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Aim The aim of this study is to clarify whether radical surgery for advanced esophageal hiatal hernia contribute to the improvement of cardiac load. Background & Methods In Japan, endoscopic surgery for esophageal hiatal hernia is increasing. In many cases, patients with mixed type hernia have the main symptom of meal passage disorder due to gastric torsion. On the other hand, there are cases in which the contents of hernia squeeze the heart and lung and the symptoms of respiratory and circulatory system get worse. And there are cases where cardiac load is exacerbated and QOL is got worse. Therefore, in addition to conventional surgical adaptation criteria such as vomiting and food loss, cardiac load aggravation may be added to the new surgical adaptation criteria. In this study, we measured BNP before and after surgery in the case of mixed type hiatal hernia who underwent surgery at our hospital, and examined changes in cardiac load. Our surgical procedure of laparoscopic fundoplication is basically toupet fundplication. In the elderly patients, the formation of toupet fundplication is about half a cycle, which is slightly looser than usual, in order to avoid passage obstruction of the wrap. If the esophageal hiatus is too large and it is difficult to suture closure, try to reduce the air pressure of laparoscopic surgery as much as possible to reduce the resistance to the suture closure. And we try not to damage the diaphragm leg. Results We experienced 70 esophageal hiatal hernia surgeries in 2012-2018 and 45 patient had mixed type hiatal hernia. In mixed type hiatal hernia case, 18 cases (40.0%) had chest symptoms such as fatigue and dyspnea on exertion. And there were 12 cases in which BNP could be measured before and after surgery as an evaluation for the presence of cardiac load. Postoperative BNP decreased in 11 of 12 cases from preoperative values. Almost all cases chest symptoms improved. In the above 45 cases, there have been no cases of reoperation and very few cases have taken proton pump inhibitors after surgery. Conclusion Surgical cases of giant hiatal hernia may increase in the future, especially in the elderly. Surgery for giant hiatal hernia can contribute to the improvement of cardiac load.