We have reviewed our experience with eight patients with paraesophageal hernias surgically repaired at this institution during an 18-month period. Three of these patients required emergent operation, and although the morbidity was higher in this group than in those undergoing elective surgery, no mortalities occurred in either group. The potential for the development of life threatening complications warrants immediate surgery on patients who are diagnosed to have paraesophageal hernias, even if asymptomatic. We recommend a transabdominal approach for the performance of a crural repair and an antireflux procedure.