Preoperative evaluation for PHH repair requires four main studies which include (1) video esophagogram, a dynamic study which provides information about the overall size and position of the stomach within the hernia; (2) esophagogastroduodenos­copy which can provide information about the mucosa of the stomach and its asso­ciated conditions such as Cameron’s erosions, erosive esophagitis, and Barrett’s esophagus (Fig. 9.2). Additionally, it provides valuable information about Hill’s endoscopic classication of hernia (Fig. 9.3), level of esophagogastric junction, length of the esophagus and importantly to rule out malignancy; (3) high resolution impedance manometry (HRIM) proves valuable in planning the antireux proce­dure which is part and parcel of hernia repair, whilst knowledge of motility patterns help plan the type of wrap created in these patients; and (4) lastly if GERD is a dominant symptom, 24h ambulatory pH study will provide an objective score of

tion and recurrence postoperatively [9]. The crural repair can be achieved either with sutures or a mesh. Cruroplasty is achieved with non- absorbable sutures, either in an interrupted or a continuous fashion (Fig.9.5). Most of the sutures are placed posterior to the esophagus, although some may need to be placed anteriorly if the crura remains splayed after posterior cruroplasty [8, 25]. It is also common to reduce the intra­abdominal insufation pressure while approximating the crura, especially for the large PHH.Some surgeons use mesh to reinforce the crural repair and the choice of mesh depends on personal preference of the surgeon and the size of the hiatal defect e.g., some choose to use mesh only when the hiatal defect is large or >5cm [26, 27]. Mesh cruroplasty may signicantly increase operating time (15–50cm) as reported in a recent meta-analysis [28], but does not necessarily increase the rate of conversion to open [29]. It is standard to perform a fundoplication following crural closure. The type of fundoplication varies from complete to partial anterior or posterior fundoplication. Most common types are Nissen [30–32] (Fig.9.6) and Toupet [33, 34]. Some sur­geons in addition to fundoplication, suture the wrap to the crura or the stomach to the anterior abdominal wall or use tube gastrostomy to further prevent recurrence [7, 35]. The use of a bougie at the time of crural repair or while performing the wrap seems to be practiced by some surgeons [30, 31, 36]. However, it has fallen out of favor and is not considered as standard practice. This is because it possibly contributes to future recurrence by leaving a larger than required gap following cruroplasty [24].