Background and Aims Laparoscopic hiatal hernia repair with mesh reinforcement combined with fundoplication has become the standard surgical approach for treating moderate to severe cases. However, intraoperative and postoperative complications remain a significant concern. This study was conducted to explore the causes of common complications and their prevention and management strategies through retrospectively analyzing clinical data from a single center to optimize perioperative care and improve surgical safety.Methods The clinical data of 432 patients who underwent laparoscopic hiatal hernia repair with mesh and fundoplication at the Sixth Affiliated Hospital of Sun Yat-sen University from January 2018 to December 2023 were retrospectively analyzed. All procedures were performed by the same surgical team using the standardized seven-step protocol for laparoscopic repair. Postoperative care followed the enhanced recovery after surgery pathway. The incidences of intraoperative and postoperative complications were recorded, and univariate analysis was used to identify risk factors for major postoperative complications.Results The overall complication rate was 15.3% among 432 patients. The most common intraoperative complication was bleeding (6.9%), primarily from the inferior phrenic vessels (3.2%), short gastric vessels (1.6%), and parenchymal organ injuries (1.9%). The most frequent postoperative complication was dysphagia (12.0%), followed by pneumothorax (3.2%), hernia recurrence (1.9%), mesh infection or erosion (0.7%), gas-bloat syndrome (6.3%), and gastroparesis (0.9%). Most complications were relieved through conservative treatment, endoscopic dilation, or interventional procedures. Two patients with persistent dysphagia underwent reoperation to remove the fundoplication wrap. The median follow-up period was 34 months, with a 6.0% loss to follow-up rate and no perioperative mortality. Univariate analysis showed that patients aged ≥50 years and those who underwent Nissen fundoplication had significantly higher rates of postoperative dysphagia (both P<0.05).Conclusion Laparoscopic hiatal hernia repair with mesh and fundoplication is generally safe and effective. However, intraoperative vascular injuries and postoperative dysphagia require special attention. Accurate dissection and identification of anatomical layers are critical during surgery. Surgical strategy should be tailored based on patient age and esophageal motility, with partial fundoplication (Toupet or Dor) preferred when appropriate. Combined with enhanced postoperative recovery protocols, standardized mesh placement and fixation can reduce complication rates and improve long-term outcomes.