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patients with a hiatal hernia of 2 cm or less. However, data is limited on efficacy of a hybrid procedure, combining both intraoperative endoscopic TIF and laparoscopic hernia repair for non-TIF candidates. The hybrid procedure allows for less extensive surgical dissection minimizing operative risks while TIF is associated with lower rates of post-fundoplication dysphagia and gas-bloating. We aimed to assess the safety, patient satisfaction, symptom resolution, and proton pump inhibitor use following the hybrid procedure with the third generation EsophyX Z Device (EndoGastric Solutions, Inc). Methods: All single session hybrid TIF combined with laparoscopic hernia repairs performed between June 2015 and September 2017 were evaluated. Data was collected with regards to procedure indication, pre and post-procedure symptoms, PPI use, patient satisfaction, and complications. Hybrid procedure was performed in the operating room under general anesthesia with laparoscopic hiatal hernia reduction and diaphragmatic defect repair followed by endoscopic TIF. Median follow-up was 11 months (1-29 months). Results: Twenty-seven patients with chronic GERD symptoms refractory to double dose PPI and with a Hill Grade 2 or higher hiatal hernia underwent hybrid procedure. The median age was 67 (33 -84) years old. 56% (15/27) of the patients were female. The prevalence of GERD symptoms was heartburn (70%), regurgitation (63%), cough (26%), and hoarse voice (11%). At post-procedure follow-up, 96% (26/27) of patients reported 50% or more satisfaction (Figure 1). 85% (23/27) of patients were completely off daily PPIs. Individual GERD symptoms improved, including decreased rates of heartburn (26%), regurgitation (11%), cough (15%), and hoarse voice (3%) (Figure 2). There were no postoperative complications. No dysphagia or gas-bloating symptoms were reported. Conclusion: In our experience, the TIF hybrid procedure is a safe and an effective therapeutic option for patients with severe GERD and large hiatal hernia that provides significant symptom relief, elimination of daily PPI use in 85% of patients, and improved patient satisfaction.