Introduction: Various studies have shown that laparoscopic repair of a large hiatal hernia using simple sutures only for the cruroplasty is associated with a high recurrence rate. Surgery for small hiatal hernias is also accompanied by recurrence. The use of mesh in repair of small diaphragmatic defects from 1cm to 5cm is still debated. We changed our practice from just primary cruroplasty of small defects to closure with reinforcement with human acellular dermal matrix for all hiatal hernias in January 2005. Aim: To compare primary cruroplasty with human acellular dermal matrix mesh reinforcement with primary cruroplasty alone in repair of small hiatal hernias of size 1cm to 5 cm. Methods: This is a retrospective study evaluating one year recurrence rates following laparoscopic paraesophageal hernia surgery. We included all patients who had laparoscopic paraesophageal hernia repair for defect size less than 5 cm from January 2001 to November 2007. All patients were evaluated at one year follow up with an Upper GI contrast study and/ or an upper endoscopy to evaluate the nissen. Results: Out of the 202 fundoplications done, we identified 76 (26 male, 50 female) patients with a median age of 51years who had hiatal defects of less than 5 cm. We used human acellular dermal matrix in 23 (30%) patients and 53 (70%) patients had a primary closure of the diaphragmatic defect. Both groups were well matched in patient demographics. There were 5 recurrences (9.4%) in the group who had primary closure alone versus none (0%) in the group with human dermal mesh reinforcement but this difference was not statistically significant (p =0.13). Conclusion: The use of human acellular dermal matrix for repair of small hiatal hernias is safe and appears to reduce recurrence rates compared to primary cruroplasty alone. Larger randomized studies will be helpful for conclusive evidence.