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LAPAROSCOPIC TREATMENT OF VOLVULUS OF THE COLON.

(David N. Armstrong, Garth H. Ballantyne, In: GH Ballantyne, PF Leahy, IM Modlin, Laparoscopic Surgery, W.B. Saunders Co., Phildelphia, 1994.)

GARTH H. BALLANTYNE, M.D., M.B.A.
F.A.C.S., F.A.S.C.R.S.

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REVIEW OF 752 LAPAROSCOPIC COLECTOMIESLAPAROSCOPIC COLECTOMY:
AN UPDATE

 

Volvulus is defined as an abnormal twisting of a segment of bowel on itself, along its longitudinal axis. This results in occlusion of the proximal bowel and a closed loop obstruction within the segment. Compromised blood supply to the involved segment, together with the increase in intraluminal pressure, leads to gangrene and perforation if unrelieved.

Worldwide, the incidence of volvulus of the large bowel varies widely, according to the population studied. In an advanced Western population large bowel volvulus accounts for 1-5% of all large bowel obstructions. In these populations, the most common site of large bowel torsion is the sigmoid colon (80%), followed by cecum (15%) transverse colon (3%) and splenic flexure (2%). The condition is common in regions of Africa, Southern Asia and South America. In the "volvulus belt" of Africa and the Middle East, 50% of large bowel obstructions are a result of volvulus, almost exclusively of the sigmoid colon. In Northern Iran sigmoid volvulus accounts for 85% of large bowel obstructions.

In the vast majority of cases, sigmoid volvulus is an acquired condition, resulting from elongation of the sigmoid loop and stretching of the sigmoid mesocolon. This is in contrast to cecal volvulus, which results most commonly from failure of retroperitoneal fixation of the cecum.


 

SIGMOID VOLVULUS

ETIOLOGY

In the West, sigmoid volvulus occurs as a result of sigmoid elongation, resulting in a redundant loop. This is seen most commonly as a result of long term neurologic or psychiatric disease. Associations with Parkinson's disease, multiple sclerosis and spinal cord patients are well known. Psychotropic drugs or sedatives interfere with colonic motility and are etiologically implicated in the high incidence seen in psychiatric institutes. The high incidence in nursing homes and mental institutions led Ronka et al to describe the condition as the "Bedford Syndrome", after the VA institute having a high proportion of psychiatric patients who developed sigmoid volvulus.

A second major etiological factor is the excessive use of laxatives, cathartics and enemas. Naturally, this may mearly represent another manifestation of chronic constipation and prolonged recumbency seen in chronic care facilities. In developing countries, a high fiber diet results in overloading of the sigmoid colon which twists around its mesentery resulting in volvulus.

Rarer conditions predisposing to volvulus include Chagas disease and Hirsprung's disease, both of these conditions result in destruction of the myenteric plexus, and culminate in megacolon. A pelvic mass may displace the sigmoid colon sufficient to cause it to twist. This explains the association of sigmoid volvulus with pregnancy and massive ovarian tumors.

Rarely, an elongated mesocolon may provide excess mobility to the sigmoid colon. This may be a result of abnormal congenital fixation. An interesting association between volvulus of the stomach, splenic flexure of colon and sigmoid colon has been described. The latter association is referred to as a "travelling volvulus". This association probably reflects an uncommon elongation of the mesenteric fixation of intraperitoneal organs.

Classically, sigmoid volvulus is described as occurring in a clockwise direction, although the author is not aware of any reported experience describing the ratio of clockwise to anti-clockwise volvulus. In contrast, and with the same provisos, cecal volvulus is described as occurring in an anti-clockwise direction.

Volvulus of the sigmoid colon occurs in the face of three conditions; 1) Elongation of the sigmoid colon; 2) Narrowing of the base of the sigmoid mesocolon and 3); A torque force to the sigmoid colon, which initiates the torsion process.

The base of the sigmoid mesocolon becomes foreshortened as a result of repeated episodes of torsion. Many of these episodes are subacute and self-limiting, and the patients never seek medical attention. Over 50% of patients presenting with volvulus give a history of previous episodes. As a result of foreshortening of the mesocolon, the narrow base acts as a fulcrum, about which the sigmoid colon may twist. In addition, adhesive bands develop between the two limbs of the sigmoid, creating a paddle-like configuration. This chronic "mesosigmoiditis" is visible in the root of the sigmoid mesentery in most patient in whom a sigmoid volvulus occurs (FIGURE 1). Chronic constipation in Western cultures results in an overloaded sigmoid loop, whose weight provides the momentum to initiate volvulus. In African and Middle Eastern societies, a high fibre diet results in an bulky sigmoid colon which provides the necessary impetus. A shift in the relative positions of the intra-abdominal organs, as seen in pregnancy or in the presence of large pelvic tumors, may shift the relative positions of the intra-abdominal organs and precipitate an episode of sigmoid volvulus.

