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Background: Laparoscopic hiatal hernia repair is associated with recurrence rates ranging from 10% to 35%. Adequate mediastinal dissection, tension free closure of the hiatus, and crural reinforcement of large hernias with bioprosthestic mesh has been shown to reduce hiatal hernia recurrence rates. Data is scarce concerning treatment of asymptomatic hiatal and paraesophageal hernia recurrences found on upper endoscopy or barium swallow. This large retrospective review evaluates incidence and management of symptomatic and asymptomatic recurrent of hiatal and paraesophageal hernias.Methods: A single institution retrospective review of all laparoscopic hiatal and paraesophageal hernias with nissen fundoplication from February 2002 to November 2010 was performed. All patients underwent reduction of the hernia sac, mediastinal dissection, primary tension free closure of the hiatus, and placement of a bioprosthetic mesh if the hiatus was greater than 5 centimeters. Patients were seen at two weeks, six months, and one year. All patients underwent a barium swallow at one year to evaluate their repairs. Patients with a hiatal hernia recurrence were identified and then classified as symptomatic or asymptomatic. Results: 243 patients with hiatal and paraesophageal hernias underwent laparoscopic repair with nissen fundoplication from 2002 to 2010. 194 of 243 had been seen at one year and underwent a barium swallow. There were 17 (7%) recurrences seen over an average follow up period of 3.5 years. 4 were symptomatic and 13 were asymptomatic. All asymptomatic patients were followed closely with either no intervention or reinstitution of proton pump inhibitors. All of the symptomatic patients underwent revisional laparoscopic nissen fundoplications. Short term follow up of these patients have shown no recurrence. Conclusion: Laparoscopic hiatal hernia repair with nissen fundoplication is an effective technique to repair hiatal and paraesophageal hernias. The use of adequate mediastinal dissection, primary tension free closure of the hiatus, and bioprosthetic mesh placement for a hiatus greater than 5 centimeters significantly decreases hiatal hernia recurrences over a 3.5 year average time period. Patients who are asymptomatic can be followed closely without intervention and those with symptomatic recurrences can be repaired again safely and adequately.