MANAGEMENT OF

SIGMOID VOLVULUS
DR. ADESIYAKAN ADEDOTUN
 OUTLINE
• INTRODUCTION

• EPIDEMIOLOGY

• RELEVANT ANATOMY

• PATHOPHYSIOLOGY

• PRESENTATION

• MANAGEMENT

• PROGNOSIS

• SPECIAL CONSIDERATIONS

• CONCLUSIONS

• REFERENCES
 “If he doesn’t evacuate for a twist in the bowel and
the phlegm does not find a way out then it shall rot in
the belly”

–Ebers papyrus 1500BC

 INTRODUCTION

• VOLVULUS originates from latin(volvere- to twist)

• Occurs when a segment of the bowel twists around its

mesenteric axis

• In about sixty-three (63) percent of cases the segment is

the sigmoid colon
 Epidemiology (1)
• Male > female ; :

• Commoner in the patients > 50; mean age 70 years

• Volvulus belt ; common in the 3rd and 4th decade

• Patients with psychiatric illness, debilitated and

institutionalized patients with underlying neurologic diseases

• Background GI diseases- crohns disease and chagas disease

• In children - hirshprungs, megacolon, anal stenosis

 Epidemiology(2)
• Udezue et al(1990) reported that sigmoid volvulus was
responsible for as much as 49.8 % (60 of 121)of cases of
large bowel obstruction over 15 years, 95 % had
gangrenous bowel with a mortality rate of 16.7 percent

• Nationwide retrospective study between 2002 and 2010

reported 3,351,152 cases of intestinal obstruction, of
which only 1.9 % was due to sigmoid volvulus with a
higher incidence in males, African Americans, mean age
of 70 and background history of diabetes and
neuropsychiatric disorder.
ANATOMY
PATHOPHYSIOLOGY(
1)
• Etiological factors ;

• A) LONG,DILATED,REDUNDANT,THICK WALLED
sigmoid colon hanging on a LONG mesentery and with the
two limbs closely tethered

• b) the attachment of the mesocolon to the posterior wall is

also NARROW

• Madiba TE et al (durban SA) - study on anatomic

predilection of African and non African fetuses.
 PATHOPHYSIOLOGY
(2)
• Colonic dysmotility :

• Dilation of the sigmoid colon may be due to overloading

with feaces as a result of chronic constipation and
increased ,bulky high residue diet, aganglionic megacolon
or acquired megacolon

• Gama A.H et al in a series in Brazil reported that majority

of the cases of sigmoid volvulus had chagas
 PATHOPHYSIOLOGY(
3)
• The twisting can vary from 90 degrees to 360 degrees in a clockwise or
anti-clockwise direction

• Closed loop obstruction of the sigmoid with secondary simple occlusion of

the bowel proximal to the sigmoid

• Rapid distention of the sigmoid with gas from rapid bacterial putrefaction

• The bowel becomes thickened and edematous if blood supply is cut off
and gangrene sets in

• Translocation of bacteria ,peritonitis ,septic shock and death.

 PATHOPHYSIOLOGY(
4)

• 180 degree. - obstruction

• 360 degree —strangulation

Sigmoid a.k.a
pelvic colon
 CLINICAL
FEATURES(1)
• Patients usually present with features of acute or subacute intestinal obstruction
• History ;
Abdominal pain - lower abdomen, colicky ,severity varies, intermittent or
constant, non radiating with previous history suggestive of minor attacks
Constipation- usually total
Marked abdominal distention- DRAMATIC sometimes enough to cause
respiratory embarrassment
General condition is usually good except when gangrene sets in
Nausea,
vomitting -usually late and ominous
 CLINICAL
FEATURES(2)
• Examination ;

• Distended ,Tenderness on palpation

• There may be emptiness of the left iliac fossa

• Tympanitic

• Severe tenderness ,rebound tenderness, guarding, rigidity,

fever and tachycardia, hypotension points towards the
presence of a gangrenous segment

• DRE - empty rectum

 INVESTIGATIONS

• FBC

• E/U/Cr

• GXM

• RADIOLOGY
PLAIN ABDOMINAL X-RAY

• Bent inner tube

• Absent rectal gases

 CONTRAST STUDIES

Points to the point of proximal obstruction

Birds beak
Bird of prey
Ace of spades sign
 RADIOLOGY

• Whorled appearance
 MANAGEMENT

• The ultimate goal of management is to achieve detorsion

and prevent recurrence

• This starts with an evaluation of the general condition of

the patient for evidence of gangrene , perforation or
peritonitis
 RESUSCITATION
• Intravenous fluids

