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The Next Era in GI The Next Era in GI Surgery Surgery BioDynamixTM
AnastomosisThe Colon Ring
Clinical Training Team
BENIGN PATHOLOGYBENIGN PATHOLOGYVolvulusVolvulus
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Sigmoid and Cecal Volvulus – Introduction
• Volvulus - rotation of the gut on its own mesenteric axis.
• Produces partial or complete intestinal obstruction.
• Blood supply is compromised, resulting in intestinal ischemia.
• Venous congestion leading to infarction can occur.
• Arterial supply is rarely compromised.
• Long narrow-based mesentery predisposes to volvulus.
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Sigmoid Volvulus
• The sigmoid is the commonest site of colonic volvulus.
• Accounts for 5% of large bowel obstruction.
• Usually seen in elderly or those with psychiatric disorders.
• Commonest cause of obstruction in Africa / Asia.
• Incidence is 10 times higher than in Europe or USA.
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Clinical Features
• Large bowel obstruction – – Pain– Constipation– Vomiting
• Disproportionate abdominal distension.
• 50% patients have had a previous episode.
• Severe pain and tenderness suggest ischemia.
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Clinical Features
• Plain abdominal x-ray may show a large ‘bean’ shaped loop of large bowel arising from pelvis.
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Sigmoid Volvulus
• Gangrenous loop—
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Management
• Conservative management can be attempted.
• Resuscitation with intravenous fluids is essential.
• Sigmoidoscopy and/or Barium enema can be both diagnostic and therapeutic.
• Obstruction is usually at ~15 cm which, when passed, produces release of flatus and decompression.
• Flatus tube can be inserted and left in place for 2-3 days.
• 80% of patients will resolve with conservative management.
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Management
• If decompression occurs, no emergency treatment is required.
• 50% will develop a further episode of volvulus within 2 years.
• If decompression fails or features of peritonitis occur, the options are:
– Sigmoid colectomy and primary anastomosis.
– Hartmann’s procedure.
– Sigmoidopexy best avoided.
Cecal Volvulus
• Less common than sigmoid volvulus.
• Less likely to result in complete obstruction.
• Usually “flops” upward on its mesentery rather than undergoing a complete rotation (such as with the sigmoid).
• Rarely requires resection.
• May usually be treated with cecopexy (to right gutter).
• Less likely to recur after cecopexy.
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