Giant Paraesophageal Hernia Research Articles

Outcomes after Laparoscopic Gastropexy as an Alternative for Paraesophageal Hernia Repair.

Background:Outcomes after laparoscopic gastropexy (LG), performed as an alternative to formal paraesophageal hernia (PEH) repair in patients with giant PEH, have been rarely studied. This manuscript evaluates complications and long-term quality-of-life after LG.Methods:An IRB-approved protocol was used to identify patients who underwent LG to alleviate symptoms of acute or chronic gastric obstruction secondary to a paraesophageal hernia. Postoperative outcomes and quality-of-life data were retrospectively collected via chart review and prospectively via phone interview.Results:Twenty-six patients underwent LG, with a median age of 76 (52 – 91). Median follow-up was 28 (3 to 55) months. Gastropexy was the chosen intervention due to comorbid conditions (23, 88%), gastric inflammation (2, 8%), or intraoperative instability (1, 4%). Nine (35%) suffered postoperative complications, and 2 (8%) required reoperation. At the time of follow-up, 7 (27%) had died, 3 (11%) could not be reached. Sixteen (62%) completed the follow-up survey. Fourteen (88%) reported symptom resolution. Ten (62%) still required antireflux medication. Median Gastroesophageal Reflux Disease-Health Related Quality of Life score was 4.5 (0 to 19). Fourteen (88%) denied current dietary restrictions. All reported satisfaction with the operation.Conclusion:Laparoscopic PEH repair remains the standard of care for the management of giant PEH. However, a subcategory of patients with high operative risk could be candidates for a shorter operative intervention. As our data infers, LG is a reasonable alternative in this patient population. While the continued use of antisecretory medications is sometimes required, LG restores the ability to tolerate full meals without restrictions and results in excellent patient satisfaction.

2715 A Hiatal Hernia Causing Atrial Fibrillation Through Direct Mechanical Irritation

INTRODUCTION: Hiatal hernia (HH) is anatomically classified into four types according to herniated structures. Giant HH refers to a herniation of >50% of the stomach. Atrial fibrillation (AF) is a common arrhythmia, frequently seen in association with cardiovascular diseases. We report a case of AF caused by a giant HH compressing the left atrium. CASE DESCRIPTION/METHODS: A 90+ year-old female with a past medical history of gastroesophageal reflux disease (GERD), was admitted for surgical evaluation of symptomatic HH. During hospital stay the patient developed AF with rapid ventricular response, became hypotensive and lightheaded. EKG (Figure 1) confirmed new onset AF with non-specific ST-T wave changes. Sinus rhythm conversion was achieved by amiodarone drip. Metabolic and endocrine causes of the AF were ruled out. Ischemic etiology of the AF was ruled out by a normal myocardial perfusion imaging study. Computed tomography Angiography of the chest (Figure 2) was only remarkable for persistent giant hiatal hernia. Echocardiogram (Figure 3) showed external material compressing against the heart and the left atrium. At that point, the patient and the surgical team have decided on conservative management for her HH due to her high surgical risk. Patient was discharged home in sinus rhythm on oral anticoagulant and beta blocking agent. DISCUSSION: Gastroesophageal reflux disease (GERD), HH and AF are often seen in association. AF in GERD patients is likely due to local cytokine release from esophageal injury or vagal overstimulation. Such association is supported by reduced AF recurrences by reflux suppression with PPI use or fundoplication. However, the underlying mechanism of AF in HH patients has not been fully understood. In our case, left atrial compression and impingement were seen, which indicates direct left atrial irritation causing atrial arrhythmia. Surgical reconstitution of HH to relieve the cardiac compression would be the definitive treatment. Unfortunately, our patient was not a candidate for such invasive thoracic surgery due to her age. A similar case scenario was previously reported, in which AF was suppressed after laparoscopic surgical repair of a giant paraesophageal hernia. More cases need to be studied to confirm the hypothesized etiology of AF in patients with giant HH.

Saint`s triade with diverticulosis of jejunum – rare variety of the syndrome

The objective was to present the case report of the patient with rare clinical finding – Saint`s triade. The examination diagnosed giant paraesophageal hernia (III type) with gastric torsion and cholelithiasis. The 72-years old woman was admitted to hospital with complaints of acute dysphagia. During the laparotomy operation, jejunal diverticulosis was also detected. The patient underwent crural repair, fundoplication, and cholecystectomy. The postoperative period was uneventful. She was discharged on the 14th day after surgery with recovery. The features of the presented case were the prevalence of the clinical picture of complicated hiatal hernia and the localization of diverticula in the jejunum. The clinical significance of the Saint`s triade was to assess the probability of this combination in identifying one of the components.

