A 78-year-old woman was admitted to our hospital because of abdominal pain. She was diagnosed with complex (type IV) paraesophageal hiatal hernia, for which an operation was performed. At laparotomy, a 50 cm long ileum was found to have herniated into the thoracic cavity through the esophageal hiatus along with the sliding hiatal hernia of the stomach. Both the organs were reduced to the abdominal cavity. The hiatal hernia defect (diameter, 7cm) was repaired with a direct suture, and the gastric fundus was sutured to the diaphragm. Presently, 6 years have passed since the operation, there is no sign of recurrence.