An 85-year-old male with a past medical history of seizure disorder, stroke, gout and chronic obstructive pulmonary disease was admitted with dysphagia and malnutrition. He was a nursing home resident with depressed level of consciousness and a history of heartburn in the distant past, which according to relatives was relieved with antacids. There were no episodes of aspiration. An upper gastrointestinal endoscopy and an upper gastrointestinal series revealed a type III hiatal hernia (Figure 1). A large portion of the stomach was in the left hemithorax. The patient had a jejunostomy tube in 1997 that was accidentally dislodged several weeks prior to his admission and was never replaced. He had also undergone open cholecystectomy in 1994. After discussing the potential treatment options and in view of his poor medical condition, the patient and his family requested placement of a feeding tube for nutritional support without repair of the paraesophageal hernia. The patient was taken to the operating room, placed supine on the table under general endotracheal anesthesia, and two pillows were placed under his left shoulder and flank. The abdomen was prepped, and the gastroscope was inserted. The room lights were dimmed but transillumination throughout the abdominal wall was not possible. Finger pressure produced no distinct indentation of the gastric wall. At that point, laparoscopy was performed using the open technique for port insertion through an incision at the umbilicus. A 0-degree scope was used. There were adhesions in the upper abdomen. A 12-mm port was inserted under direct vision along the left anterior axillary line, slightly below the level of the umbilicus. The adhesions were divided using ultrasonically activated shears. The stomach was visualized herniating through an enlarged hiatus into the thoracic cavity. Using an atraumatic grasper, the body of the stomach was partially reduced and retracted in a caudad direction. Maintaining traction on the stomach, transillumination of the gastroscope light was possible through the abdominal wall. Under laparoscopic and gastroscopic visualization, a needle with a sheath was inserted into the stomach (Figures 2 and 3); a wire was passed through the sheath and grasped with a snare placed through the endoscope. The wire was pulled out through the mouth and attached to the tapered end of the PEG tube. The tube was then pulled through the mouth, the stomach wall and the anterior abdominal wall. The gastric and anterior abdominal wall were apposed without tension (Figure 4); the position of the mushroom appeared satisfactory through the gastroscope, and the catheter was secured in place. Feedings were initiated on postoperative day one. There were no postoperative complications, and the PEG is functioning well six months after the procedure. The patient has minimal intake by mouth, and his nutritional needs are meet entirely through tube feedings.