Does a hill grade 3 hiatal hernia necessarily require surgery? can it be treated solely with ppis? can it be treated solely with lifestyle changes?

Typically grade III has symptoms beyond just reflux and symptoms beyond the the typical range of reflux disease symptoms, and the risk of entrapment, constitute the main indications for surgical treatment in patients with type II, III, and IV hiatal hernias. In Grade III, the transition to the stomach is more than 3 cm into the esophagus. So unlikley to treat nonsurgically.