Abstract Background Literature reports up to 66% recurrence following mesh or no mesh repair of giant para-oesophageal hernias (GPEH). Tension-free closure, key for any hernia repair, can be challenging for some patients. This study assesses safety, feasibility, and short-term outcomes for patients undergoing combined diaphragm release and biological hiatal mesh reinforcement. Method Retrospective analysis of prospectively collected data of demographics, symptoms, investigations (OGD, CT), operative details including complications and follow up of 3 patients between May-October 2024 in a large DGH. Laparoscopic GPEH biological mesh repair was combined with full thickness right/left (based on hiatal defect) diaphragm release reinforced with composite mesh closure. Results Study included 2 females and 1 male of 63, 70 and 62 years, ASA II, BMI 32, 31 and 27 respectively. Operative findings were hiatal defect 6*cm with 75% intrathoracic stomach. 1 right and 2 left diaphragm release incisions allowed tension free hiatus closure with 10* (8-10) sutures and biological mesh hiatal reinforcement followed by 360° fundoplication. Operative time 300*(240-360) minutes. Pneumothorax addressed through intraoperative chest drain removed after 72 hours and managed in HDU. Hospital Stay 7*(2-10) days and follow up at 8 weeks. Pre and postoperative GORD-HRQOL scores were 20*(19-29) and 0 respectively with 100% patient satisfaction. Conclusion The diaphragm is extremely dynamic, and laparoscopic hiatal mesh reinforcement, a challenging surgery, does not guarantee definite positive outcomes for GPEH repairs. Adding diaphragmatic release to enable tension-free hiatal closure is safe in experienced hands and could improve patient outcomes and satisfaction. Median *
Allwin et al. (Fri,) studied this question.