A 75 year old female with large type IV paraesophageal hernia underwent Davinci robotic repair with Toupet fundoplication. The stomach and greater omentum were located in the chest with the stomach in organoaxial rotation. After reduction and dissection of the hernia sac, the defect was reconstructed with suture crural repair. A right crus relaxing incision was performed to reduce tension on the sutures. Synthetic SoftMesh was used to buttress the cruroplasty and a second biosynthetic mesh was placed on top to prevent direct contact of polypropylene to the esophagus. Finally, Toupet fundoplication and anterior gastropexy were performed. Patient has done well post-operatively without any dysphagia or reflux symptoms in 6-month follow up.