The operative management for GERD and treatment of PEHs increased dramati­cally in the past decade. This increase occurred with the introduction and advance­ment in the minimally invasive techniques which was demonstrated to be safe, effective, and with a low risk of operative morbidity and mortality [26]. This led to more patients with failed primary surgical repair being encountered in the clinical setting. Most studies report recurrence rates of around 28% after primary repair. The pathogenesis of PEH recurrence is multi-factorial and includes patient characteris­tics, physiologic factors such as repetitive movement of the diaphragm, and techni­cal factors. Patient related factors include obesity, presence of atypical symptoms, poor response to medications, pulmonary disease, smoking, prior abdominal surger­ies, and size of the PEH [27]. Technical factors that have been associated with increased rates of recurrence include inadequate dissection of hiatus, failure to rec­ognize short esophagus or inadequate dissection of the esophagus, false identica­tion of GE junction, sub-optimally constructed wrap, and vagal nerve injury. Upon reoperation, transdiaphragmatic migration of wrap and disruption of wrap were the two most common causes for failure [28–30]. Despite the relatively high recurrence rate of laparoscopic PEH, only a minority of patients are symptomatic and require reoperation. The most common indication for reoperation includes reux, dyspha­sia, and bloating along with a documented radiographic abnormality [31].