In the last years surgeons began to report experience with laparoscopic repair of large hiatus hernias, and this approach is now considered to be the technique of choice for the repair of large hiatus hernia[
45]. However, controversy exists regarding four important issues of laparoscopic hernia repair: surgical approach (open or minimally invasive), the need of complete hernial sac excision, crural repair without or with mesh reinforcements and the exigency of an antireflux procedure addition. Primarily an open transthoracic approach, performing a left postero-lateral thoracotomy, was the technique of choice to giant hiatal resolution[
28,
46]. Anyhow it is well known that this access, when compared to most recent laparoscopic approaches, show an elevated mortality and morbidity, with longer convalescence[
47]. In addition, during the early 90's, while laparoscopic techniques were developing, it was believed that the left open transthoracic approach would provide better access to the distal esophagus, allowing not only a best estimate of its length, but also the recourse to the Collis procedure in cases of short esophagus[
28]. Progression to open transabdominal techniques for antireflux surgery in the 70's was also followed by the development of techniques for open abdominal hiatal hernia treatment[
4]. All this is likely to be associated with less morbidity due to an abdominal rather than a chest incision, although there is not a high level of evidence to support these claims. It is, instead, well clear that both the thoracic and abdominal open approach are associated by high levels of postoperative pain, which is one of the most important trigger factors of perioperative morbidity. Many randomized controlled trials reported better short term operative and postoperative outcomes of laparoscopic Nissen fundoplication when compared to open technique[
48]. Furthermore the quality of life and symptom score improvements related to laparoscopic correction of giant hiatal hernia are similar to those of open surgery, as reported in literature[
3,
28,
49]. Our mortality rate (0%) is comparable to 0–3.7% mortality rate as reported by Hashemi, Low et al.[
3,
6,
28,
49]. In our population study there were no conversions to open technique and intraoperative complications. Postoperatively, only 2 patients (15.3%) had transient subcutaneous emphysema in the neck that resolved spontaneously in few hours and other two patients (15.3%) had pleural effusion adsorbed after a few days. Exactly the minimally invasive approach offers an excellent visualization of the hiatal region, far superior to that of laparotomy, and it is associated with low morbidity and mortality rates, a short hospital stay, and excellent patient compliance. From a technical point of view, during the phase of hernia reduction, the laparoscopic approach allows very precise identification of the anatomic structure (e.g., vagus nerves, parietal pleura, distal esophagus), and the dissection is facilitated by pneumoperitoneum[
20,
22,
28]. One of the most crucial technical points in surgery for large hernias concerns the complete excision of hernia sac. The first procedures did not give proper importance to the dissection of the hernia sac, aiming to reduce the stomach completely laparoscopically and performing the preparation of the esophagus within hernia sac. This surgical strategy was not reliable, especially when stomach occupied more than 30-40% of hernia content; a conversion rate to open surgery of 40-50% was observed after first minimally invasive hernia reduction[
41,
50]. At the end of the 80’s Edye et al.[
50] reported studies showing that when the laparoscopic approach focused initially on the dissection and reduction of the hernia sac from the mediastinum before performing esophageal mobilization, the conversion rate to open surgery was reduced to 10%. Recent experiences suggest that when the operation is performed by expert surgeons conversions to open surgery are quite uncommon[
51], as in our series (no conversion rate was registered). The other debated issue is the need of mesh to reinforce the hiatoplasty. Surgeon who treats a giant hiatal hernia has to choose between the risk of hernia recurrence[
52] and formidable complications due to mesh use[
53]. Many scientific papers show that there is a significant decrease of 6-months hernia recurrence with hiatoplasty reinforcement by means of biomesh compared to only direct hiatus closure (9% versus 24%)[
54]. We did not register any recurrence rate at 12 months follow up and our outcomes were in contrast with the high rates of radiographic recurrence published in some series of laparoscopic repair without mesh reinforcement[
28,
52,
55‐
57]. We believe that it is possible to get satisfactory results even without using these devices, with the possibility of efficacy lost over long time, avoiding serious complications predicted by some authors in relation to the different type of meshes[
58‐
62]: erosion or migration of the mesh into the esophagus or stomach, as well as complications due to severe mesh adhesions, infection, or the development of fibrotic strictures in the hiatal region. Although different series report complication rates from 1.3%[
62] to 20%[
58,
63], the true rate of mesh-related complications is currently unknown[
64], probably due to the lack of long-term follow-up studies. It should be noted that the use of meshes should limited, according to the surgeon personal experience, in cases characterized by extreme fragility of the pillars or excessive hiatus opening after direct closure, when the hiatoplasty seems inadequate. For these reasons, encouraged by the results presented by some authors[
17‐
21], crural reinforcement is used in only two cases at our center, but without hesitation for problems with crural integrity or tension. In our opinion, although the study was conducted on a small number of patients with relatively short follow-up, to avoid the use of mesh are crucial complete dissection of sac and wide preparation of the oesophagus and diaphragmatic pillars to the maximum extent possible, to pull down the stomach and oesophagogastric junction in the abdomen for a length sufficient to prevent excessive pressure loading of the hiatal repair. This condition, therefore, is a prerequisite for a successful treatment. At this time, the decision to carry out a mesh cruroplasty rather than a direct closure after repairing a hiatal hernia is based on personal experience, and additional randomized studies on standardized use of reinforcement procedures are needed[
10]. Another often discussed issue concerns the need for antireflux surgery in hiatal hernia repair. The extensive dissection required to obtain a quite long esophageal segment in the abdomen can make the gastroesophageal junction fail, resulting in postoperative reflux symptoms[
10]. A number of authors[
65,
66] have reported an incidence of reflux symptoms in up to 47% of patients whose repair did not include any kind of fundoplication. It has been suggested that a fundoplication might reduce the recurrence rate by fixing the stomach in the abdomen, but this has not been demonstrated prospectively[
10]. We performed an antireflux procedure in all the cases with a good control of reflux symptoms. Esophageal manometry 3 months after surgery showed a neo-high pressure zone mean value of 23.4 ± 2.1 mmHg, and 12 months after operation evidenced a mean value of 21.2 ± 1.6 mmHg, significantly higher than preoperative value (p < 0.05). Combined 24-h multichannel impedance pH and bilirubin monitoring showed at 12 months follow up no evidence of pathological acid or non acid reflux (p < 0.05) compared to preoperative assessment. Moreover we documented a reduction of liquid and gas reflux episodes after surgery, as a probable consequence of total fundoplication hindrance on the transient lower oesophageal sphincter relaxations due to the compression on the lower oesophageal sphincter segment, complying the observations of Linke GR et al. carried out in patients with proven GORD or hiatal hernia treated with laparoscopic mesh-augmented hiatoplasty without fundoplication[
67]. Interestingly the postoperative mean total percentage of oesophageal acid exposure (pH < 4) and the postoperative Symptom Index of our series were also comparable with Linke GR et al. pH-impedance analysis results after laparoscopic mesh-augmented hiatoplasty without fundoplication[
67].