BACKGROUND Acute sigmoid volvulus is one of the commonest causes of benign large bowel obstruction. Its incidence varies considerably from one geographic area to another. OBJECTIVE To review the management of acute sigmoid volvulus in a relatively high prevalence area. METHODS All adult patients with acute sigmoid volvulus seen at the Royal Victoria Teaching Hospital (RVTH) Banjul, between September 2000 and January 2005 were studied. Information obtained for analysis from the records included age, sex, clinical features, test results, and outcomes. RESULTS A total of 48 patients, 45 (93.8%) males and three (6.3%) females, with a male: female ratio of 14.3:1, age range of 19 to 78 years and mean age of 45.8 +17.6 years, underwent treatment for acute sigmoid volvulus. Twenty-one (43.8%) of the patients were aged 40 to 59 years. Two (4.2%) had rectal tube detortion followed by elective sigmoidectomy and primary anastomosis on the same admission, while 24 (50%) had emergency laparotomy at which bowel decompression, one-stage resection and primary anastomosis without on-table lavage was done. The rest of the patients, 22 (45.8%) had gangrenous sigmoid colons at laparotomy and consequently had Hartmann's procedure done. Fourteen patients (29.1%) developed wound infection and five (10.4%) had prolonged ileus that was managed conservatively. There was no anastomotic leak. The mean hospital stay was 11.1 days. There were five deaths giving a mortality rate of 10.4%. CONCLUSIONS Acute sigmoid volvulus in the Gambia is almost exclusively a male disease. Sigmoid colectomy and primary anastomosis can be carried out safely in those with viable colon without on-table colonic lavage.