A 63 year old woman presented with several month history of post prandial pain. A subsequent barium contrast study demonstrated a large type III paraesophageal hernia with organoaxial gastric volvulus. The consenting patient was brought to the operating theatre electively. The patient was positioned supine on a split leg operating table. Following generation of CO2 pneumoperitoneum to 12 mm Hg through a 5 mm umbilical port, one 12 mm and four 5 mm ports are placed under direct vision. Division of the gastro-hepatic ligament is performed to gain access to the right crus. The hernia sac is dissected from both mediastinal and diaphragmatic attachments without violating either pleura and then excised. Development of a retro-esophageal junction. The crura are repaired posteriorly by interrupted 00 braided nylon sutures. Short gastric arteries are not divided, as the chronic intra-thoracic position of the stomach often leads to lengthening of these vessels. A 1.5 cm posterior 360 degree fundoplication is fashioned around a 54 french dilator. A final tacking suture is placed between the fundoplication and right crus. The patient is fed a liquid diet on POD #1 and discharged on POD #2. An endoscope and contrast study at three months confirm the integrity and intra-abdominal position of the fundoplication.