Laparoscopic Management of Giant Paraesophageal Hernia

Abstract Giant paraesophageal hernias (GPEHs) present both technical and clinical challenges, requiring careful surgical planning and precise technique for successful repair. This study outlines our preferred stepwise laparoscopic approach for the safe and effective management of GPEH. Key steps include appropriate patient positioning, port placement, and careful mediastinal dissection to reduce the herniation of stomach and other contents into the abdomen, while preserving their blood supply and confirming viability. In cases with hiatal defects larger than 5 cm, weak crura, or a D-shaped hiatus, additional measures such as pledget-reinforced sutures, relaxing incisions, mesh reinforcement, or the posterior rectus sheath hiatal augmentation technique are selectively employed. A tailored fundoplication is then performed, guided by the patient’s symptoms and preoperative manometry findings. This structured and stepwise approach aimed to achieve a durable repair with low recurrence rates and good functional outcomes. Despite all these efforts, recurrence rates following GPEH repair remain high, and newer strategies or techniques may be needed to further improve long-term outcomes.