The last 2 decades have witnessed a revolution in the treatment of patients with paraesophageal hernia.

The advent of laparoscopy has significantly improved postoperative outcomes in patients undergoing surgical repair of a paraesophageal hernia. Nowadays, the laparoscopic repair with fundoplication is considered as the primary treatment modality in most academic centers for symptomatic patients.

Although this minimally invasive approach considerably reduces postoperative pain and recovery times, and may improve physiologic outcomes, laparoscopic paraesophageal hernia repair remains a complex operation. Three findings have clearly emerged: (1) this procedure is technically demanding requiring advanced laparoscopic skills and experience with the anatomy of the gastroesophageal junction and diaphragmatic hiatus; (2) it is associated with relief of symptoms in most patients; and (3) most recurrences are small and asymptomatic. In this lecture, we describe our approach to patient selection, preoperative evaluation, operative technique, and postoperative management. Specific attention is paid to performing an adequate esophageal mobilization, the decision of whether to use a mesh to reinforce the crural repair, and construction of an adequate antireflux barrier using a fundoplication.