Sigmoid volvulus has a definite age and sex predilection. In a review by Ballantyne, sigmoid volvulus was more common in men (63.7% of 571 patients), the lower incidence in women being attributed to a wider pelvis. In Western cultures, volvulus is a disease of the sixth decade, but occurs 15-20 years earlier in developing nations. A racial trend was also noted, with 67% of patients being black and 33% white.


 

DIAGNOSIS

The volvulus patient is often debilitated and bedridden. Because of the frequent association with neurologic or psychiatric impairment, a reliable history is often not available. The patient, or their attendant, may give a history of previous episodes of abdominal pain and distension, with the inability to pass flatus. An unknown proportion of these episodes of volvulus are self limiting. With each episode of volvulus, the base of the mesocolon becomes increasingly narrow and therefore predisposed to recurrent bouts. Abdominal distension is frequently massive and characteristically tympanitic over the gas-filled, thin-walled sigmoid loop. Overlying tenderness or peritonism raises the concern of ischemic or perforated bowel. Depending on the extent of ischemia or leakage, systemic toxicity may be apparent.

Diagnosis of sigmoid volvulus is usually obvious from a plain abdominal radiograph, which shows the characteristic "omega" or "inverted loop" sign. In doubtful cases a limited Gastrografin enema will reveal the characteristic "beaked" appearance of the apex of the volvulus in the distal sigmoid.


 

TREATMENT - Resuscitation.

The first priority is resuscitation of the patient. This should be performed in a well staffed facility which is equipped for X-rays, invasive monitoring and rigid sigmoidoscopy. Vomiting and third space fluid loss into the sigmoid colon results in hypovolemic shock which must be corrected with intravenous balanced salt solutions such as Ringer's Lactate. Fluid resuscitation should be initiated before any attempts are made to reduce the volvulus. In the event of inadvertent perforation, the patient will be more adequately perfused and any further delay to optimize the patient's general condition before surgery will be minimized.

Hypovolemic shock may be compounded by sepsis in the presence of ischemic bowel. For the same reasons given above, broad spectrum antibiotics (aerobic and anaerobic) should be given to pre-empt a sigmoidoscopic perforation. The patient is laid in the left lateral position to improve venous return which may be compromised as a result of massive abdominal distension. Oxygen is given, since splinting of the diaphragm impedes respiratory efforts and results in "shunting" of blood through the pulmonary circulation. A foley catheter is inserted to assess fluid balance and a nasogastric tube should be placed if vomiting is a prominent symptom or X-ray reveals significant small bowel obstruction.


 

RATIONALE OF DEFINITIVE TREATMENT

The treatment of sigmoid volvulus has evolved over the past decades from one requiring immediate surgical correction, which carries a high mortality, to one of immediate sigmoidoscopic reduction and elective surgery with its attendant lower mortality. Even from the time of Hippocrates, reduction of the volvulus was attempted using a long suppository "10 digits long" into the rectum. This mode of deflating the volvulus was suggested again in 1859 by Gay in England, but did not gain widespread acceptance until the middle of the next century. In the latter part of the 20th century, percutaneous deflation of the loop using trochars was described by Crisp, who performed his studies in cadavers. Open reduction of the volvulus at laparotomy was first described by Atherton in 1883, although recurrence rates were high (Table 2) and fixation or resection of the sigmoid were attempted. Emergency resection carried a mortality rate of well over 50% (Table 3), and sigmiodopexy was found to have a high rate of recurrence (Table 4). The failure of sigmiodpexy was illustrated during re-exploration of the abdomen for recurrent volvulus, which often revealed little evidence of the attempted fixation. In 1947 Bruusgaard revived the technique of transanal deflation using sigmoidoscopy. By providing the means of averting the high mortalities incurred by urgent laparotomy, it was with relief that sigmoidoscopic decompression gained widespread acceptance. More recently the use of the flexible sigmoidoscope or colonoscope provides a further weapon in the armamentarium of the surgeon attempting nonoperative reduction of the sigmoid loop.

After successful endoscopic deflation, the question then arises, whether or not subsequent surgery is required. Simple deflation, without operative fixation or resection is followed by subsequent episodes of volvulus in over half the patients, with its own attendant complications and mortality. Elective resection, during the same hospital stay is advocated by Bak, who cites a 6% operative mortality, compared to a mortality of 30% from recurrent episodes of volvulus (Table 5).

These statistics are disputed by Arnold et al, who cite an operative mortality of 15% from resection after the first episode, yet a lower mortality (9%) from recurrent episodes of volvulus requiring surgery. The authors further stratified their patients according to age (< 70, and > 70 years of age) and found, not surprisingly, that two thirds of the deaths occurred in the older population. They concluded that resection should be performed after the first episode only in patients under 70 years of age, and in patients older than 70, resection should be deferred until the second or subsequent episode. The lower operative mortalities for recurrent episodes was attributed to an increase in the blood supply as a result of recurrent episodes of volvulus.

