Laparoscopic repair is the standard surgical approach to the problem of large paraesophageal hiatus hernia. It is associated with low risks of morbidity and mortality, although there is a small risk (less than 5%) of a clinically significant recurrent hernia. Various techniques have been proposed to minimise this risk, including esophageal lengthening procedures and mesh reinforcement of the hiatus. Both remain controversial. Radiological outcomes from randomised trials suggest that a reduction in hernia recurrence rates can be achieved with the use of mesh repair, although these trials have not demonstrated any clinically significant benefits for mesh repair. The risk of complications following mesh placement at the esophageal hiatus or an esophageal lengthening procedure needs to be balanced against potential benefits. More work is required to define the optimal approach to repair of large paraesophageal hiatus hernias.