Paraesophageal hernia is an unusual disorder of the esophageal hiatus that may be associated with life-threatening mechanical problems. We report a case of a large paraesophageal hernia that presented with acute thoracic herniation and incarceration of the stomach. The patient underwent laparoscopic operation, including reduction of an intrathoracic stomach, hernial sac removal, and tension-free repair of the hiatus with polytetrafluoroethylene (PTFE) mesh. The mesh was fixed with a straight hernia stapler. Postoperatively the patient developed a fatal cardiac tamponade secondary to a coronary vein laceration due to fixation of the mesh with the stapler. Different operative techniques and possibilities for prevention of the complication are discussed.