Background <p>Hiatal hernia (HH) is frequent in patients with obesity who have undergone bariatric surgery, but there is controversy about HH repair (HHR) during bariatric surgery. This study aimed to analyze the safety and efficacy of concomitant laparoscopic sleeve gastrectomy (LSG) and HHR in patients with severe obesity.</p> Methods <p>A propensity score–matched analysis was conducted for patients who underwent LSG. Preoperative barium meal, upper endoscopy, and intraoperative findings were used to diagnose HH. The GERD health-related quality of life (GERD-HRQL) questionnaire was used to diagnose gastroesophageal reflux disease (GERD). Patients were divided into two groups: one underwent concomitant LSG with HHR and the other underwent LSG only. HHR was performed by cruroplasty and reconstruction of the phrenoesophageal ligament (PEL). Gastropexy was performed by fixing the gastric tube to the omentum and peripancreatic fascia. Outcomes included blood loss, operative time, postoperative complications, GERD, and percent excess weight loss.</p> Results <p>Of the 406 patients included in the study, 203 patients with HH underwent LSG with HHR, while 203 underwent LSG alone. There was significantly longer operative time in the LSG with HHR group, but no statistical difference between the groups regarding postoperative complications, except postoperative GERD. De novo GERD symptoms developed significantly in the LSG only group. These results indicate that <i>concomitant LSG with HHR leads to improvement of GERD and decreases the rate of </i>de novo<i> GERD symptoms.</i></p> Conclusions <p>HH should be repaired by cruroplasty and reconstruction of the PEM during LSG. HHR helps to improve postoperative GERD symptoms.</p>