Hiatus hernia is a condition in which part of the stomach protrudes into the thoracic cavity through the esophageal hiatus of the diaphragm. Large hiatus hernias, often defined as those with more than 30–50% of the stomach herniated or with a significant intrathoracic component, can lead to severe gastroesophageal reflux, dysphagia, chest discomfort, or respiratory symptoms. While small hiatus hernias may be managed conservatively, large hiatus hernias require surgical repair to alleviate symptoms and prevent complications such as volvulus, strangulation, or chronic reflux-induced esophagitis. Laparoscopic techniques have become the gold standard for repair, offering minimally invasive access, improved visualization, and faster recovery.

Introduction

Large hiatus hernias are typically classified as type II (paraesophageal), type III (mixed), or type IV (complex). Patients may present with heartburn, regurgitation, difficulty swallowing, chest pain, anemia due to chronic bleeding, or respiratory problems due to aspiration. Historically, open surgery was the standard approach; however, laparoscopic repair has transformed management, providing superior outcomes with minimal morbidity.

Advantages of laparoscopic repair include:

Smaller incisions and reduced postoperative pain

Shorter hospital stay and quicker return to normal activities

Superior visualization of the esophageal hiatus and mediastinal structures

Ability to perform concomitant anti-reflux procedures such as fundoplication

Indications

Surgery is indicated in patients with:

Symptomatic large hiatus hernias causing reflux, dysphagia, or chest discomfort

Evidence of esophagitis or Barrett’s esophagus due to reflux

Paraesophageal hernias with risk of strangulation or volvulus

Recurrent or complicated hernias after previous conservative management

Asymptomatic patients with small hernias may not require surgery; however, large or symptomatic hernias warrant operative intervention.

Preoperative Evaluation

Comprehensive preoperative assessment is essential:

Barium swallow study to evaluate the size, type, and mobility of the hernia

Upper GI endoscopy to assess mucosal injury, esophagitis, or Barrett’s changes

Esophageal manometry to evaluate esophageal motility, which helps in planning fundoplication

pH monitoring if reflux is significant

Routine blood tests, ECG, and chest imaging to assess comorbidities

Patient counseling regarding laparoscopic procedure, postoperative care, and potential complications

Surgical Technique

Laparoscopic repair of large hiatus hernia is performed under general anesthesia with the patient in a supine position and slight reverse Trendelenburg to facilitate exposure of the esophageal hiatus.

Port Placement

Pneumoperitoneum is established using a Veress needle or open technique.

A 10 mm camera port is placed supraumbilically.

Additional 5 mm or 10 mm working ports are placed in a semicircular pattern in the upper abdomen for instrument access.

Hernia Reduction

The herniated stomach and other contents are gently reduced into the abdominal cavity.

The hernia sac is carefully dissected from the mediastinum to allow mobilization of the esophagus and stomach.

3. Esophageal Mobilization

The distal esophagus is mobilized in the mediastinum to ensure at least 2–3 cm of intra-abdominal esophagus, which is critical to prevent reflux recurrence.

Hiatal Closure

The diaphragmatic crura are approximated posterior to the esophagus using non-absorbable sutures to close the enlarged hiatus.

For very large defects, a biologic or synthetic mesh may be used to reinforce the crura, reducing tension and recurrence risk.

Fundoplication

A 360-degree Nissen or 270-degree Toupet fundoplication is often performed around the distal esophagus to restore the anti-reflux barrier.

The fundus of the stomach is wrapped securely without tension and sutured to the esophagus and diaphragmatic crura.

Completion

Hemostasis is confirmed, ports are removed, and incisions are closed.

A nasogastric tube may be used temporarily for gastric decompression.

Postoperative Care

Early mobilization and deep-breathing exercises to prevent thromboembolism and pulmonary complications

Gradual advancement of diet, starting with liquids and progressing to soft solids

Pain control with oral or intravenous analgesics

Hospital stay is usually 2–4 days, depending on patient recovery and comorbidities

Avoidance of heavy lifting and straining for 4–6 weeks to ensure hiatal healing

Outcomes and Advantages

Laparoscopic repair of large hiatus hernia provides:

Excellent symptom relief from reflux, dysphagia, and chest discomfort

Low recurrence rates when crural closure and fundoplication are performed correctly

Reduced postoperative pain, faster recovery, and shorter hospital stay

Improved visualization and precise dissection in the mediastinum

Potential Complications

Although generally safe, potential complications include:

Esophageal or gastric injury during reduction

Bleeding from diaphragmatic or gastric vessels

Pneumothorax due to mediastinal dissection

Dysphagia or gas-bloat syndrome after fundoplication

Hernia recurrence if crural closure is inadequate

Careful surgical planning, meticulous technique, and adherence to laparoscopic principles minimize these risks.

Conclusion

Laparoscopic repair of large hiatus hernia is the preferred approach for symptomatic or complicated cases. It combines the principles of hernia reduction, hiatal repair, and anti-reflux surgery in a minimally invasive manner. Patients benefit from reduced pain, shorter hospital stays, and excellent long-term outcomes. With proper preoperative assessment, meticulous surgical technique, and attentive postoperative care,