The experience of Arnold et al can be interpreted another way. The elderly (> 70 years old) debilitated patient may not live long enough to develop another episode of volvulus, and this subgroup remove themselves from the equation. Yet the less drbilitated septuagenarians may survive long enough to experience one or many further episodes. If resection is performed only in this healthier subgroup, the operative mortality will naturally be lower. Candidates for elective resection should therefore be selected not only on basis of greater or less than 70 years of age, but on the usual cardi-respiratory and metabolic criteria which determine fitness for surgery. It is very unlikely that patients above the age of 70 in reasonable health will benefit from recurrent episodes of volvulus, not to mention the humanitarian and financial burden placed on them from repeated admissions to hospital. In addition, it is difficult to define a "first" episode of volvulus, since many patients (circa 50%) give a history of similar, self resolving episodes in the past.

In the past 2 years, another historic treatment for sigmoid volvulus has gained popularity, with the renewed description of percutaneous deflation of the sigmoid loop by Salim. The authors describe a 100% success rate using percutaneous deflation of the sigmoid loop, followed by peranal intubation and elective band sigmiodopexy. This regime was attended by a 0% mortality and 5% morbidity, compared with a 13% morbidity and 13% mortality with conventional sigmoidoscopic reduction and elective sigmoid resection.

The recent explosion of laparoscopic surgery provides another dimension to the evolving treatment of sigmoid volvulus. Although laparoscopic intervention, in its current mode, will not play a role in reduction of the acute volvulus, its use in elective resection of the redundant sigmoid loop may be facilitated by anatomic considerations. The base of the mesocolon is foreshortened and contracted, so facilitating its mobilization and division. The mobile nature of the sigmoid loop itself may also facilitate its mobilization and reduce the risk of damage to adjacent structures. Lastly, the close apposition of the proximal rectum and distal left colon (as a result of the shortened mesosigmoid) may facilitate the performance of a stapled end-to-end anastomosis.


 

SIGMOIDOSCOPIC REDUCTION.

With the patient in the left lateral position, a rigid sigmoidoscope is advanced into the rectum under direct vision, with using adequate illumination. Air is insufflated into the rectum at frequent intervals. This assists in identifying the apex of the volvulus and, by expanding the rectal ampulla, helps prevent inadvertent perforation. Occasionally the air pressure itself may reduce the twist. The apex of the volvulus is identified by a spiralling of the rectal mucosa, which is often edematous. The tip of a well-lubricated #32 rubber rectal tube is pushed gently into the apex of the spiral and advanced into the obstructed segment. If initial attempts are unsuccessful, use a larger, not smaller, diameter tube and apply constant pressure at the apex. Try moving the patient into alternate positions, such as the knee-elbow position, if the patient's condition permits. This allows the colon to fall away and open up the angle of the volvulus. Do not be tempted to push a narrow, rigid probe into the apex, as this will perforate the already compromised bowel wall. If visibility is poor, place the end of the sigmoidoscope directly on the apex and, without moving the sigmoidoscope, slide the tube up the scope and the tip will then lie at the apex. Never use undue force and never probe blindly. There will be no doubt when decompression has been achieved. A polythene-lined bucket should be on hand to avoid unnecessary spillage from the sudden, forceful rush of gas and liquid stool.


 

SURGERY FOR SIGMOID VOLVULUS.

The timing and nature of surgery for sigmoid volvulus are determined by two main factors: Firstly, suspected presence of ischemic or necrotic bowel and ; second success or failure of sigmoidoscopic reduction.

Suspected ischemic or necrotic bowel.

The suspicion of ischemic or necrotic bowel mandates laparotomy and resection of the compromised segment. This will usually take the form of a Hartmann's resection, since the distal margin at the rectosigmoid junction is usually too short to permit its mobilization onto the anterior abdominal wall as a mucous fistula.

Successful sigmoidoscopic reduction.

Sigmoidoscopic decompression is successful in over 90% of cases. Decompression should be confirmed radiologically and the rectal tube taped securely to the buttocks. Retorsion occurs in up to 50% of unoperated patients, and elective surgery should be performed during the same admission. In the interim, the patient can be further stabilized and assessed for surgery. A mechanical bowel prep is given and broad spectrum antibiotics administered, irrespective of the planned procedure. This allows for a change in tactics (sigmoid resection, instead of planned sigmiodopexy) if the need arises.

Laparotomy for sigmoid volvulus.

