Repair of hiatal hernias is associated with an elevated recurrence rate, a fact that has long driven modifications to surgical technique. During the past 20 years, reinforcement of the repair with mesh has formed the basis of many of these modifications. However, despite early success, the use of synthetic and biologic mesh at the hiatus has been found to carry increased complication and high long-term recurrence rates, respectively. In this article, we review available evidence as well as our current practice for mesh-reinforced hiatal hernia repair.