An 87-year-old woman presented with a traumatic fracture of her right femoral neck. After admission she became tachypneic, tachycardic, and had increased oxygen requirements. Computed tomography showed no pulmonary embolism, but revealed a 17 × 10-cm type-IV paraesophageal hernia (Figs. 1 and 2). The hernia included the entirety of her stomach, majority of the pancreas, portions of the duodenum, the splenic flexure of the colon, and associated vasculature. Fewer than 5% of paraesophageal hernias involve viscera beyond the stomach,1 and pancreatic involvement is especially rare.2,3 Her acute dyspnea was attributed to immobility, atelectasis, and the massive hernia. She ultimately had a right hip hemiarthroplasty with successful postoperative extubation. She was weaned off oxygen and was asymptomatic at discharge.

Figure 1.
figure 1

Massive paraesophageal hernia—coronal view. Black arrow: pancreas. The pancreatic head is adjacent to the right diaphragm, and the associated pancreatic vasculature can be seen inferior to the pancreas. White arrow: stomach. The stomach is adjacent to the carina and left mainstem bronchus. White star: splenic flexure of the colon.

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Figure 2.
figure 2

Massive paraesophageal hernia—axial view. White arrow: pancreas. The majority of the pancreatic outline can be seen in this view.

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Elective surgery of asymptomatic paraesophageal hernias was historically thought to be required to prevent the development of life-threatening complications.4 However, the mortality rate from elective laparoscopic repair is approximately 1.4%, while the lifetime risk of death from watchful waiting is estimated to be approximately 1%.4 The lifetime risk of developing acute symptoms requiring emergency surgery also decreases exponentially after 65 years of age.4 Thus, watchful waiting appears to be a reasonable strategy for some minimally symptomatic or asymptomatic paraesophageal hernias.