A giant hiatus hernia is defined as a herniation of more than 30–50% of the stomach, or sometimes the entire stomach, through the esophageal hiatus into the thoracic cavity. It is often associated with symptoms such as dysphagia, regurgitation, gastroesophageal reflux, chest discomfort, anemia due to Cameron ulcers, and, in severe cases, respiratory compromise. Surgical repair is recommended in symptomatic patients and in those at risk of complications such as volvulus or strangulation.

Laparoscopic repair has become the preferred approach because it reduces morbidity, shortens hospital stay, and provides improved recovery compared to open surgery. In cases of large or giant hiatus hernia, mesh reinforcement is frequently employed to reduce recurrence rates, which are higher with primary suture repair alone.

Preoperative Considerations

Before surgery, patients undergo a detailed evaluation including:

Upper GI endoscopy: To assess esophagitis, Barrett’s esophagus, or ulcers.

Barium swallow study: To delineate the size and type of hernia.

High-resolution manometry: To evaluate esophageal motility before considering fundoplication.

CT scan: In selected cases to confirm hernia size and mediastinal extension.

Optimization of comorbidities such as chronic obstructive pulmonary disease or cardiac disease is essential, as these patients are often elderly.

Surgical Technique
Patient Positioning and Port Placement

The patient is placed in a supine, reverse Trendelenburg position with legs apart.

A standard four- or five-port technique is used, with a 10 mm camera port at the umbilicus and additional working ports in the upper abdomen.

Dissection and Hernia Reduction

The hernia sac is identified and carefully dissected from the mediastinum.

Herniated stomach and, in some cases, omentum or colon are reduced back into the abdominal cavity.

The hernia sac is usually excised to prevent recurrence.

Crural Dissection and Closure

Adequate mobilization of the esophagus is performed to ensure at least 2–3 cm of intra-abdominal esophagus.

The diaphragmatic crura are approximated posteriorly with interrupted non-absorbable sutures.

In giant hernias, tension-free closure may be difficult; here, mesh reinforcement is indicated.

Mesh Reinforcement

Mesh reinforcement is used to strengthen the crural closure and minimize recurrence.

Mesh can be placed in an onlay or keyhole configuration, depending on surgeon preference.

Both synthetic meshes (e.g., polypropylene, PTFE) and biologic meshes (derived from acellular dermis or porcine tissue) are used. Biologic meshes are often preferred due to lower risk of erosion into the esophagus.

The mesh is fixed with non-absorbable sutures, tacks, or fibrin glue.

Fundoplication

To prevent postoperative reflux, an anti-reflux procedure is usually added.

A 360° Nissen fundoplication or partial Toupet fundoplication is performed depending on esophageal motility.

Drain Placement and Closure

A drain may be placed in the mediastinum or left subphrenic space if contamination is suspected.

Ports are removed, and skin incisions are closed.

Postoperative Care

Patients are started on liquids within 24 hours, progressing to soft diet as tolerated.

Adequate pain control and early ambulation are emphasized.

Proton pump inhibitors may be prescribed in the immediate postoperative period.

Follow-up imaging or endoscopy is considered in patients with recurrent symptoms.

Outcomes and Advantages

The laparoscopic mesh repair of giant hiatus hernia offers several benefits:

Lower recurrence rate: Mesh reinforcement significantly reduces anatomical recurrence compared with primary suture repair alone.

Improved symptom control: Relief of dysphagia, reflux, and chest discomfort is achieved in most patients.

Minimally invasive benefits: Reduced postoperative pain, shorter hospital stay, and faster recovery compared with open surgery.

Better visualization: Laparoscopy provides superior visualization of mediastinal structures and precise dissection.

Potential Complications

Although effective, mesh repair carries risks that require careful consideration:

Mesh-related complications: Erosion into the esophagus or stomach, fibrosis, and stricture formation. These are rare but serious, more common with synthetic meshes.

Recurrent hernia: Despite reinforcement, recurrence can occur, especially in very large defects or in patients with poor tissue quality.

Dysphagia: May result from tight fundoplication or excessive narrowing at the hiatus.

Intraoperative injuries: To the esophagus, stomach, or vagus nerve during dissection.

Choice of Mesh

Synthetic mesh: Durable but carries a higher risk of erosion and stricture.

Biologic mesh: Lower risk of erosion, integrates well with native tissue, but cost is higher and durability may be less.

Current evidence supports the selective use of biologic mesh in giant hiatus hernia repair to balance efficacy with safety.

Conclusion

Laparoscopic mesh repair has become a widely accepted and effective method for managing giant hiatus hernia. It combines the advantages of minimally invasive surgery with the added reinforcement of mesh to reduce recurrence. Careful patient selection, meticulous surgical technique, and judicious choice of mesh material are crucial for optimizing outcomes. While recurrence remains a challenge, particularly in very large hernias, laparoscopic mesh repair provides durable symptom relief, improved quality of life, and faster recovery for most patients.