Introduction and importanceGastric perforation due to a hiatal hernia is a rare cause of acute abdominal pain that often requires surgical intervention. Conservative management for this condition is an effective option in certain cases, although fewer reports of this exist. Herein, we report a unique case of gastric perforation caused by a recurrent hiatal hernia that was successfully treated with conservative management.Case presentationA 74-year-old man developed a high fever and an elevated inflammatory response on the third day after a laparoscopic paraesophageal hernia repair using a mesh. Computed tomography confirmed the recurrence of the hiatal hernia, with gastric fundal prolapse into the mediastinum and surgical emphysema in the gastric wall. This was followed by a gastric perforation within the mediastinum. The patient was treated using an ileus tube through the perforation site.Clinical discussionIn similar cases, if the clinical symptoms are mild, there are no signs of serious infection, and the perforation remains in the mediastinum and can be appropriately drained, conservative treatment is considered an option.ConclusionUnder favorable conditions, conservative management can be an option for gastric perforation in patients with recurrent hiatal hernias, which is a serious potential postoperative complication.