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Background: Laparoscopic operations on the esophagus, including paraesophageal hernia (PEH) repair, fundoplication for gastroesophageal reflux, and myotomy for achalasia, involve dissecting and opening of the diaphgramatic crura and mobilizing the mediastinal esophagus. During these maneuvers, tears in the mediastinal pleura can occur, resulting in capnothorax, and, potentially, hemodynamic or respiratory instability. The incidence of intraoperative pleural tears, their clinical significance, and factors predictive of occurrence have not been studied. Methods: A single-surgeon prospective database of laparoscopic operations on the esophagus was analyzed. During each operation, the presence of any recognized pleural tear was recorded, as were any hemodynamic or respiratory changes that occurred as a result. These data, along with the primary operator (resident, fellow, or attending), procedure duration, need for adhesiolysis, EBL, other complications, and length of stay were all recorded prospectively. Results: 382 laparoscopic operations were performed: 64 PEH repairs, 199 Nissen fundoplications, and 119 Heller myotomies. 57 (15%) cases were re-do procedures. Pleural tears occurred in 44 (12%) cases, of which 13 (30% of pleural tears, 3% of all cases) resulted in a transient increase in peak airway pressures, decrease in oxygen saturation, or decrease in blood pressure. All 13 cases of hemodynamic and/or respiratory instability were resolved successfully by decreasing the abdominal insufflation pressure to <10mmHg. In no case was intra or postoperative tube thoracostomy insertion required. Comparing cases with or without a pleural tear, there were no differences in rates of other complications (5 vs. 12%; p=ns) or length of stay (mean 1.4 vs. 1.3 days). The incidence of pleural tears was significantly different for each procedure: PEH repair (36%), Nissen (11%) and Heller (3%) (p<.05 for each paired comparison). Re-do and primary operations had a similar incidence of pleural tears (12% vs. 11%; p=ns). The level of training of the primary operator did not affect the pleural tear rate (resident: 8%, fellow: 14%, attending: 12%, p=ns). When patient demographics were compared between cases with and without pleural tears there were no differences in gender distribution, age, or BMI. Cases with and those without pleural tears did not differ in terms of length, EBL, or need for adhesiolysis. Conclusions: In this series of laparoscopic esophageal operations, pleural tears occurred in 12% of cases. Nearly a third of pleural tears caused transient hemodynamic or respiratory changes, but in all cases these were successfully managed by decreasing insufflation pressure without need for tube thoracostomy. Pleural tears occurred more frequently during PEH repair, but there do not appear to be other demographic or operative predictors of increased occurrence.