Sigmoid volvulus treated by mini-incision

Left iliac fossa sigmoidectomy with mechanical anastomosis in the management of uncomplicated sigmoid volvulus: an observational study at Principal Hospital of Dakar, Senegal

Introduction

sigmoidectomy is the definitive treatment of Sigmoid Volvulus (SV). It can be done either by laparotomy or laparoscopy. Our objective was to describe the left iliac fossa sigmoidectomy with mechanical anastomosis recently introduced in our practice, assess our results after 5 years and evaluate its feasibility in our setting.

Methods

we conducted a prospective, descriptive and analytic study on all patients admitted for uncomplicated SV with successful non-surgical decompression and treated by a left iliac fossa sigmoidectomy with mechanical anastomosis. This study was held, from May 2016 to May 2021, at the Visceral Surgery Department of Principal Hospital of Dakar, Senegal. We studied the demographic variables, the data of the preoperative planning (time between sigmoid decompression and surgery, moment of the sigmoidectomy, mechanical bowel preparation or not, type of anesthesia), the peroperative findings (length and diameter of the sigmoid loop), the surgical procedure (the type of staplers used for the mechanical anastomosis, the duration of the operation, incidents or accidents during sigmoidectomy), the immediate and long-term postoperative course.

Results

we collected 53 patients with a mean age of 50 years ± 17. They were 50 men and 3 women. Mechanical colonic preparation was performed in 18 patients (Group 1) and 35 patients did not benefit from a mechanical bowel preparation before surgery (Group 2). The mean length of the sigmoid loop was 74.5cm ± 16.5. The mean diameter of the descendant branch was 7.8cm ± 0.7 for Group 1 and 5.5cm ± 1 for Group 2 with p = 0.01. One linear cutter stapler was used for the side-to-side anastomosis. It was a 100mm in 43% (n=23) of cases. The terminalization of the side-to-side anastomosis was performed with 1 linear stapler in 37 cases, 2 linear staplers in 15 cases and 3 linear staplers in 1 case. The median duration of the operation was 50 minutes for Group 1 and 37 minutes for Group 2 with p = 0.004. Morbidity was nil in Group 1. In Group 2, we had 1 anastomotic leakage and 1 anastomotic stenosis. Mortality was nil in the 2 groups. The mean hospital stay was 5 days ± 3.7. The mean follow-up was 31 months with no recurrence or incisional hernia.

Conclusion

this surgical method is rapid, simple, reproducible and feasible in our setting with a good postoperative course. Colonic mechanical preparation may not be necessary.

Circular Mini-Incision in the Left Iliac Fossa Followed by Purse-String Closure as a Minimally Invasive Approach for the Sigmoid Volvulus: A Technical Note

Introduction: Volvulus of the sigmoid is a common cause of intestinal obstruction in Morocco. It is a serious condition with substantial mortality. Initial endoscopic decompression followed by resection of the redundant colon via laparotomy or laparoscopy is the procedure of choice. Exteriorization of the sigmoid colon through a linear skin incision in the left iliac fossa has been described as an alternative approach for the classic midline incision, with or without laparoscopic assistance, with acceptable results.

Methods: We describe herein a novel, minimally invasive approach for fit patients with non-complicated volvulus sigmoid. This approach consists of a skin-disk incision in the left iliac fossa, exteriorization of the redundant colon, and resection with or without primary anastomosis, followed by a purse-string closure.

Results: A 65-year-old patient with no prior notable medical history, presented to the emergency department with his first episode of sigmoid volvulus. A skin-disk incision was made in the left iliac fossa, exteriorization of the sigmoid was done easily through the incision, and resection and manual anastomosis were done. The closure was made in a purse-string fashion. Recovery was uneventful and the patient was discharged home on the fourth postoperative day. No wound infection was noted and the cosmetic result was satisfactory.

Conclusion: Left iliac skin-disk incision followed by a purse-string closure is an option for approaching the abdomen in the case of sigmoid volvulus. It has been demonstrated that this technique helps reduce wound-related complications in patients undergoing stoma reversal. Authors suggest that cosmetic results are better and the incidence of surgical site infection can be lower with this technique as compared to the classic linear skin incision. Results, however, should be confirmed by larger studies.

