gastric volvulus is characterized by a rotation of the stomach along its axis in variable degrees and may present either acutely or chronically .
it may cause a complete gastric outlet obstruction and strangulation , leading to ischemic necrosis and perforation with a mortality rate of 3050% .
primary gastric volvulus results from abnormalities of the four gastric ligaments that restrict rotation : gastrocolic , gastrophrenic , gastrosplenic and hepatogastric .
we report a case of a gastric volvulus in a patient with a history of a diaphragmatic hernia .
an emergent laparoscopic diaphragmatic hernia mesh repair and gastropexy was performed , resulting in a complete recovery .
a 49-year - old woman presented to our emergency department with a 2-week history of epigastric pain and vomiting with no prior trauma . her past medical history included hypertension , iron deficiency anemia , laparoscopic cholecystectomy and an open uterine myomectomy .
upon arrival to the emergency department , she had a pulse of 135 beats per minute , a blood pressure of 110/90 mmhg , a respiratory rate of 20/min , a body temperature of 37.6c and an oxygen saturation of 98% on room air .
her clinical examination revealed tenderness over the epigastric region , and her bowel sounds were hyperactive . she had decreased air entry at the left basal region of the chest .
the initial laboratory results were white blood cell count 22.1  10/l ( neutrophilic ) , blood urea nitrogen 7.8 mmol / l , creatinine 121 umol / l and normal liver function tests , amylase and lipase .
a chest radiograph demonstrated a significant air - fluid level near the left lung base ( fig .  1 ) . 

figure  1:chest x - ray showing an elevated air - fluid left in the left basal lung region .
chest x - ray showing an elevated air - fluid left in the left basal lung region .
two days prior to her admission , she had undergone upper gastrointestinal endoscopy for the same complaint in another center that revealed a dilated gastric lumen with herniation of the distal stomach , pylorus and first part of the duodenum into the left hemi - thorax ( fig .  2 ) .
resuscitation was commenced with immediate nasogastric decompression , intravenous hydration and analgesia , proton - pump inhibitors and electrolyte replacement .
a double contrast - enhanced computed tomography ( ct ) scan of the chest and the abdomen demonstrated a large diaphragmatic defect ( 7  7 cm ) and a left diaphragmatic hernia containing a dilated stomach , suggestive of a gastric outlet obstruction ( fig . 
3 ) . a water - soluble gastrografin meal was performed , showing an intra - thoracic , mesentero - axial gastric volvulus ( fig . 
figure  2:flexible upper endoscopy showing herniation of the distal stomach , the pylorus and the first part of the duodenum into the left hemi - thorax . 

figure  3:different views of a double contrast - enhanced ct scan showing a left diaphragmatic hernia with an acute dilated stomach . 

figure  4:water - soluble gastrografin meal showing an intra - thoracic mesentero - axial volvulus .
flexible upper endoscopy showing herniation of the distal stomach , the pylorus and the first part of the duodenum into the left hemi - thorax .
different views of a double contrast - enhanced ct scan showing a left diaphragmatic hernia with an acute dilated stomach . water - soluble gastrografin meal showing an intra - thoracic mesentero - axial volvulus .
the patient was listed emergently , underwent general anesthesia and was placed in a 30-degree split - leg reverse trendelenburg position .
a four - port approach was used after verres pneumoperitoneum was achieved . on inspection of the peritoneal cavity ,
the stomach and the first part of the duodenum were incarcerated in the peritoneal sac in the left hemi - diaphragm ( fig . 
the rotated stomach and the first part of the duodenum were completely reduced from the thoracic cavity into the abdomen .
once the dissection of the sac was complete , we confirmed that there was no visceral injury and proceeded to repair of the 7  7 cm diaphragmatic hernia ( fig . 
a gore bio - a tissue reinforcement absorbable mesh ( 15  12 cm ) was selected to encourage the formation of vascularized neotissue .
it was fixed in place using ethicon securestrap absorbable strap fixation device ( fig . 
a gastropexy was then performed to the anterior abdominal wall using a 2 - 0 polypropylene suture . 

figure  5:laparoscopic view showing the incarcerated content in the peritoneal sac with a twisted stomach . 
 figure  6:laparoscopic view showing a large ( size 7  7 cm ) diaphragmatic defect . 

figure  7:laparoscopic view showing the primary closure of the diaphragmatic defect using an interrupted pds ii suture . 

figure  8:laparoscopic view showing bio - a tissue reinforcement absorbable mesh ( size 15  12 cm ) fixed intraperitoneally below the defect .
laparoscopic view showing the primary closure of the diaphragmatic defect using an interrupted pds ii suture .
laparoscopic view showing bio - a tissue reinforcement absorbable mesh ( size 15  12 cm ) fixed intraperitoneally below the defect . on the first post - operative day
, a water - soluble meal study was repeated and revealed a marked regression of the stomach size and a normal intra - abdominal position of the stomach and the first part of the duodenum with no evidence of obstruction ( fig . 
the patient had an unremarkable recovery and was discharged on post - operative day 3 .
she was followed up in clinic 2 weeks post - operatively , and a follow - up upper gastrointestinal endoscopy was performed , which showed normal anatomy to the second part of the duodenum ( fig . 
figure  9:water - soluble gastrografin meal showing normal intra - abdominal position of the stomach . 

a detailed history of the risk factors associated with gastric volvulus including previous surgical procedures , gastro - oesophageal reflux disease or history of trauma should be obtained .
the initial management includes nasogastric decompression ( endoscopically if necessary ) , fluid resuscitation and correction of electrolyte imbalances [ 1 , 6 ] .
endoscopic decompression , de - rotation and percutaneous endoscopic gastrostomy ( peg ) fixation of the stomach to the posterior abdominal wall are the first - line management for cases of primary gastric volvulus .
it is also employed in cases of secondary gastric volvulus who are unfit for surgical repair under anesthesia .
the use of two peg tubes is optimal as the stomach may still rotate over a single peg .
surgical intervention is the treatment of secondary gastric volvulus and cases of volvulus in which an endoscopic or nasogastric decompression and de - rotation have failed .
there are no randomized control trials available ; however , observational studies support laparoscopy for its benefits of reduced inpatient stays and improved post - operative morbidity
. a recurrence rate of 42 vs. 15% post laparoscopic and open gastropexy , respectively , has been described in one study .
however , it is important to stress that this is for gastric fixation alone and does not compare recurrence rates after hernia repair .
the laparoscopic approach is defined by the need to de - rotate and reduce the gastric contents into the abdominal cavity .
 gastric volvulus is an uncommon but serious surgical condition mandating an early diagnosis and surgical intervention . 
 it may present either acutely or chronically with epigastric pain , retching and vomiting . 
 there are two types of gastric volvulus : organo - axial and mesentero - axial . 
 we report a case of a mesentero - axial gastric volvulus in a 49-year - old woman with a left - sided diaphragmatic hernia . 
 she presented with a significant epigastric pain and vomiting . 
 a flexible upper endoscopy , a barium meal and a contrast - enhanced computed tomography imaging had confirmed the diagnosis . 
 she was treated with a laparoscopic mesh repair of the diaphragmatic defect followed by a gastropexy . 
 she had an uneventful postoperative course and was asymptomatic thereafter . 