A 59-year-old presented to the clinic with a history of laparoscopic Rou-en-Y gastric bypass in 2007 with a chief complaint of progressively worsening acid reflux and dysphagia. The patient had been prescribed a variety of proton pump inhibitors which did little to her relieve her symptoms. The patient underwent further testing to define the severity of her acid reflux disease. The patient underwent manometry and pH monitoring with our gastrointestinal colleagues. The patient was found to have normal motility and a DeMeester score of greater than 45. Given the patient's significant reflux. Given the patient significant reflux disease she was taken for upper endoscopy to evaluate for a hiatal hernia and for operative planning given her surgical history. The patient was found to have a significant portion of the gastric pouch herniating into the mediastinum. At this time the patient was consented for a LINX magnetic sphincter augmentation with possible hiatal hernia repair. The procedure was performed in November 2018 with operative findings significant for a large hiatal hernia with the patient's gastric pouch chronically herniated into the anterior mediastinum. The procedure was safely performed after the reduction of the herniated contents and hiatal hernia with repair. The patient tolerated the procedure well and was discharged from the hospital on postoperative day one.