The Journal of Trauma and Acute Care Surgery 3-Minute Expert Consult Video: “Hard to Stomach!: Giant Paraesophageal Hernia with Perforation”

The Journal of Trauma and Acute Care Surgery 3-Minute Expert Consult Video: “Hard to Stomach!: Giant Paraesophageal Hernia with Perforation”

Comparison of Dor and Nissen fundoplication after laparoscopic paraesophageal hernia repair

BackgroundFundoplication is performed routinely during laparoscopic repairs of a paraesophageal hernia, but the degree of fundoplication remains controversial. The purpose of this study is to assess postoperative dysphagia and reflux after a Dor versus a Nissen fundoplication in patients undergoing laparoscopic repair of giant paraesophageal hernias. MethodsWe performed a retrospective cohort study of all patients undergoing laparoscopic repair of giant paraesophageal hernias with Nissen or Dor fundoplication between January 2012 and December 2017 at a high-volume center, excluding revisional and emergency cases. Primary outcomes were reflux and dysphagia at 1 and 6 months. Severe dysphagia was defined as intolerance to liquids. Balanced cohorts were created using coarsened exact matching. ResultsA total of 106 patients were included, and 87 were matched (Dor = 48, Nissen = 58). Baseline characteristics were well balanced between matched groups. Mean follow-up duration was 17.7 months (standard deviation 16.4). The incidence of severe dysphagia at 1 month was less in the Dor group (0 of 48 vs 8 of 58, P = .02) with similar reflux symptoms. There was no difference in severe dysphagia and reflux symptoms at 6 months and at the latest visit. ConclusionDor fundoplication is associated with less severe, early postoperative dysphagia. Future studies assessing the relative importance of dysphagia and reflux on quality of life should be conducted to tailor the operative technique and optimize patient satisfaction.

Tu1301 – Increased Frequency of Giant Paraesophageal Hernia Repair At a Safety Net Hospital

Tu1301 – Increased Frequency of Giant Paraesophageal Hernia Repair At a Safety Net Hospital

Tu1298 – Robotic Fundoplications for Giant Paraesophageal Hernia: Role of Biosynthetic Tissue Reinforcement After Cruroplasty

Tu1298 – Robotic Fundoplications for Giant Paraesophageal Hernia: Role of Biosynthetic Tissue Reinforcement After Cruroplasty

Tu1293 – Laparoscopic and Robotic Assisted Repair of Giant Paraesophageal Hernias Associated to Previous Nissen Fundoplication: Report of 38 Cases. Technical Considerations and Surgical Key Points

Tu1293 – Laparoscopic and Robotic Assisted Repair of Giant Paraesophageal Hernias Associated to Previous Nissen Fundoplication: Report of 38 Cases. Technical Considerations and Surgical Key Points

The other explanation for dyspnea: giant paraesophageal hiatal hernia repair routinely improves pulmonary function

Paraesophageal hiatal hernias (PEHs) are most commonly associated with gastrointestinal symptoms; less widely appreciated is their potentially important influence on respiratory function. We hypothesize that surgical repair of PEH will significantly improve not only gastrointestinal symptoms, but also preoperative dyspnea and spirometry scores. A prospective Institutional Review Board-approved database was used to review all patients undergoing PEH repair from 2000 to 2016. Patients with pre- and postoperative pulmonary function tests assessed by spirometry were included. Postoperative changes in spirometry measurements were compared to PEH size as reflected by the percentage of intrathoracic stomach observed on preoperative contrast studies. Patients were stratified according to improvement in forced expiratory volume in 1 second (FEV1). Patients with >12% ('significant') improvement in FEV1 after surgery were compared to the remaining patient population. In total, 299 patients met the inclusion criteria. Symptomatic improvement in respiratory function was noted in all patients after PEH repair. Age, gender, BMI, presenting symptoms, Charlson comorbidity index as well as preoperative comorbidities did not significantly impact the functional outcome. Spirometry results improved in 80% of the patients, 21% of whom showed an improvement of >20% compared to the preoperative level. 'Significant' improvement in respiratory function was seen in 122 of 299 (41%) patients. Patients presenting with moderate and severe preoperative pulmonary obstruction demonstrated 'significant' improvement in FEV1 in 48% and 40% of cases, respectively. Large PEHs, characterized by a percentage of intrathoracic stomach >75%, was strongly associated with 'significant' improvement in FEV1 (P = 0.001). PEHs can impact subjective and objective respiratory status and surgical repair can result in a significant improvement in dyspnea and pulmonary function score that is independent of preoperative pulmonary disease. Gastric herniation of more than 75% was associated with higher possibility for improvement of pulmonary function tests. Patients with persistent and unexplained dyspnea and coexistent PEH should be assessed by an experienced surgeon for consideration of elective repair.

