Laparoscopic hiatal hernia repair combined with fundoplication has become the standard surgical procedure for moderate to severe hiatal hernia, but intraoperative bleeding, postoperative dysphagia, hernia recurrence, and mesh-related complications remain significant concerns. This article summarizes the prevention and management strategies for these core complications based on the clinical data and surgical experience of 432 patients with moderate to severe hiatal hernia who underwent laparoscopic hiatal hernia repair combined with fundoplication at the Department of Hernia and Abdominal Wall Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, from 2018 to 2023. The overall complication rate in the 432 patients was 15.3% (66 cases). Among intraoperative complications, bleeding was the most common, occurring in 30 cases (6.9%). Among postoperative complications, dysphagia was the most frequent, occurring in 52 cases (12.0%). Hernia recurrence occurred in 8 cases (1.9%), and mesh-related complications in 3 cases (0.7%). Univariate analysis showed that age ≥50 years and Nissen fundoplication were associated factors for postoperative dysphagia (both P<0.05). By standardizing preoperative evaluation, optimizing surgical approach selection, strengthening intraoperative precise manipulation, and establishing stepwise management protocols, the incidence of complications can be effectively reduced. Individualized surgical strategies based on precise anatomy, standardized operative procedures, and stepwise management approaches are key to reducing complications and improving surgical safety.