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AIM: Laparoscopic Nissen fundoplication represents the gold standard in GERD therapy, although, a frequent failure of this primary repair is represented by the breakdown of the hiatoplasty. Aim of our work is to evaluate if ultrastructural alterations of the diaphragmatic pillars in patients with hiatal hernia, can explain the physiopathology of hernia recurrence. MATERIAL OF STUDY: The patients were divided into two groups: group A comprised 51 patients affected by hiatal hernia and group B (control) included 30 patients not affected by hiatal hernia.. Each patient underwent four biopsies, two from the phrenoesophageal membrane and two from the diaphragmatic pillars during laparoscopic procedures. Three hundred and twenty-four specimens, 204 from the group A and 120 from the group B, were processed and analyzed by transmission electron microscopy. RESULTS: No alterations were found in the phrenoesophageal membrane in both groups; samples from the diaphragmatic pillars showed no alteration in the group without hiatal hernia (group B). Instead, 90,2% of the muscular samples from the crura of group A patients presented ultrastructural alterations: in almost 75% of the cases the lesions were considered severe with extended disruption-degeneration of the muscle architecture. DISCUSSION: Patients with hiatal hernia have ultrastructural abnormalities of the muscular tissue of the diaphragmatic pillars that are absent in patients with normal gastroesophageal junction. CONCLUSIONS: The outcome of GERD surgery could depend not only on a correct technique but also on the underlying status of the diaphragmatic crura.