Hiatal hernia (HH) is commonly associated with obesity, significantly increasing the risk of gastroesophageal reflux disease (GERD). Diagnosing type I HH is particularly challenging due to the mobility of the gastroesophageal junction (GEJ) and variability in measurements from endoscopy and barium swallow studies. The American Foregut Society’s (AFS) endoscopic classification enhances diagnostic accuracy by evaluating both the flap valve and hiatal disruption, promoting standardized assessments. In bariatric patients, combining laparoscopic sleeve gastrectomy (LSG) with hiatal hernia repair (HHR) is a growing practice to address HH and reduce GERD. While studies report reduced GERD rates with HHR, outcomes remain inconsistent, influenced by factors like hernia size and surgical techniques. Emerging methods such as omentopexy, phrenoesophagopexy, mesh reinforcement, and combined approaches like Sleeve-Nissen aim to improve outcomes, addressing complications like sleeve migration and HH recurrence. The variability in surgical outcomes highlights the need for personalized approaches, emphasizing the preservation of anatomical structures like the phrenoesophageal ligament. Further research is essential to refine diagnostic tools, optimize surgical techniques, and enhance long-term outcomes for bariatric patients with HH and GERD.