Introduction Gastric banding is a frequently performed operation for patients with morbid obesity. Complications have been described extensively. We describe a rare and severe complication of an intrathoracic stomach in a patient with gastric banding, 6 months after the initial procedure, and its treatment. Case Report 1 Fig. 1 Intrathoracic position of the stomach with a shift of the mediastinum to the right  2 Fig. 2 Complete atelectasis of the left lung caused by an intrathoracic stomach and a left-sided pneumothorax  During laparotomy an ischemic gastric perforation was identified at the orifice of the paraesophageal hernia, with spill of gastric content into the abdomen and thoracic cavity. The intrathoracic stomach was reduced into the abdomen. The gastric perforation was oversewn. The    Lap-band was removed, and a Nissen fundoplication was performed. At last, a thoracic drain was placed to treat the pneumothorax. The patient was treated with intravenous antibiotics (metronidazole and cefuroxime) for 5 days. After 2 days, she was able to leave the Intensive Care Unit. Her postoperative course was uneventful. Thirteen days after surgery, she left the hospital. Discussion 1 2 4 We describe the first case in which both perforation and herniation have occurred simultaneously after obesity surgery and even not as an immediate consequence of the operation. In our case, the gastric band was not the primary cause of the perforation. Most probably, the stomach had moved into the thoracic cavity through a preexistent paraesophageal hernia. Because of air-trapping distal to the band accompanied by having a copious meal, the intrathoracic stomach distended, rotated, and perforated at the orifice of the hernia. The acute onset of pain can be explained by the perforation and the dyspnea appears to be caused by mediastinal shift as well as the pressure atelectasis of the left lung. Retrospectively, our patient was known to have a paraesophageal hernia before she underwent gastric banding. The possible severe complications of this combination should be considered. A Nissen fundoplication before or in the same operation could be an option for this subgroup of obese patients.