Minimally invasive approach in the repair of hiatal hernias became a standard of care during the last two decades. Laparoscopy offers faster recovery, shorter hospital stay and less morbidity than traditional laparotomy. Several studies have shown higher recurrence rates after a suture-based repair of hiatal hernias. A “tension-free” repair with prosthetic mesh allowed to decreased recurrence, but the use of synthetic materials produced potentially serious problems, such as erosion and dysphagia. Multiple reports showed reduction in short-term recurrence rate after hiatal hernia repair with biologic grafts. However, the improvement in hiatal hernia recurrence decreased at long-term follow-up.