Fifty per cent of esophageal hiatal hernias are probably asymptomatic. Of patients with hiatal hernias, 38% have cholelithiasis, whereas approximately 25 per cent have duodenal ulcers. Only approximately one-third of patients with hernias have the characteristic symptom complex of regurgitant peptic esophagitis. Massive upper gastrointestinal hemorrhage in the presence of a sliding hernia is frequently associated with a low lying gastric or duodenal ulcer. These facts suggest that transabdominal approach for the repair of hiatal hernia is necessary for proper exploration of the abdomen. Satisfactory repair can be performed by this approach. Eight case reports illustrate the problems encountered which favor transabdominal approach, as well as the manner in which the difficult complications of this entity—such as peptic esophagitis with stricture—can be dealt with.