The patient is placed in Lloyd Davis stirrups. The marginal loss of elbow-room for the surgeon and his assistants is more than made up for by the ability to pass an EEA stapler per anum, if an unexpectedly low anastomosis is necessary. Both abdomen and perineum are prepped separately in the standard fashion. The perineum remains draped until it becomes necessary to pass the stapling device. Low midline incision is mandatory to provide necessary exposure and reduction of an often enormously dilated sigmoid loop. The first priority is to reduce the volvulus. The sigmoid colon generally twists in an anti-clockwise direction.

If the colon is clearly viable, the surgical options are sigmoidopexy or resection. If the colon appears ischemic, apply warm packs and wait for a timed five minutes. In the presence of frank gangrene or nonviable bowel, resection is mandatory. Several options are open; 1) Paul Mickulitz exteriorization and resection, 2) Hartmann procedure, 3) resection and primary anastomosis.

Colopexy

Several techniques of colopexy have been described. The simplest involves suturing the sigmoid colon to the lateral abdominal wall using interrupted sutures. More elaborate methods include enclosing the sigmoid in a lateral retroperitoneal "pouch"; plicating the mesentery (mesenteropexy); Gortex banding of the sigmoid colon to the abdominal wall; and sigmoid colostomy. All these techniques have recurrence rates similar to unoperated patients are often more time consuming than a simple resection.

Resection: Sigmoid Colectomy

This provides the simplest approach and has the lowest rates of re-volvulus.

How Much To Resect?

As a result of foreshortening of the mesentery, the peritoneal reflection of the rectum and the descending colon are brought into close proximity. Recurrence rates are lowest after simply resecting the omega loop of the sigmoid and more extensive resections are unnecessary. The inferior mesenteric artery is divided at its most accessible location, since this is a benign disease process. The remaining blood supply is divided up to the edge of the colon, so as not to compromise viability of the suture line. The sites of transection are chosen to allow a well-perfused, tension-free anastomosis.

Failed Sigmoidoscopic Reduction or Suspected Ischemic Bowel

Paul Mickulitz Resection

This involves exteriorization of the nonviable segment through a lateral oblique incision. The sigmoid loop is amputated distal to crushing clamps. A double barrelled colostomy is fashioned using interrupted all-coats bowel to subdermal sutures. A few interrupted sutures are placed between the two adjacent limbs of the colostomy. This is of largely historic interest, as the distal stoma is usually too short to allow exteriorization.

Hartmann's Procedure

Exteriorization of the proximal colon and closure of the rectal pouch may be necessary if the viability of the bowel beyond the limits of resection is in doubt. Prior perforation of the sigmoid and significant peritoneal soiling would also make this the procedure the operation of choice. A primary anastomosis in this setting carries a high incidence of anastomotic leak. Resection and Primary Anastomosis

In selected patients this has resulted in satisfactory outcome with low leak rates. Absence of peritoneal soiling and viable bowel ends are prerequisites.

LAPAROSCOPIC SURGERY FOR SIGMOID VOLVULUS

The role of laparoscopic surgery for sigmoid volvulus is not yet defined. Since the abdomen is often already massively distended during the acute stages of the volvulus, laparoscopic procedures are impracticle. After sucessful sigmoidoscopic decompression, stabilization of the patient and aa adequate bowel prep, elective resection of the sigmoid colon may have a role. Two factors make this procedure an attractive adjunct to the surgical armamentarium. First, the patients are generally elderly and debilitated and would potentially benefit to a large degree from minimally invasive surgery. Second, the long sigmoid mesocolon seen in sigmoid volvulus lends itself to easy laparoscopic mobilization of the redundant omega loop. Furthermore, the base of the mesocolon is foreshortened, so the proximal and distal ends of the colon are easily brought together, so facilitating a stapled primary anastomosis. Two techniques can be used for elective laparoscopic-assisted sigmoid resection in patients in whom the volvulus has been non-operatively reduced.

Laparoscpoic-assisted Sigmoid Resection with a Side-to-side Functional End-to-end Anastomosis. In patients that have severe scarring of the root of the sigmoid mesentery from chronic mesi-sigmoiditis, intracorporeal division of the sigmoid vessels is difficult. In addition, the long redundant sigmoid colon makes exposure of these vessels problematic. In these patients, a modification of the Paul-Mikiculitz resection is easily accomplished.

The patient undergoes a standard mechanical and antibiotic bowel preparation. In the operating room, the patient is placed in a supine position with legs supported by Lloyd-Davies stirrups. The lower legs are wrapped with pneumatic compression boots. After induction of general endo-tracheal anesthesia, a nasogastric tube and urinary catheter are inserted. The abdomen is prepared and draped in a sterile fashion. The patient is dropped into deep Trendelenberg position. A carbon dioxide pneumoperitoneum is established with a Veress needle inserted in a supraumbilical position. The Veress needle is re-placed with a 10 mm trocar. the abdomen is inspected with the 10 mm 0 degree laparoscope. Four additional 10 mm trocars are inserted: two in the right lower quadrant and two in the left lower quadrant (FIGURE 2).

