Malrotation of bowel with other associated anomalies is not uncommon. Congenital malrotation often presents in childhood and occasionally diagnosed in adulthood. A very unusual combination of right central diaphragmatic hernia, malrotation of bowel and mediastinal right kidney in an adult patient is reported. 

A 39 years old male had presented with pain abdomen. The pain was of moderate severity with small quantity bilious vomiting. Abdomen was not distended. There was guarding on the right upper part bowel sound was normal. Reduced breath sounds were noted in the right lower half of chest. His routine haematological and biochemical parameters were normal. X-ray chest (Figure 1) showed doubtful bowel shadow on the right chest and this was confirmed on barium picture (Figure 2) which demonstrated the duodenum going straight right and upward (Figure 3). Right kidney was not located on the USG. Hence a CT scan was done. It demonstrated the mediastinal right kidney behind the heart (Figure 4), almost placed transversely. Diagnostic laparoscopy was done, the diagnosis was confirmed, the colon and omentum content were reduced. The patient had no features of bowel obstruction, no dilatation of  small bowel was seen and to avoid injury to the right ureter, the abdomen was opened and mesh-plasty was done (Figure 5), The liver was pushed towards the right hemi-diaphragm. The bowel was left as it is, as he had no bowel symptoms to avoid retro-peritoneal exposure to avoid right ureteric injury. Right chest tube was placed and abdominal right subcostal incision was closed. Post operatively he recovered well with one stich abscess as wound complication. The right lung expanded fully after which chest tube was removed on the 5th day. During 13 years of follow up, he has led a healthy life. 

Congenital diaphragmatic hernia (CDH) is a developmental defect, which allows abdominal viscera to enter the chest, compressing the developing lung. The mortality of the babies is high because of lung hypoplasia³. Right thoracic kidney has been reported earlier in a 22 years old male who presented with right varicocele and right kidney cranial to the right hemi diaphragm. Ectopic location may not affect the kidney function unless the ureter is obstructed⁴ Developmentally, mediastinal location can be explained during the three stages of pro, meso and metanephric development, where the middle stage may get arrested at the mediastinal level. Even if, the ectopic location of kidney is confirmed, surgery is not indicated in a functioning kidney and best modality is not yet known⁶.