Background: Radiological follow-up following repair of large hiatus hernias have identified recurrence rates of 20–30 %, although most are small and asymptomatic. Whether patients will eventually develop clinical problems is uncertain. This study evaluated the outcome for individuals identified with an asymptomatic hiatus hernia following previous repair vs. asymptomatic controls. Methods: One hundred fifteen asymptomatic patients who had previously undergone sutured repair of a large hiatus hernia and then underwent barium meal X-ray 6–60 months after surgery within a clinical trial were identified and divided into two cohorts: with (n = 41) vs. without (n = 74) an asymptomatic hernia. Heartburn, dysphagia, and satisfaction with surgery were assessed prospectively using a standardized questionnaire applying analogue scales. Consumption of antisecretory medication and revision surgery were also determined. To determine the natural history of asymptomatic recurrent hiatus hernia, outcomes for the two groups were compared at 1 and 5 years and at most recent (late) follow-up. Results: Outcomes were available at 1 year for 98.2 % and 5 years or the latest follow-up (range 6–237 months) for 100 %. Heartburn and dysphagia scores were low and satisfaction scores high in both groups at all follow-up points, but heartburn scores and medication use were higher in the recurrent hernia group. At late follow-up, 94.6 % of the recurrent hernia group vs. 98.5 % without a hernia regarded their original decision for surgery to be correct. Two patients in recurrent hernia group underwent revision surgery. Conclusions: Patients with an initially asymptomatic recurrent hiatus hernia are more likely to report heartburn and use antisecretory medication at later follow-up than controls. However, overall clinical outcomes remain good, with high satisfaction and low surgical revision rates. Additional interventions to reduce the risk of recurrence might not be warranted.