The small bowel is pulled out of the pelvis with grasping instruments. The deep Trendelenberg position causes the small bowel to roll up towards the diaphragm. From the right side of the patient, the assistant surgeon inserts two Endo-Babcockstm (United Sytates Surgical Corporation, Norwalk, CT) and grasps the distal sigmoid colon and proximal rectum. He retracts them medially and anteriorly. This exposes the left iliac vessels and the root of the sigmoid mesentery (FIGURE 3). If the adhesions are scant or moderate in density, the rectum and distal sigmoid mesentery are divided intra-corporeally and an end-to-end anastomosis is constructed (see below). If the mesosigmoiditis is severe, the resection is accomplished extra-corporeally.

In patients with dense adhesions, the rectosigmoid and descending colon are mobilized. The surgeon, on the left side of the patient, uses Endo-Shearstm (United States Surgical Corporation, Norwalk, CT) and a grasping instrument to incise the retroperitoneum (FIGURE 4). The left ureter is exposed. The retroperitoneal incision is extended down the left side of the pelvis and then up the left gutter. The rectum, sigmoid and descending colon are bluntly swept medially using the shafts of the Endo-Shearstm. The rectum and descending colon are mobilized enough that they can be pulled up to the abdominal wall for construction of an extra-corporeal anastomosis.

The surgeon and assistant surgeon trade sides. The retroperitoneum of the sacral promintory is incised with electr-cautery scissors. This gives the rectosigmoid additional mobility. Dissection is continued until the rectosigmoid can be elevated easily upto the plan site of incision in the left lower quadrant.

An Endo-Babcocktm is inserted through the caudad trocar in the left lower quadrant and used to grasp the apex of the sigmoid loop. The trocar is pulled out of the abdominal wall over the shaft of the Babcock (FIGURE 5). A transverse incision about 1.5 inches in length is made through the trocar site. The apex of the sigmoid colon and then the entire sigmoid loop is pulled through the incision (FIGURE 6).

Two enterotomies are made in the antimesenteric sides of the proximal rectum and distal descending colon. A GIA 60tm (United States Surgical Corporation) is inserted through the enterotomies and used to construct a side-to-side, functional end-to-end anastomosis (FIGURE 7). The staple line is inspected for hemoorhage. The edges of the enterotomy are apposed with Allis clamps and closed with a TA 90tm (United States Surgical Corporation) stapling device (FIGURE 8). The sigmoid mesentery is included within the staple line. Thus, firing the stapling device both closes the enterotomy and ligates the sigmoid mesentery. Care is taken that the inferior mesenteric vessels are not injured. This will ensure an excellent blood supply for the colorectal anastomosis. The sigmoid colon and sigmoid mesentery are resected and handed off the field. The specimen is opened within the operating room by a surgical pathologist.

The anastomosis is dropped back into the abdomen. The abdomen is liberally irrigated through the incision with warmed saline. This facilitates removal of any clots which have accumulated within the operative field. The incision is closed with interrupted sutures. The pneumoperitneum is re-inflated. The anastomosis is scrutinized. The colon is traced proximally to make sure that a volvulus was not generated during construction of the anastomosis. A colonoscope is passed transanally to examine the anastomosis (FIGURE 9). The colon is insufflated and checked for evidence of leaks.

The trocars are removed one at a time. The fascial defects are closed with interrupted sutures. The skin edges are apposed with skin staples. Band-Aids (Johnson & Johnson, Inc.) are applied over the wounds.

Laparoscopic Sigmoid Resection with End-to-End Anastomosis. In patients with little scarring of the sigmoid mesentery, a more standard-type of sigmoid resection can be accomplished. The patient is prepared and positioned as described above. The pneumoperitoneum is insufflated. Five 10 mm trocars are inserted as shown in Figure 2. The retroperitneum is incised and the left ureter identified. The proximal rectum, sigmoid and descending colon are mobilized medially. The retroperitoneum on the right is incised over the sacral promintory. The presacral space is entered between the fascia propria and the retrorectal (Waldeyer's) fascia. The inferior mesenteric and superior hemorrhoidal vessels are identified.

The feasibility of exposing the distal sigmoid branches is assessed. The redundancy of the sigmoid colon and limited space for retraction within the abdominal cavity make this difficult. If this proves inadequate, an extra-corporeal resection is performed (see above). If visualozation is satisfactory, intracorporeal transection of the proximal rectum and division of the distal sigmoid branches is performed.