Risk factors affecting failure of colonoscopic detorsion for sigmoid colon volvulus: a single center experience

PURPOSE

Colonoscopic detorsion (CD) is the first treatment option for uncomplicated sigmoid volvulus (SV). We aim to examine the factors affecting the failure of CD.

METHODS

The files of patients, treated after diagnosis of SV between January 2015 and September 2020, were retrospectively reviewed. Patients' demographic data, comorbidities, endoscopy reports, and surgical and other treatments were recorded. Patients were divided into two groups, as the successful CD group and unsuccessful CD group. The data were compared between the groups, and multivariate analysis of statistically significant variables was performed.

RESULTS

There were 21 patients in the unsuccessful CD group and 52 patients in the successful CD group. The unsuccessful CD rate was found to be 28.76%; this is likely a function of more neuropsychiatric disease, more accompanying sigmoid diverticulum, previous abdominal surgery, abdominal tenderness, onset of symptoms for more than 48 h, higher mean intra-abdominal pressure (IAP), IAP over 15 mmHg, larger mean diameter of the cecum, the cecum diameter over 10 cm, and higher mean C-reactive protein (CRP) values as statistically significant. In the multivariate analysis, previous abdominal surgery and cecum diameter over 10 cm were seen as predictive factors for failure of CD (p=0.049, OR=0.103, and p = 0.028, OR=10.540, respectively).

CONCLUSIONS

CD failure rate was significantly associated with previous abdominal surgery and a cecum diameter over 10 cm. We found that patients with these factors will tend to need more emergency surgery.

Uncomplicated Sigmoid Volvulus Is Ideal for Laparoscopic Sigmoidectomy With Transrectal Natural Orifice Specimen Extraction

INTRODUCTION

Natural orifice specimen extraction is the next step in minimally invasive colorectal surgery but can be technically challenging, with additional risks, especially for oncologic surgery. For several key reasons, sigmoid volvulus is well suited for natural orifice specimen extraction surgery. We describe our method and experience with double-stapled anastomosis transrectal natural orifice specimen extraction for sigmoid volvulus.

TECHNIQUE

Using 3- or 4-port laparoscopy, the mesentery is separated from the long sigmoid loop. After the distal bowel is tied off and washed out, the rectum is completely transected and the proximal bowel delivered transrectally through a wound protector. Proximal transection is performed externally, and the circular stapler anvil is set before the bowel is returned into the abdominal cavity. The rectum stump is closed with an endoscopic linear stapler, and a circular-stapled anastomosis is performed.

RESULTS

After successful endoscopic decompression, 6 patients underwent elective laparoscopic sigmoidectomy with natural orifice specimen extraction for volvulus at China Medical University Hospital from 2015 to 2020. The median operative time was 179 minutes (range, 151-236 min). No intraoperative complications were encountered. The median postoperative length of stay was 4 days (range, 2-9 d). One patient experienced postoperative small-bowel ileus resulting in readmission. The median follow-up duration was 12 months (range, 2-49 mo). One recurrence of volvulus was recorded 27 months postsurgery.

CONCLUSION

Uncomplicated sigmoid volvulus can be treated effectively with sigmoidectomy and natural orifice specimen extraction. Surgeons who attempt this procedure should be well versed with conventional laparoscopy but do not necessarily need to be experienced with natural orifice specimen extraction for successful surgery.

Risk factors affecting failure of colonoscopic detorsion for sigmoid colon volvulus: a single center experience

PURPOSE

Colonoscopic detorsion (CD) is the first treatment option for uncomplicated sigmoid volvulus (SV). We aim to examine the factors affecting the failure of CD.

METHODS

The files of patients, treated after diagnosis of SV between January 2015 and September 2020, were retrospectively reviewed. Patients' demographic data, comorbidities, endoscopy reports, and surgical and other treatments were recorded. Patients were divided into two groups, as the successful CD group and unsuccessful CD group. The data were compared between the groups, and multivariate analysis of statistically significant variables was performed.

