A massive incarcerated hiatal hernia is a frequent finding in elderly people. The aim of this report has been to review from 1987 to 1992 the clinical aspects, therapeutic options and results of surgical treatment in a series of twenty-eight patients (23 females and 5 males) with a large incarcerated hiatal hernia. Age averaged 66 +/- 10 years; thirteen patients (46.5%) had a sliding type of hernia, 8 (28.5%) a mixed one, and 7 (25%) a paraesophageal hernia. In 9 patients (32%) there was a chronic volvulus of the incarcerated stomach. Twenty-seven patients underwent elective repair; one patient developed a perforated gastric ulcer into the pericardial sac with pneumopericardium and died before surgery. The surgical technique included reduction of the hernia, closure of the hiatus and an antireflux procedure (Nissen 25, Toupet 1 and Dor 1). There was no mortality and the morbidity (18%) was not directly related to the surgical procedure. In our series there were no cases of acute volvulus requiring emergency surgery. Our results suggest that surgical correction of massively incarcerated hiatal hernias is well tolerated in the elderly, it relieves symptoms, and avoids potential serious complications.