The assistant surgeon grasps the proximal rectum on either side of the planned point of transection with two Endo-Babcockstm. The caudad 10 mm trocar in the right lower quadrant is replaced with a 12 or 15 mm trocar. The rectum is transected and closed with multiple applications of the Endo-GIA 30tm (United States Surgical Corporation) or a single firing of the Endo-GIA 60tm (United States Surgical Corporation) (FIGURE 10). The staple lines are inspected for hemorrhage.

Traction on the two rectal staple lines exposes the proximal rectal and distal sigmoid mesentery. The mesenteric vessels are divided between clips or with serial applications of the Endo-GIA 30tm stapling device using white vascular cartridges. The inferior mesenteric and superior hemorrhoidal vessels are carefully preserved since the blood supply of the anastomosis will be based on these vessels. Division of the sigmoid branches continues while exposure is satisfactory.

An Endo-Babcocktm is inserted through the caudad trocar in the left lower quadrant. The trocar is pulled out of the abdominal wall over the shaft of this instrument. An one inch transverse incision is made through this trocar site. The end of the specimen and then the entire sigmoid colon is pulled through the incision. Any remaining proximal sigmoid vessels are divided between clamps and ligated (FIGURE 11).

The point of proximal resection is selected. The mesenteric fat is cleared for a distance of one inch around the circumference of the colon at this point. The Automatic purse-string devicetm (United States Surgical Corporation) is fired (FIGURE 12). The colon is transected. The specimen is opened within the operating room. The diameter of the colon is sized. The anvil-shaft assembly of the Premium CEEAtm stapling device is inserted into the lumen of the colon (FIGURE 13). The low profile anvil and modified shaft are used. The modified shaft has an additional groove which facilitates grasping of the shaft with an Endo-Bacocktm. The purse-string is tied and the bowel is placed back into the abdomen. The tip of the anvil-shaft assembly is positioned in the pelvis so that it points directly at the rectal stump.

The abdomen is liberally irrigated through the incision. The incision is closed with interrupted sutures. The pneumoperitoneum is re-inflated. The anus is dilated so as to admit four fingers. The head of the CEEAtm is introduced through the anus and advanced up through the rectum. The white trocar tip is screwed out through the previous stapled closure of the rectum. It is lassoed with a pre-tied laparoscopic ligature and withdrawn oout through the 12 or 15 mm trocar. The anvil-shaft assembly is grasped with an Endo-Babcocktm and docked into the orange collar of the cartridge of the Premium CEEAtm stapling device (FIGURE 14). The CEEAtm is screwed closed and fired. It is removed. The donut-like rings of the anastomosis contained within the stapling device are checked. A colonoscope is inserted through the anus and advanced upto the anastomosis. The colon is insufflated and checked for evidence of air leakage under water.

The tocars are removed and the fascial defects closed. The skin edges are apposed with skin staples. Band-Aidstm cover the wounds.


 

CECAL VOLVULUS

Cecal volvulus may be organo-axial (true volvulus) or mesenterico-axial (cecal bascule). The former involves the distal ileum and ascending colon twisting around each other, in much the same way as a sigmoid volvulus. Mesenterico-axial volvulus (cecal bascule) involves the cecum "folding" in an axis at right angles to the mesentery. Cecal volvulus is less common than its sigmoid equivalent (1/7th - 1/10th as common) and its demographic features appear to have changed over the last half-century from a condition of both sexes in the second or third decade, to one affecting predominately females in the sixth decade.

In contrast to sigmoid volvulus, which is usually an acquired condition, cecal volvulus is due to congenital incomplete retroperitoneal fixation of the cecum or ascending colon. In an autopsy study by Anson, over 10% of ascending colons had a mobile mesentery, permitting volvulus to occur. In a further 25% of cadavers, the cecum alone was sufficiently mobile to permit cecal bascule to occur. Further anomalies included undescended right colon, and previous surgical mobilization of the cecum, both permitting sufficient mobility for volvulus.

In contrast to sigmoid volvulus, cecal volvulus is usually described as occurring in a clockwise direction, although no data exists to support this anecdotal observation.

As in sigmoid volvulus, a space-occupying lesion in the pelvis, such as a gravid uterus or an ovarian tumor may precipitate an episode of cecal volvulus, by altering the relative positions of the intra-abdominal organs.


 

DIAGNOSIS

Low intestinal obstruction and a distended, tympanitic abdomen are the hallmarks of cecal volvulus. The diagnosis is rarely made clinically, and only 50% of radiographs show the characteristic "coffee-bean" (cecal volvulus) or "tear-drop" (bascule) appearances. Contrast studies with barium or water soluble contrast risk perforation, due to the extensive insufflation required to get the contrast to the right colon. Water soluble contrast can be delivered via the colonoscope, in the event of diagnostic uncertainty. However, by this stage in the diagnostic work-up, laparotomy will nearly always be required, irrespective of the nature of the obstruction. Diagnostic colonoscopy reveals a cul-de-sac at the hepatic flexure in cases of volvulus, and in cecal bascule, a broad based obstructing fold is seen in the ascending colon. The role of colonoscopy is debatable, since perforation is a hazard, and surgery will usually be required, whatever the findings.


