Paraesophageal hiatal hernia (PHH), accounting for only 5% of all hiatal hernias, may result in potentially life threatening complications such as obstruction, acute dilatation, perforation, or bleeding of the gastric mucosa. It is traditionally believed that PHH is an indication for surgery. The repair of paraesophageal hernia is technically challenging and controversial. The purpose of this article is to overview the current status of indication of surgery; operative techniques including hernia sac resection, esophageal lengthening procedure, crural repair, and additional antireflux procedure.All symptomatic patients should be surgically treated, when operation is possible. It seems reasonable that asymptomatic or minimally symptomatic patients do not necessarily require surgery and that a more selective approach should be used. The penetration rate is not high, laparoscopic approach is currently the standard care. The hernia sac should be excised and resected circumferentially. Collis-Nissen procedure continues to be the method of choice also in the laparoscopic era, when lengthening procedure of the shortened esophagus is in consideration. Although symptomatic recurrence after suture closure of the crura is uncommon, primary repair is associated with a high rate of anatomic recurrence. Prosthetic mesh repair is reportedly associated with a recurrence rate as low as 5%, at the price of rare but serious complications such as erosion and fibrosis. Although scientific proof is lacking, fundoplication is the most common procedure to be added after crural repair.