RESULTS

There were 21 patients in the unsuccessful CD group and 52 patients in the successful CD group. The unsuccessful CD rate was found to be 28.76%; this is likely a function of more neuropsychiatric disease, more accompanying sigmoid diverticulum, previous abdominal surgery, abdominal tenderness, onset of symptoms for more than 48 h, higher mean intra-abdominal pressure (IAP), IAP over 15 mmHg, larger mean diameter of the cecum, the cecum diameter over 10 cm, and higher mean C-reactive protein (CRP) values as statistically significant. In the multivariate analysis, previous abdominal surgery and cecum diameter over 10 cm were seen as predictive factors for failure of CD (p=0.049, OR=0.103, and p = 0.028, OR=10.540, respectively).

CONCLUSIONS

CD failure rate was significantly associated with previous abdominal surgery and a cecum diameter over 10 cm. We found that patients with these factors will tend to need more emergency surgery.

Left iliac fossa mini-incision sigmoidectomy for treatment of sigmoid volvulus. Case series of six patients from Qatar

BACKGROUND

Midline laparotomy is the definitive treatment for sigmoid volvulus after initial colonoscopic detorsion. We successfully adopted another technique at our center on 6 patients, treating sigmoid volvulus by left iliac fossa mini-incision.

PRESENTATION OF CASES

We report our experience of six non-consecutive cases of sigmoid volvulus treated by left iliac fossa mini-incision. The cases were a 33 year old Egyptian female, a 21 year old Bangladeshi male, a 58 year old Qatari male, a 30 year old Ethiopian male, a 36 year old Ugandan male, and a 58 year old Indian male. The six cases are unique in the surgical technique employed in their management. This is possibly the second case series of left iliac fossa mini-incision for sigmoid volvulus in the Middle East and North Africa Region.

DISCUSSION

All patients underwent initial colonoscopic detorsion followed by sigmoidectomy and anastomosis. The procedure was successful in treating the volvulus in five patients with no complication or recurrence over a mean follow up of 8 months (range: 1-36 months). One patient required further laparotomy and resection with anastomosis due to incompletely removed sigmoid colon.

CONCLUSIONS

Left iliac fossa mini-incision for sigmoid volvulus is safe, feasible, cosmetically appealing and with low morbidity.

Novel Approach to Treat Uncomplicated Sigmoid Volvulus Combining Minimally Invasive Surgery with Enhanced Recovery, in a Rural Hospital in Zambia

AIM

In sub-Saharan Africa, sigmoid volvulus is a frequent cause of bowel obstruction. The aim of this study was to evaluate the results of acute sigmoid resection and anastomosis via a mini-laparotomy in patients with uncomplicated sigmoid volvulus, following the principles of "Enhanced Recovery After Surgery (ERAS)", in a low-resource setting.

MATERIALS AND METHODS

Patients with uncomplicated sigmoid volvulus were operated acutely, via a mini-laparotomy, according to the principles of ERAS. Intraoperative complications, duration of operation, morbidity, mortality and length of hospital stay were evaluated, retrospectively.

RESULTS

From 1 March 2012 to 1 September 2017, 31 consecutive patients were treated with acute sigmoid resection and anastomosis, via a mini-laparotomy. There were 29 men and 2 women, median age 57 (range 17-92) years. Patients were operated after a median period of 4 (range 1.5-18) hours. The median duration of the operative procedure was 50 (range 30-105) minutes. Two patients died (6.3%). One patient died during an uncomplicated operation. The cause of death is unknown. One patient with a newly diagnosed HIV infection had an anastomotic dehiscence. After Hartmann's procedure, he died on the 17th post-operative day as a result of a HIV-related double-sided pneumonia, without signs of abdominal sepsis. One patient had an urinary retention and 1 patient haematuria after bladder catheter insertion.

CONCLUSION

Acute sigmoid resection and primary anastomosis via a mini-laparotomy for uncomplicated sigmoid volvulus, without preoperative endoscopic decompression is a safe procedure with a low morbidity and mortality.