More Evidence Supporting Combined Surgery Approach: Hiatal Hernia & TIF

As discussed during our last blog article, unfortunately, a patient’s anatomy may preclude them from having a TIF alone. When a patient’s hiatal hernia is too large, or the Hill Grade (laxity of the gastroesophageal junction) is too high, we know that TIF alone may achieve inadequate or less durable relief. In such patients, in order to avoid the long-term complications of full surgical intervention with a Nissen fundoplication, we offer a combination procedure that involves laparoscopic hiatal hernia repair followed by endoscopic fundoplication.

A recent article has been published providing more support for this approach. In this article, Dr. Janu reports the outcomes in 99 patients that underwent combined laparoscopic hernia repair + TIF. All of these patients had hiatal hernias larger than 2 cm (ranging from 2 to 5 cm), and therefore were not candidates for TIF alone. In addition, all of these patients had persistent symptoms of acid reflux despite proton-pump inhibitor therapy.

Significant control of heartburn and acid regurgitation was achieved following this combination/hybrid procedure. No procedure-related complications occurred. Furthermore, and very importantly, long-term problems that occur after conventional anti-reflux surgery, i.e. difficulty swallowing and gas-bloat syndrome, were not seen in any patients following the hybrid approach. Based upon this study, we are more confident that in patients whose anatomy excludes them from TIF alone, the combination laparoscopic + endoscopic procedure we offer provides an excellent method for achieving acid reflux relief while minimizing the potential for long-term side effects.

We can help!

If you suffer from acid reflux, you have options. Give us a call. We can work together and see if this combined procedure may be right for you. The majority of health insurance companies cover hiatal hernia repair along with the TIF when the procedures are performed together. As always, it’s important to check with your insurance company to verify coverage.


Your IES Doctors.


Janu P et al. Laparoscopic hiatal hernia repair followed by transoral incisionless fundoplication with the EsophyX device (HH + TIF): efficacy and safety in two community hospitals. Surg Innov. 2019 Dec;26(6):675-686.

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