Aim: To report a case of a perforated strangulated roux limb in diaphragmatic hernia as a rare complication following laparoscopic total gastrectomy for gastric cancer. Background: As minimally invasive surgery (MIS) becomes increasingly performed for esophagogastric cancers, diaphragmatic hernias (DHs) pose new challenges for surgeons. Case description: We report the case of a 59-year-old patient who presented with hematemesis, epigastric pain, and hemodynamic instability. The patient had a history of gastric adenocarcinoma and had undergone a laparoscopic total gastrectomy 3 years before. The computed tomographic scan demonstrated a diaphragmatic hernia with a strangulated and perforated roux limb. The patient underwent staged resection of the necrotic roux limb to manage sepsis, followed by restoration of alimentary continuity. Conclusion: A diaphragmatic hernia (DH) is a challenging complication of MIS for esophagogastric cancers and may be difficult to prevent. A staged approach was invaluable, allowing for careful assessment, expert opinion, and reconstruction. Clinical significance: As MIS becomes increasingly performed, cases of complicated DH may become more apparent. Preventing DH may be difficult. A sutured crural repair with or without pexy of the roux limb may be performed if DH is identified at the time of gastrectomy. The value of mesh is unclear, and erosion remains a main concern.