Modern era surgical outcomes of elective and emergency giant paraesophageal hernia repair at a high-volume referral center.

Repair of giant paraesophageal hernia (PEH) has historically been associated with significant morbidity and mortality such that elective repair is only offered to symptomatic patients. Recent reports suggest modern era outcomes have improved such that elective repair may now be safer than historically thought. Furthermore, the morbidity of emergency surgery may still be significant. These changes may have important implications for patient selection for elective repair. The objectives of this study were to determine and compare modern era surgical outcomes after elective and emergency repair of giant PEHs at a high-volume tertiary care center. A retrospective review was conducted for all Type II-IV giant PEH repairs performed between 1 January 2012 and 31 December 2017. Type 1 hiatal hernias, fundoplication for reflux, and any co-surgery other than cholecystectomy were excluded from the final analysis. Baseline patient demographics, operative details, postoperative complications within 30 days and in-hospital or 30-day mortality were tabulated from the electronic medical record. Data were reported as median (interquartile range) unless otherwise specified. A total of 352 cases were reviewed, of which 204 met inclusion criteria (18 emergency, 186 elective). Eight had Type II PEH, 146 had Type III, and 50 had Type IV. Median length of stay was shorter in the elective group [1 (1) day elective vs. 5 (7) days emergency, p < 0.0001], and emergency patients were less likely to return directly to their original residence at discharge (13, 72% emergency vs 185, 99.4% elective, p < 0.0001). There were significantly more major complications (Clavien-Dindo score ≥ 3) in the emergency group (5, 28% emergency vs. 10, 5% elective, p = 0.005). There were no perioperative deaths in either group. Morbidity and mortality in both groups were less than historically reported. Informed consent discussions and patient selection for repair of giant PEHs should reflect modern era and institution-specific outcomes.

Emergency presentation of a giant paraoesophageal hernia- A case report

An emergency presentation of a paraoesophageal hernia with acute respiratory distress and an acute abdomen is a rare presentation. Hereby, we are presenting a 73year old female who presented with an acute dyspnoea and acute bowel obstruction, the imaging revealed large paraoesophageal hernia almost collapsing the right lung, she had an emergency surgery, an anterior gastropexy was performed since she was unstable. Despite subsequent surgeries e.g Collis gastroplasty and mesh cruroplasty, patient developed recurrent hiatal hernia. Unfortunately, the patient ultimately passed away from a vancomycin resistant enterococci (VRE) bacteraemia and due to overwhelming medical comorbidities. As presentation of paraoesophageal hernia with acute dyspnea and acute abdomen is a rare incidence, we discuss this and its management options through a case report.

Long-term outcomes following surgical repair of giant paraoesophageal hiatus hernia.

There are limited data regarding long-term outcomes after surgical repair of giant paraoesophageal hiatus hernia (GPHH). The aim of this study was to assess symptomatic recurrence and patient-reported outcomes following GPHH repair. 178 patients undergoing elective (127) and emergency (51) GPHH repair between 1994 and 2015 were identified from the prospectively collected Lothian Surgical Audit database. Electronic patient records were used to determine rate of clinical recurrence. A postal questionnaire was used to assess modified DeMeester, 'Gastrointestinal Symptom Rating Scale' symptom scores, breathing and exercise tolerance, and patient satisfaction. Median follow-up was 35months (range 12-238). 15 (8.4%) patients developed a clinical recurrence and 13 (7.3%) underwent a further operation. The clinical recurrence rates were similar in patients followed-up less than 5years and beyond 5years [10/128 (7.8%) vs 5/50 (10%)]. Mortality rate was 1.6% for elective compared with 16.7% for emergency procedures (P < 0.001). Completed questionnaires were received from 95 (78.5%) of 121 eligible patients. Mean symptom scores were low (Modified DeMeester 2.6). 83.7% of patients reported a good or excellent outcome, and 97.8% believed they had made the correct decision to undergo surgery. Surgical repair of GPHH is associated with high levels of patient satisfaction and good overall symptom outcome. There is a clinical recurrence rate of 8.4%, which does not significantly increase with long-term follow-up.

