The existing classification system of hiatal and paraesophageal hernias has been developed and presented through textbooks and the gastrointestinal literature for generations. However, experience has shown that this classification system does not serve as an adequate basis for surgical decision-making, as there is wide variability among actual paraesophageal hernias of a given classification type. Recent advances in imaging capabilities, and computer software that allows graphic representations of actual patient's anatomy, have allowed for a clearer understanding of the true anatomical relationships in these complex foregut hernias.