt, eggs) to support healing. Dr. Kakarla provides detailed dietary guidance at your post-operative visit.
After your surgery
Recovery and Activity Timeline
When to call after surgery
Call our office first for: fever over 101.5°F · worsening abdominal pain · increasing difficulty swallowing · persistent vomiting or dry heaving · increasing redness or drainage from incisions · inability to keep liquids down · severe bloating. We can often evaluate you quickly and advise on next steps.
Call 911 for: severe chest pain or difficulty breathing · fainting · vomiting blood.
Common Activity Questions
- Driving — when off narcotic pain medication and comfortable (typically day 5–7)
- Desk work — most return within 1–2 weeks
- Lifting — nothing over 10 lbs for 1 month, then nothing over 20 lbs until 3 months
- Bending forward — avoid for 1 month (increases abdominal pressure on the repair)
- Exercise — walking from day 1; gym/weights after 3 months
- Sexual activity — when comfortable
- Showering — brief shower same day; no baths/pools until Dermabond sloughs off
- Sleeping — sleep with your head elevated on a wedge pillow for the first 2–4 weeks. Back or side is fine
- Coughing or sneezing — hold a pillow against your upper abdomen for support. One cough or sneeze will not disrupt the repair
- Stairs — fine from day 1, go at your own pace
- CPAP — resume immediately after surgery
- Constipation — milk of magnesia prescribed; stay hydrated
Multimodal pain management
Dr. Kakarla uses an ERAS-based (enhanced recovery using multiple non-opioid strategies) multimodal approach: TAP block during surgery, scheduled acetaminophen and ibuprofen after. Most patients manage recovery with over-the-counter medication.
Understanding the risks
Possible Risks and Complications
Most patients do very well, but no operation is risk-free. It helps to understand the difference between expected side effects (normal part of recovery) and true complications (uncommon).
Expected Side Effects (Normal)
- Temporary dysphagia (difficulty swallowing) — expected in the first 2–4 weeks due to post-operative swelling. This is the reason for the gradual diet progression, not a sign that something went wrong. Persistent dysphagia beyond 3 months is uncommon with the Toupet technique
- Gas-bloat and fullness — bloating, pressure, and difficulty belching are common in the first few weeks and usually improve as the body adjusts. Significantly less common with the Toupet (partial wrap) than the Nissen (complete wrap)
- Fatigue and decreased appetite — normal for 1–2 weeks
- Mild weight loss — expected during the pureed diet phase and usually temporary
Possible Complications (Uncommon)
- Wrap failure or hiatal hernia recurrence — the wrap may loosen or the hernia may recur in approximately 10–15% of patients over 10 years. Some small recurrences cause no symptoms and do not require further treatment. Others may resume low-dose PPI medication; revision surgery is possible if needed
- Bleeding — rare; usually minor
- Infection — uncommon with minimally invasive technique
- Esophageal or gastric perforation — rare
- Vagal nerve injury — rare; may affect stomach emptying
- Need for esophageal dilation — uncommon; performed endoscopically if dysphagia persists beyond 3 months
- Conversion to open surgery — rare with robotic technique
- Anesthesia risks — discussed with your anesthesiologist
Dr. Kakarla discusses your individual risk profile during consultation. Your specific risks, benefits, and alternatives are reviewed before you consent to surgery.
This information is general and may not apply to every patient. Your own risks, benefits, and recovery plan will be discussed with you in person before surgery.
Practical details
Hiatal Hernia Surgery Cost and Insurance
- Medicare and Medicaid — typically covered, subject to your plan rules and patient responsibility
- Commercial insurance — Aetna, Anthem/BCBS, Cigna, Humana, UnitedHealthcare, Tricare, and most major plans
- We verify your benefits before scheduling — you know your out-of-pocket cost upfront
- No referral needed unless your specific insurance plan requires one. You do not need to see your PCP or GI first
Common questions
Frequently Asked Questions
Will I be able to eat normally again?
Yes. Most patients return to a normal, unrestricted diet by 8–10 weeks after surgery. The gradual progression from liquids to pureed to soft to normal food allows the wrap to heal properly. Many patients find they can eat foods that triggered reflux before surgery — without symptoms.
Will I still need to take reflux medication?
Most patients gradually taper off PPI medication after surgery under Dr. Kakarla’s guidance. The majority discontinue reflux medication entirely. A small percentage may need occasional or low-dose medication long-term.
Can I still drink coffee?
Yes. Most patients resume coffee after the initial liquid/pureed diet phase. Coffee was a reflux trigger before surgery because it relaxes the lower esophageal sphincter — the fundoplication replaces that valve, so coffee tolerance usually improves significantly.
Can I still drink alcohol?
