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Background: Spontaneous diaphragmatic hernias are a rare surgical emergency, encompassing 1% of diaphragmatic injuries. The most common aetiology is that of a sudden increase in intra-abdominal pressure, such as post vomiting, coughing, defaecation, physical exercise, and vaginal delivery. There were no such precipitating factors in the following case. Methods: Here we discuss the case of a 46-year-old female who presented to her local Emergency Department with a one-day history of epigastric pain radiating to the left scapular region and neck, which was associated with nausea and vomiting. She had no preceding trauma, with no clear aetiology identified. She was haemodynamically stable with an isolated tachycardia. Abdominal examination revealed marked guarding and rebound tenderness epigastrically. Computed tomography (CT) Abdomen Pelvis demonstrated the stomach herniating through a narrownecked defect of the left hemidiaphragm with no definitive evidence of strangulation. She was subsequently transferred to our institution and underwent emergency laparoscopic converted to open exploration, reduction of the stomach and repair of the defect. Intra-operatively a necrotic wedge of the greater curve was identified and resected, with its attached omentum. The diaphragmatic defect was closed with interrupted sutures. Results: The patient was admitted to intensive care unit (ICU) for close observation and was commenced on total parenteral nutrition (TPN) in the immediate post-operative period with broad spectrum antimicrobial cover. Her postoperative recovery was uneventful. Conclusions: Diaphragmatic hernias are rare in the absence of trauma, with early recognition and definitive surgical management being imperative to achieve favourable postoperative outcomes.

AB161. SOH21AS140. Spontaneous diaphragmatic hernias: The Twisted Tango