Which hiatal hernia’s need to be fixed? Large, small or none?

: Hiatal hernias are a common occurrence in the western population, with an estimated prevalence of 15% to 20%. These hernias may become symptomatic and lead to gastroesophageal reflux disease (GERD), dysphagia, dyspnea, and may affect cardiac and respiratory function. If untreated, they may progress to gastric volvulus necessitating emergency surgery and partial or total resection of the stomach with resultant increased morbidity, length of stay, and mortality. Conversely, they may also be entirely asymptomatic and never progress. Since there is wide variability in the symptomatology and severity of hiatal hernias, it is important to understand when repair of these hernias is indicated. The current body of literature is constantly expanding, with new evidence for and against aggressive repair of these hernias appearing on a monthly basis. This review will synthesize the most recent body of knowledge to clarify which hiatal hernias should be repaired and which should be observed.