84 year old female with significant kyphoscoliosis and signs of acute colonic obstruction is found to have a massive Type IV paraesophageal hernia. The hernia contains incarcerated stomach, duodenum, colon, pancreas, and spleen. She undergoes a laparoscopic reduction of the massive hernia, which takes up the majority of the left hemithorax. The hernia sac and contents are carefully reduced laparoscopically until the herniated abdominal viscera are properly situated below the diaphragm. The hiatal hernia is repaired with sutures and biologic mesh. Finally, a Toupet fundoplication is performed.