Giant paraesophageal hernia repair: technical pearls.

The optimal operative management of giant paraesophageal hiatal hernias continues to evolve, with recent series reporting promising results with minimally invasive approaches. The laparoscopic repair of a giant paraesophageal hernia is one of the more challenging cases a minimally invasive surgeon may perform. Our technical approach to this procedure involves a consistent emphasis on several key operative points: circumferential sac dissection with maintenance of crural integrity; extensive mediastinal esophageal dissection; crural closure with pledgeted sutures; wedge Collis gastroplasty for shortened esophagus; 3-stitch fundoplication incorporating esophageal tissue with each bite; additional sutures securing the top of the fundoplication to the crura; and biologic mesh buttressing. We believe that diligence paid toward these key steps permits laparoscopic giant paraesophageal hiatal hernia repair to be performed with similar outcomes as the open approach while avoiding the morbidity of thoracotomy or laparotomy.