Background Sigmoid volvulus (SV) is the commonest form of colonic volvulus (50–80%). It accounts for 3–5% of all causes of intestinal obstruction. Redundant sigmoid with long narrow mesentery and chronic constipation are the main predisposing factors. It usually affects elderly and may be unfit for surgery, so it is difficult to be managed and pushes surgeons to look for a simple surgical procedure, especially in failed or unavailable endoscopic deflation. Patients and methods This study was conducted on 26 uncomplicated SV cases in high-risk patients. Patients were divided into two equal groups: group A was managed by open deflation, detorsion, and sigmoidopexy, whereas group B was managed by sigmoidectomy and primary anastomosis. The procedures were carried out under local anesthesia (bilateral ultrasound-guided transversus abdominis plane block) with sedation through left iliac incision. Results The study included 26 cases of SV in high-risk patients (American Society of Anesthesiologists III–IV) with age ranged between 50 and 75 years. Patients presented mainly with distention, vomiting, pain, and intestinal obstruction. Postoperative complications such as recurrence were detected in 23% of patients in group A only, and anastomotic leak in 15.4% of patients in group B. Wound infection was detected in 23% of patients in group A and 15.4% of patients in group B. Conclusion Although deflation, detorsion, and sigmoidopexy is a safe and simple maneuver for SV, it has a high recurrence rate. Sigmoidectomy carried out under local anesthesia and sedation, through a left iliac incision nearly, has the same advantages but with no recurrence. It can extend the possibility of definitive surgical intervention and improve postoperative outcomes in high-risk patients.