Debate continues as to the optimum method of surgical repair of large paraesophageal hernias. In some series, laparoscopic repair has been associated with equivalent symptomatic relief to the open approach but higher incidence of hernia recurrence. The laparoscopic approach, including posterior hiatal cruroplasty with non-absorbable sutures, has demonstrated a rate of recurrence with Type 1 sliding hiatal hernias in the range of 4-42$ or more. Alternative approaches, including the use of prosthetic mesh have been reported with improved recurrence rates. However, the use of prosthetic materials has been associated with esophageal complications including stricture, erosion, and perforation. Biomaterial grafts may provide the benefits of a reinforced crural repair while minimizing these risks. For large paraesophageal hernia repairs we reinforce the sutured crural closure with an overlying piece of Surgisis®, a collagen-matrix derived from sheep intestinal submucosa. Our standard laparoscopic approach involves reduction of the herniated contents and the hernia sac with complete sac dissection. The crural defect is closed posterior to the esophagus with interrupted, non-absorbable sutures. For large defects, this closure is reinforced with an overlying layer of Surgisis® that is tacked in place around the hiatus. A Nissen fundoplication is then performed. To date, we have had no adverse events or early symptomatic recurrences with the use of Surgisis®. This material is easily placed and fixed laparoscopically and may provide an alternative to prosthetic reinforcement of the hiatal closure. Long-term studies are required to validate the use of this tissue graft.