RA06.05: LAPAROSCOPIC GIANT PARAESOPHAGEAL HERNIA REPAIR: CT SCAN AND QUALITY OF LIFE TOOL EVALUATION OF SUCCESS

Abstract Background Our objective was to analyze the results of laparoscopic giant paraesophageal hernia (GPEH) repair in tertiary hospital setting. The main endpoints were recurrence of the hernia, postoperative quality of life, symptoms and satisfaction with the operation. To assess radiographical recurrence we used computerized tomography imaging, which has not been used in previous studies. Methods We identified all non-emergent giant (more than 30% of stomach in the chest) esophageal hernia repairs in our hospital from medical records. The patients were sent standardized 15D health-related quality of life and Gastroesophageal reflux disease (GERD-HRQL) questionnaires. Patients who gave their consent were assigned to a non-contrast computerized tomography (CT)-study to assess radiographical recurrence. Results Altogether 165 patients were reviewed. 74% of the patients were female, with a mean age of 67. 1 patient (0.6%) had died perioperatively. Complications were reported in 28 patients (17%). 10 patients (6.1%) had to undergo reoperation within 30 days. 7 patients (5.9%) were dissatisfied with the operation. 66% had an excellent result on GERD-HRQL. 4 patients had a major recurrent hernia in CT, but the radiographic findings did not correlate with symptoms. The mean D15 score was 0853 for our patients and 0896 for the age-adjusted control population (P &amp;lt; 0001). Conclusion The complication rate was comparable to previous studies. Perioperative mortality was low, significant radiographical recurrences were rare and only few patients were dissatisfied with the result. However the overall quality of life of the study group was slightly below age-adjusted population average. Disclosure All authors have declared no conflicts of interest.

Abnormal High-Resolution Manometry Findings and Outcomes after Paraesophageal Hernia Repair

Abnormal esophageal peristalsis diagnosed by high-resolution manometry is frequently found as part of the preoperative evaluation of patients with paraesophageal hernia (PEH). Currently, the clinical relevance of these findings is largely unknown. From 2013 to 2016, two hundred and twelve patients undergoing PEH repair were prospectively recorded in an IRB-approved database. Preoperative high-resolution manometry was available for reanalysis according to the latest Chicago Classification (version 3.0) in 200 patients. Outcomes in patients with abnormal motility (AM) were compared with patients with normal motility (NM). Abnormal motility was documented in 106 (53%) patients. Abnormal motility was associated with older age (72 vs 69 years) and increased age-adjusted Charlson Comorbidity Index (both, p= 0.04). Compared with preoperative symptoms, postoperative retrosternal pain in AM vs NM patients went from 79% to 5% vs 75% to 2%, regurgitation from 52% to 2% vs 59% to 0%, and dysphagia from 56% to 7% vs 67% to 7%. An esophagogram was performed at a median of 4 months and 3.5 months postoperatively. Postoperative reflux in AM vs NM went from 54% to 21% vs 57% to 16%, and abnormal esophageal motility, visually assessed during the esophagogram, was stable (52% to 56% vs 41% to 48% for AM vs NM, respectively). Patients found to have AM according to the Chicago classification before surgical repair of PEH demonstrated similar symptomatic improvement compared with patients with NM. Selective motility disorders diagnosed by preoperative high-resolution manometry should not preclude surgical repair of giant PEHs.

Large Paraesophageal Hiatus Hernia: Is Surgery Mandatory?

