Obesity is a significant independent risk factor for hiatal hernia (HH), markedly increasing its prevalence. In recent years, with the rising volume of bariatric surgeries, the management of concomitant HH during these procedures has become a key clinical focus. Sleeve gastrectomy, as a mainstream bariatric procedure, combined concurrently with hiatal hernia repair (HHR), has emerged as an important strategy for treating obesity complicated with HH. Laparoscopic sleeve gastrectomy (LSG) combined with HHR is widely used and can effectively promote weight loss, provide anti-reflux benefits, and reduce the incidence of postoperative gastroesophageal reflux disease (GERD). Roux-en-Y gastric bypass combined with HHR demonstrates superior outcomes in weight reduction and GERD improvement, albeit with higher technical difficulty. Furthermore, novel techniques such as LSG combined with HHR with preservation of the anterior phrenoesophageal ligament have shown promising anti-reflux effects, although their long-term efficacy requires further validation. In conclusion, the surgical treatment of obesity with HH should involve an individualized selection of the surgical approach to achieve optimal therapeutic results.