TREATMENT

Reduction of the volvulus.

Detorsion of the cecum and operative fixation or resection are the goals of treatment. Due to its relative inaccessibility, compared to sigmoid volvulus, colonoscopic decompression of the cecum is more frequently unsuccessful and because of its inherent risks is not recommended as a routine.

Percutaneous deflation of the cecum was described in 1987 by Patel et al. The authors used a simple intravenous cannula inserted via an anterior approach. The cecum deflated and the cannula was removed after a few minutes. Spontaneous detorsion occurred and no further surgery was performed. The patient died 3 months later from unrelated causes. Percutaneous deflation of the colon has been successful employed in colonic pseudo-obstruction (Ogilvie's syndrome) via a retroperitoneal approach; however, decompression of a free intraperitoneal cecum must have attendant risks of leakage. Although more experience is required, the procedure may prove to be a useful alternative in poor risk patients.

Fixation or resection?

Surgical options for cecal volvulus in the absence of gangrene include cecopexy, cecostomy and right colectomy. Simple operative detorsion alone is generally considered prone to recurrence, although Andersson found only a 4% recurrence rate after simple operative detorsion (Table 1). Other authors report similar results, but the follow-up period is short and the true incidence of life time re-volvulus is probably higher. Furthermore, due to edema in the bowel wall, simple detorsion often does not completely relieve the obstruction, making resection necessary.

Cecopexy can be achieved by simple suturing of the cecum to the lateral paracolic gutter, or fixation using a peritoneal flap. Recurrence after cecopexy remains a problem: Anderson et al reported a 20% incidence of revolvulus after cecopexy (Table 2). Rabinovici et al found similar recurrence rates (12-13%) after cecopexy and operative detorsion alone. The authors concluded that fixation of the cecum is unnecessary, however a more adequate technique of cecopexy, such as peritoneal flap, is probably what is really required.

Cecostomy as a mode of cecal fixation has received very mixed reviews (Table 3). Jacobs et al describe cecostomy (combined with cecopexy) as "the procedure of choice". In contrast, Rabinovici et al conclude that cecostomy "should be abandoned" because of its high rate of complications such as wound infection, abdominal wall necrosis and leakage. In this series of 561 reported cases of cecal volvulus, recurrence rates, morbidity and mortality were higher than any procedure, including resection. Despite the controversy, cecostomy provides a viable option for decompressing the cecum and providing some degree of fixation in circumstances where resection is inappropriate.

Resection for non gangrenous bowel eliminates the possibility of recurrence. Reported mortality rates, however, vary widely (Table 4). Since the bowel is already completely mobilized resection can usually be performed expeditiously. Resection also offers the distinct advantage that obstructed segment of bowel is removed and cosequently ongoing bacterial translocation is ablated. The authors consider resection as the therapy of choice in patients that can tolerate the procedure.

Resection is required in the presence of non-viable or excessively friable bowel. Resection of the right colon avoids the risks of recurrence and deals definitively with ischemic bowel as a potential source of sepsis. Primary anastomosis should be avoided in the presence of peritoneal contamination from perforation, by the use of a diverting ileostomy. The distal end can be brought out as a mucous fistula or stapled and returned to the peritoneal cavity. Mortality rates for cecal volvulus are primarily determined by the degree of bowel ischemia and vary from 12% for viable bowel and increase almost three fold to 32% in the presence of gangrene.

LAPAROSCOPIC SURGERY FOR CECAL VOLVULUS

As in sigmoid volvulus, there is little experience with laparoscopic surgery for cecal volvulus. Because of the abdominal distension present in the acute stages, it is unlikely that laparoscopic resection will have a significant role in emergent resection. This is because of the risks of perforation of the closed loop during introduction of the cannulae, and the difficulties in maneuvering within the abdomen, in the presence of a dilated thin walled cecum.

After successful colonoscopic detorsion of the loop, however, elective laparoscopic right hemicolectomy has the same potential advantages as in sigmoid volvulus. These include reduction in postoperative ileus and reduced analgesic requirements. The technique is facilitated by the presence of a mobile cecum and ascending colon, minimizing the amount of retroperitoneal dissection required, and close proximity of the proximal and distal sites of anastomosis.


 

VOLVULUS OF TRANSVERSE COLON

This constitutes only 4% of cases of volvulus of the large bowel and affects predominately young females. Predisposing conditions include a long mesocolon, close proximity of hepatic and splenic flexures or hepatodiaphragmatic interposition of the colon (Chilaiditi syndrome). Distal colonic obstruction elongates and expands the transverse colon, with the potential for volvulus.