Purpose/Aim: Paraesophageal hiatus hernias are seldom found, however the incidence is increasing accounting for 5-10% of all hiatal hernias. The aim of this review is to emphasize controversies in clinical presentation, essential workup investigations and highlight non-surgical and surgical management options. Materials and Methods: A PubMed literature search using the keywords "large or giant paraesophageal hernia", "hiatus or hiatal hernia", "laparoscopic surgery", "antireflux surgery", "mesh", "gastric volvulus" and "diaphragmatic hernia" published between 1998 until 2017 was conducted. Results: Presenting symptoms are non-specific and can be erroneously attributed to various more common medical conditions. Significant complications as gastric volvulus and stomach necrosis, may occur and the obscured clinical presentation can be confusing for the clinician. Management options in the elective setting are controversial, and surgical repair cannot be easily justified for a minimally symptomatic condition, especially in an elderly and perhaps frail patient. However, in the era of laparoscopic surgery around the hiatus, reduced operative stress makes surgical repair appealing in the elective setting. Surgical matters as the adjunct of an antireflux procedure or not, the use of prosthetic mesh to reinforce the hiatus, gastropexy and the clinical importance of radiological or endoscopic recurrence are still under debate. Conclusions: The laparoscopic treatment of paraesophageal hiatus hernias is effective with low morbidity rates, offered in symptomatic patients and good operative risk asymptomatic individuals. More studies are needed to assess improvement suggestions, as the use of prosthetic mesh or gastropexy, regarding complications and recurrence risks.

Treatment of giant paraesophageal hernia: pro laparoscopic approach.

Giant paraesophageal hernias (GPEH) are relatively uncommon and account for less than 5% of all primary hiatal hernias. Giant Secondary GPEH can be observed after surgery involving hiatal orifice opening, such as esophagectomy, antireflux surgery, and hiatal hernia repair. Surgical treatment is challenging, and there are still residual controversies regarding the laparoscopic approach, even though a reduced morbidity and mortality, as well as a shorter hospital stay have been demonstrated. A Pubmed electronic search of the literature including articles published between 1992 and 2016 was conducted using the following key words: hiatal hernia, paraesophageal hernias, mesh, laparoscopy, intrathoracic stomach, gastric volvulus, diaphragmatic hernia. Given the risks of non-operative management, GPEH surgical repair is indicated in symptomatic patients. Technical steps for primary hernia repair include hernia reduction and sac excision, correct repositioning of the gastroesophageal junction, crural repair, and fundoplication. For secondary hernias, the surgical technique varies according to hernia type and components and according to the approach used during the first surgery. There is an ongoing debate regarding the best and safest method to close the hiatal orifice. The laparoscopic approach has demonstrated a lower postoperative morbidity and mortality, and a shorter hospital stay as compared to the open approach. A high recurrence rate has been reported for primary GPEH repair. However, recent studies suggest that recurrence does not reduce symptomatic outcomes. The laparoscopic treatment of primary and secondary GPEH is safe and feasible in elective and emergency settings, especially in high-volume centers. The procedure is still challenging. The main steps are well defined. However, there is still room for improvement to lower the recurrence rate.

Laparoscopic repair of giant paraesophageal hernia: are there factors associated with anatomic recurrence?

Repair of giant paraesophageal hernia (PEH) is associated with a favorably high rate of symptom improvement; however, rates of recurrence by objective measures remain high. Herein we analyze our experience with laparoscopic giant PEH repair to determine what factors if any can predict anatomic recurrence. We prospectively collected data on PEH characteristics, variations in operative techniques, and surgeon factors for 595 patients undergoing laparoscopic PEH repair from 2008 to 2015. Upper GI study was performed at 6months postoperatively and selectively thereafter-any supra-diaphragmatic stomach was considered hiatal hernia recurrence. Exclusion criteria included revisional operation (22.4%), size <5cm (17.6%), inadequate follow-up (17.8%), and confounding concurrent operations (6.9%). Inclusion criteria were met by 202 patients (31% male, median age 71years, and median BMI 28.7). At a median follow-up of 6months (IQR 6-12), overall anatomic recurrence rate was 34.2%. Symptom recurrence rate was 9.9% and revisional operation was required in ten patients (4.9%). Neither patient demographics nor PEH characteristics (size, presence of Cameron erosions, esophagitis, or Barrett's) correlated with anatomic recurrence. Technical factors at operation (mobilized intra-abdominal length of esophagus, Collis gastroplasty, number of anterior/posterior stitches, use of crural buttress, use of pledgeted or mattress sutures, or gastrostomy) were also not correlated with recurrence. Regarding surgeon factors, annual volume of fewer than ten cases per year was associated with increased risk of anatomic failure (54 vs 33%, P=0.02). Multivariate analysis identified surgeon experience (<10 cases per year) as an independent factor associated with early hiatal hernia recurrence (OR 3.7, 95% CI 1.34-10.9). Laparoscopic repair of giant PEH is associated with high anatomic recurrence rate but excellent symptom control. PEH characteristics and technical operative variables do not appear to significantly affect rates of recurrence. In contrast, surgeon volume does appear to contribute significantly to durability of repair.

