Repair of the large paraesophageal hernias-types II, III, and IV is a challenging surgical problem. There are many technical modifications to the numerous aspects of surgical repair. The 2 most critical aspects of repair are: (1) aggressive mobilization of the esophagus to restore and ensure length and (2) the underestimated and understudied technique of hiatal closure. We describe the techniques and unique modifications such as a combined Hill and Nissen repair utilized at Swedish Medical Center There remains considerable opportunity through research and surgical innovation to improve on existing techniques in the repair of the paraesophageal hernia.