Objective: To present 2 cases of massive hiatal hernia and review the literature on the subject. Materials and Methods: Information is obtained from electronic records of both cases and a review of the literature on classification and management is carried out. Results: 2 clinical cases of massive hiatal hernia with different forms of presentation are presented, both with surgical management and good postoperative evolution. Discussion: Type IV paraesophageal hiatal hernias usually contain the entire stomach, trans-verse colon, omentum, sometimes the small intestine and, more rarely, the spleen. In massive hiatal hernia (MHH), the duodenum, bile duct and pancreas are added to the indicated organs. MHH is a rare occurrence and constitutes a surgical challenge. The literature reports just over thirty cases in the last 50 years, not all of which have been operated on. Management must be surgical and early, in order to promptly restore the anatomy and performed by a team with experience in the management of complex hiatal hernias.