The Importance of Age on Short-Term Outcomes Associated With Repair of Giant Paraesophageal Hernias

Older patients have an increased incidence of paraesophageal hernia (PEH) and can be denied surgical assessment due to the perception of increased complications and mortality. This study examines the influence of age and comorbidities on early complications and other short-term outcomes of PEH repair. From 2000 to 2016, data of surgically treated patients with PEH were prospectively recorded in an Institutional Review Board-approved database. Only patients whose hernia involved over 50% of the stomach were included. Patients were stratified by age (<70, 70 to 79, ≥80 years of age) and compared in univariate and multivariate analyses. Overall, 524 patients underwent surgical PEH repair (<70: 261 [50%]; 70 to 79: 163 [31%]; ≥80: 100 [19%]). Patients greater than or equal to 80 years of age had higher American Society of Anesthesiologists class, more comorbidities, larger hernias, and higher incidences of type IV PEH and acute presentation. Patients greater than or equal to 80 years of age had more postoperative complications, but not higher grade complications (Clavien-Dindo grade ≥IIIa). Median length of stay was 1 day longer for patients greater than or equal to 80 years of age (5 days versus 4 days for patients <70 and 70 to 79 years of age, respectively). Objective, radiologic hernia recurrence at 4.3 months postoperation was 17.3% and was not increased in the greater than or equal to 80 years of age group. After adjustment for comorbidities and other factors, age greater than or equal to 80 years was not a significant factor in predicting severe complications, readmission within 30 days, or early recurrence. PEH repair is safe in physiologically stable patients, irrespective of age. Incidence of complications is higher in older patients, but complication severity and mortality are similar to those of younger patients. Patients with giant PEH should be given the opportunity to review treatments options with an experienced surgeon.

Prospective study of giant paraesophageal hernia repair with 1-year follow-up

ObjectiveEvaluating giant paraesophageal hernia (GPEH) repair requires long-term follow-up. GPEH repair can have associated high recurrence rates, yet this incidence depends on how recurrence is defined. Our objective was to prospectively evaluate patients undergoing GPEH repair with 1-year follow-up. MethodsPatients undergoing elective GPEH repair between 2011 and 2014 were enrolled prospectively. Postoperatively, patients were evaluated at 1 month and 1 year. Radiographic recurrence was evaluated by barium swallow and defined as a gastroesophageal junction located above the hiatus. Quality of life was evaluated pre- and postoperatively with the use of a validated questionnaire. ResultsOne-hundred six patients were enrolled. The majority of GPEH repairs were performed laparoscopically (80.2%), and 7.5% were redo repairs. At 1-year follow-up, 63.4% of patients were symptom free, and radiographic recurrence was 32.7%. Recurrence rate was 18.8% with standard definition (>2 cm of stomach above the diaphragm). Quality of life scores at 1 year were significantly better after operative repair, even in patients with radiographic recurrence (7.0 vs 22.5 all patients, 13.0 vs 22.5 with recurrence; P < .001). Patients with small radiographic recurrences have similar satisfaction and symptom severity to patients with >2 cm recurrences. ConclusionsGPEH repair can be performed with low operative mortality and morbidity. The rate of recurrence at 1 year depends on the definition used. Patient satisfaction and symptom severity are similar between patients with radiographic and greater than 2 cm hernia recurrences. Longer follow-up and critical assessment of our results are needed to understand the true impact of this procedure and better inform perioperative decision making.

Relaxing incision of the diaphragm for esophageal hiatal closure for giant paraesophageal hiatal hernia

Between December 1994 and December 2015, we performed 500 laparoscopic antireflux surgeries (LARS) in our clinic. Among them, we experienced 4 cases (0.8%) who had giant paraesophageal hiatal hernias (GPEH) with markedly enlarged esophageal hiatuses that made suturing of the right and left crus of the diaphragm difficult during crural repair. Therefore, we developed a procedure that allows crural repair without applying excessive tension after making a relaxing incision on the crus. This technique was applied in 5 cases in the current study. The mean surgical time and loss of bleeding volume were 280.2 ± 45.7 (227–339) min and 46.0 ± 87.1 (0–200) mL, respectively. No adverse events were observed during surgery, and no patients were converted to open surgery. No recurrent case has been observed after three sutures were added for fixation of the stomach and abdominal walls. This technique could be a safe and effective procedure for closure of the crural defect in GPEH.