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Background: The transition from open to laparoscopic repair of paraesophageal hernia (PEH) has allowed for significant reduction in morbidity and mortality but higher recurrence rates were reported. While the addition of synthetic mesh at the hiatus can decrease the recurrence rate, it also can be associated with complications such as stricture formation, erosion and perforation. When biomesh is placed at the hiatus, the anticipated result is less local inflammation and tissue reaction than that observed with synthetic mesh while still establishing a more durable PEH repair. However, it is possible that the addition of any material at the hiatus may result in decreased pliability and increased patient complaint. Therefore, our hypothesis in this study was that patients who had a PEH repaired with biomesh would have increased dysphagia in the post-PEH repair period. Methods: A retrospective review of prospectively collected data on patients who underwent PEH repairs using a standardized biomesh placement technique. A comparable cohort of patients who had PEH repairs performed using a standardized technique without mesh was also reviewed. Patient demographics, details of hernia repair, postoperative esophageal manometry and patient symptomotology and results of a validated subjective questionnaire (dysphagia, gas bloat, heartburn, chest pain, abdominal pain, inability to belch) were recorded. Results: One hundred and sixty-two patients were reviewed. Ninety patients completed 6 month follow-up (57 mesh, 33 primary). At the 2 week evaluation, mesh patients had significantly more gas bloat (15.8% vs 0%, p=0.012) nearly significant less dysphagia (10.5% vs 24.2%, p= 0.08). By 6 months, despite mesh patients having a higher mean lower esophageal sphincter residual pressure (18.5 vs1.2 mmHg, p<0.0001) there was no significant difference between the 2 groups’ symptoms or need for dilation.Conclusion: Patients who underwent PEH repair with biomesh did not have higher rates of dysphagia compared to primary repairs after 6 month observation. This information combined with previous publications regarding lower recurrence rates when mesh is placed advocates for the use of mesh is all patients who have a large hiatal defects.