Recurrent hiatal hernia presents a difficult diagnostic and therapeutic challenge. The authors present a series of 121 patients in whom recurrent hiatal hernia was investigated by history, radiology, endoscopy and manometry and acid perfusion testing before surgical correction by thoracoabdominal total fundoplication gastroplasty. The preoperative findings were compared with those of 238 patients who had undergone primary repair. Roentgenography was found to be less accurate in the diagnosis of anatomic recurrence than of the original hernia. Manometry and endoscopy increased the diagnostic accuracy of recurrent hernia. The thoracoabdominal approach was used to allow direct vision dissection both above and below the diaphragm. Gastroplasty minimized the risk of anatomic recurrence and allowed reflux control even in patients with an irreducible hiatal hernia. Total fundoplication, added to gastroplasty, is the most effective method of preventing reflux. There were no anatomic recurrences and no evidence of reflux in the 121 patients who had secondary repair. Two patients have required further surgery to modify the total fundoplication gastroplasty. With a 96.7% follow-up, 94.2% of the patients are considered to have excellent results.