Alcohol should be avoided during the recovery diet phases. After full recovery (typically 8–10 weeks), most patients can enjoy alcohol in moderation.
Can I still vomit if I need to?
One advantage of the Toupet (partial) fundoplication over the Nissen (complete wrap) is that the ability to belch and vomit is generally preserved. While vomiting may be more difficult or uncomfortable than before, it is usually possible.
What is the difference between Nissen and Toupet fundoplication?
Nissen wraps the stomach 360 degrees completely around the esophagus. Toupet wraps 270 degrees around the back. For many patients, both control reflux well, but the Toupet offers a lower risk of difficulty swallowing, gas-bloat, and inability to belch. Dr. Kakarla typically performs the Toupet based on this evidence and your manometry results.
How long do the results last?
85–90% of patients have excellent reflux control at 5–10 years. A small percentage (10–15%) may experience some return of symptoms over time, usually from the wrap loosening or the hiatal hernia recurring. Revision surgery is possible if needed, and some patients manage mild recurrent symptoms with low-dose medication.
I’ve been on PPIs for years. Are they safe long-term?
PPIs are generally safe. The associations with bone density, kidney function, and nutrient absorption seen in observational studies have not been confirmed in the only large randomized trial. However, many patients prefer a one-time surgical solution over decades of daily medication — and for patients with regurgitation, large hiatal hernias, or breakthrough symptoms, surgery offers what medication cannot.
What if surgery doesn’t work?
The success rate is 85–90%. For patients with recurrent symptoms, evaluation with endoscopy and pH testing determines the cause. Some benefit from low-dose PPI supplementation. Revision surgery is an option for anatomic recurrence and is performed by Dr. Kakarla.
What if my hiatal hernia comes back?
Hiatal hernia recurrence occurs in approximately 10–15% of patients over 10 years. Not all recurrences cause symptoms. Symptomatic recurrence can be managed with medication or, if needed, revision surgery.
Can I have surgery if I’m overweight?
Excess weight increases reflux and can affect surgical outcomes. For significantly overweight patients, Dr. Kakarla may recommend discussing weight-loss strategies (including newer GLP-1 medications) with your primary care doctor before proceeding with surgery, especially if symptoms are currently manageable with medication. Each case is evaluated individually.
Do I need a referral or to see my PCP or GI first?
No. You can call our office directly to schedule an evaluation. You do not need to see your primary care doctor or gastroenterologist first, and you do not need any testing done before your visit — unless your specific insurance plan requires a referral. Dr. Kakarla performs his own EGD and orders the necessary workup.
What happens at my first appointment?
Dr. Kakarla reviews your history and symptoms, examines you, and discusses whether surgery may be appropriate. If additional testing is needed, it is ordered at that visit. Most patients leave with a clear understanding of their options. The visit typically takes 30–45 minutes. You are welcome to bring a family member.
Will I be asleep during surgery?
Yes. The procedure is performed under general anesthesia. A board-certified anesthesiologist monitors you throughout. A TAP block provides long-lasting pain relief after you wake up.
Do I need to shave before surgery?
No. The surgical team handles any necessary hair removal.
Will I have stitches to remove?
No. Incisions are closed with Dermabond medical skin adhesive, which sloughs off naturally in 5–10 days.
How much pain should I expect?
Most patients describe mild to moderate soreness at the incision sites that improves over the first few days. The TAP block provides significant relief for the first 12–24 hours. Most patients manage with Tylenol and ibuprofen after the first day or two. The temporary swallowing tightness is more of a sensation of pressure than pain — it is caused by post-operative swelling around the wrap and improves over 2–4 weeks.
When can I shower after surgery?
Brief shower is fine the same day. No soaking in baths or pools until Dermabond sloughs off (5–10 days).
I see negative stories online about fundoplication. Should I be worried?
Online stories can be helpful, but they often overrepresent patients who had difficult recoveries or older styles of surgery. Patients who recover uneventfully — which is the vast majority — rarely post about their experience. Your results depend on the accuracy of your diagnosis, the type of wrap performed, your anatomy, and the experience of your surgeon. The Toupet (partial wrap) technique Dr. Kakarla uses has a lower risk of the side effects that generate most complaints. He is happy to discuss any specific concerns during your consultation.
Questions to bring to your consultation
- Based on my symptoms and workup, am I a good candidate for surgery?
- Will you perform a Toupet or Nissen wrap, and why?
- What are the chances surgery will eliminate my need for medication?
- How long will I be on the restricted diet?
- What happens if the repair doesn’t hold long-term?
- How many of these procedures do you perform each year?
- Do you perform revision surgery if my prior fundoplication failed?
- What is my out-of-pocket cost after insurance?
What is Barrett’s esophagus? Do I have it?
