Management of the Difficult Hiatal Hernia

The ideal operative solution to giant paraesophageal hernias involves a complex evaluation of the functional anatomy and the intraoperative assessment of both esophageal length and crural closure tension. The addition of surgical adjuncts such as extended transmediastinal dissection, Collis gastroplasty, and mesh reinforcement are all necessary, on an individualized basis, to address these 2 primary causes of hernia recurrence. The authors discuss the options available.