Treatment includes laparotomy and resection. Detorsion alone is followed by recurrence in 75% of cases. Segmental resection of the transverse colon or extended right hemicolectomy are the preferred options. Elaborate techniques of colopexy are described but the simpler and most reliable option remains resection.


 

VOLVULUS OF SPLENIC FLEXURE

The splenic flexure is the least common site for volvulus in the large bowel. The majority of reported cases are female (2:1, female:male). As in volvulus elsewhere, predisposing conditions are previous abdominal surgery and distal colonic obstruction or megacolon. The options available are detorsion alone, cecopexy with or without colostomy or resection. The rarity of the condition prevents a large surgical experience. On an empiric basis however, resection has the advantage of eliminating recurrent volvulus and removes suspect bowel.


 

REFERENCES

1. Anderson, J.R. and Lee, D. The management of acute sigmoid volvulus. Br.J.Surg. 68:117-120, 1981.

2. Anderson, J.R. and Welch, G.H. Acute volvulus of the right colon: An analysis of 69 patients. World J.Surg.10:336-342, 1986.

3. Arnold, G.J. and Nance, F.C. Volvulus of the sigmoid colon. Ann.Surg.177:527-537, 1972.

4. Bak, M.P. and Boley, S.J. Sigmoid volvulus in elderly patients. Am.J.Surg.151:71-75, 1986.

5. Ballantyne, G.H. Volvulus of the splenic flexure. Dis.Colon Rectum. 24:630-632, 1981.

6. Ballantyne, G.H. Review of sigmoid volvulus. Clinical patterns and pathogenesis. Dis.Colon & Rectum 25:823-830, 1982.

7. Ballantyne, G.H. Sigmoid volvulus: high mortality in county hospital patients. Dis.Colon & Rectum 24:515-520, 1981.

8. Ballantyne, G.H., Brandner, M.D., Beart, R.W.,Jr. and Ilstrup, D.M. Volvulus of the colon. Incidence and mortality. Ann.Surg. 202:83-92, 1985.

9. Ballantyne, G.H. Review of sigmoid volvulus: history and results of treatment. Dis.Colon & Rectum 25:494-501, 1982.

10. Drapanas, T. and Stewart, J.D. Acute sigmoid volvulus. Am.J.Surg.101:70-77, 1961.

11. Farringer, J.L. and Wilson, H. Volvulus of the sigmoid colon. Am.J.Surg.90:588-592, 1955.

13. Gabriel, L.T., Campbell, D.A. and Musselman, M.M. Volvulus of the sigmoid colon. Gastroenterol. 24:378-384, 1953.

14. Hines, J.R., Geurkink, R.E. and Bass, R.T. Recurrence and mortality rates in sigmoid volvulus. Surg.Gynecol.Obstet.124:567-510, 1967.

15. Knight, J., Bokey, E.L., Chapius, P.H. and Pheils, M.T. Sigmoidoscopic reduction of sigmoid volvulus. Med.J.Australia.2:627-628, 1980.

16. Mangiante, E.C., Croce, M.A., Fabian, T.C., Moore, O.F. and Britt, L.G. Sigmoid volvulus. A four-decade experience. American Surgeon 55:41-44, 1989.

17. Pahlman, L., Enblad, P., Rudberg, C. and Krog, M. Volvulus of the colon. A review of 93 cases and current aspects of treatment. Acta Chir.Scand.155:53-56, 1989.

18. Pasch, A.R. and Adams, J.T. Acute volvulus of the sigmoid colon: Current management. Contemp.Surg.26:65-68, 1985.

19. Peoples, J.B., McCafferty, J.C. and Scher, K.S. Operative therapy for sigmoid volvulus. Identification of risk factors affecting outcome. Dis.Colon & Rectum 33:643-646, 1990.

20. Rabinovici, R., Simansky, D.A., Kaplan, O., Mavor, E. and Manny, J. Cecal volvulus. Dis.Colon & Rectum 33:765-769, 1990.

21. Salim, A.S. Percutaneous deflation and colopexy for volvulus of the sigmoid colon: a new approach. J.Royal Coll.Surg.Edin. 35:356-359, 1990.

22. Shepherd, J.J. Treatment of volvulus of the sigmoid colon. Br.Med.J. 1,280-283, 1968.

23. Smith, W.R. and Goodwin, J.N. Cecal volvulus. Am.J.Surg.126:215-222, 1973.

24. Taha, S.E. and Suleiman, S.I. Volvulus of the sigmoid colon in the Gezira. Br.J.Surg. 67:433-435, 1980.

25. Wuepper, K.D., Otteman, M.G. and Stahlgren, L.H. An appraisal of the operative and non operative treatment of sigmoid volvulus. Surg.Gynecol.Obstet.122:84-88, 1966.


 

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