Optimal crural closure techniques for repair of large hiatal hernias

Since the advent of laparoscopic anti-reflux surgery (LARS) in 1991, this approach rapidly became more acceptable not only for surgeons but also for the medical community. As a consequence the number of referrals for surgery increased considerably. Numerous reports in the literature have shown that minimally invasive surgery for reflux disease offers excellent results in 85% to 95% of patients, with short hospital stay, decreased postoperative discomfort, and early return to regular activities. Over the years the increasing experience gathered with this procedure has made the technique available even for the most technically challenging operations, such as large hiatal hernias. Despite the encouraging low morbidity and mortality rates, the reported rates of anatomical failure have been from 12% to 42%.