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The only treatment currently available for paraesophageal hernia is surgery, which is effective in most cases if the principles of operative therapy are followed. These principles include reducing the stomach, resecting the hernia sac, effectively closing the hiatus, and achieving sufficient gastropexy. The authors believe that a laparoscopic approach to paraesophageal hernias is safe and effective, allowing excellent visualization of the hiatus and superior esophageal mobilization, with significantly less physiologic insult to the debilitated patients in this population. Two questions remain, hoever. First, is an antireflux procedure necessary? The authors believe it is, because of the high rate of postoperative reflux. Additionally, the procedure does not add significant time to the overall operation and provides an excellent anchoring mechanism. Second, is there a higher rate of recurrence with laparoscopic repair? This concern, introduced by Hashemi et al, has not been raised by other authors. The authors have had few recurrences but currently are studying all of their asymptomatic patients for confirmation. For now, the authors consider laparoscopic paraesophageal hernia repair with Nissen fundoplication the procedure of choice for this difficult problem.