• Intravenous antibiotics

• Urinary catheter

• Nasogastric tube

• Serial monitoring

• TED stockings

• Supplemental O2 as respiratory embarrassment may ensue

• Transfuse if indicated
 NON -OPERATIVE
Endoscopic detorsion
• Patient is stable with no feature of gangrene

• Patient is prepared for exploration with consent signed

• Rigid or flexible Sigmoidoscopy is done and the apex of the

volvulus is identified as a spiraling of the mucosa

• Well lubricted Rectal tube is gently wriggled through the apex

with a let out of gas

• 18F rectal tube is left in for a few days

• Patient is observed closely

• Elective surgery is planned in the same admission

• In the event of complications or visualized gangrenous bowel

emergency resection of gangrenous segment is done

• Oren et al in a retrospective analysis of 827 patients noticed a

success rate of 78.1 and 78.7 % for rigid and flexible
sigmoidoscopic detorsion respectively with a recurrence rate
of 50 %

• Mortality rate of 0.9 and 0.6 % respectively

• Perforation and reperfusion syndrome

 Operative
• definitive procedure

• Patient is positioned supine ,prophylactic antibiotics ,general

anesthesia ,skin preparation and draping applied

• Peritoneal access could be via a midline incision or left

paramedian

• An assistant could pass a rectal tube which is guided by the

surgeon and maneuvered via the twist with deflation achieved

• Bowel is untwisted
 PROCEDURE

• DESCENDING COLON IS MOVED TO THE MIDLINE

WITH CAREFUL RESECTION OF THE LINE OF TOLDT

• THE DESCENDING COLON IS THUS MOBILIZED

Mobilization of
The descending
colon
• MESSENTERIC DISSECTION IS DONE WITH THE
SIGMOIDAL VESSELS IDENTIFIED AND LIGATED

• SIGMOID IS INSPECTED AND RESECTED

• PROXIMAL AND DISTAL STOMA MUST BE PINK AND

BLEEDING FREELY

• THE DISCENDING COLON IS MOVED INFERIORLY

• RESECTION AND PRIMARY COLORECTAL

ANASTOMOSIS

• HARTMANNS IS DONE
 ISCHAEM
ISCHAEMIC
/VIABLE
ANASTOMOSIS
RECTUM
• Primary resection and anastomoses (PRA) vs hartmanns

• PRA with protective proximal colostomy

• Hughes (1960) -sigmoid volvulus offers a unique pathology for

exercising resection and primary anastomosis on the left colon and
sites two important reasons.

• 1) The wall of the distal part of the colon is hypertrophied which

allows excellent anchorage for the sutures

• 2) The risk of spillage is minimal as the proximal part of the bowel

hardly contains any constipated faeces, probably from a short
period of evacuation prior to complete obstruction.
 HARTMANNS VS RESECTION AND PRIMARY ANASTOMOSIS OUTCOME

RESECTION AND
S/N PRIMARY HARTMANNS
ANASTOMOSIS

MORTALITY
9.9 19.6(18.8 +0.8)
RATE

WOUND
9.3 29.1(24.2 +4.9)
INFECTION

STOMA COMPLICATIONS 10.3

13.9
+ ANASTOMOTIC LEAKS 4.3

003) DEALING WITH SURGICAL OPTIONS FOR BENIGN DISEASES OF THE SIGMOID -salem
• Paucity of extensive randomized control trials makes
concrete decision making difficult. RPA is discouraged
where;

• Difficulty in finding a clear line of demarcation

• presence of skip lesions, severe fecal soilage

• inability to achieve a tension free anastomosis

• hemodynamic instability,

• lack of experience on the part of the operating surgeon to

perform a meticulous anastomosis
• PAUL MICKULICZ PROCEDURE

• MESOSIGMOIDOPLASTY

• DETORSION + SIGMOIDOPEXY

• LAPAROSCOPY
 PROGNOSIS
• AGE > 60 YEARS

• PRESENCE OF COMORBIDITIES

• GANGRENOUS SEGMENT (11-60 %)

• EMERGENCY > ELECTIVE

• PREOPERATIVE SHOCK

• RECURRENCE > 50 % (after 1st);

 SPECIAL
CONSIDERATIONS
• RECURRENCE FOLLOWING RESECTION

• PREGNANCY AND SIGMOID VOLVULUS

• ILEO-SIGMOID KNOTTING

Type 1: Ileum revolves around the sigmoid colon

Type 2: Sigmoid colon revolves around the ileum
Type 3: Ileocaecal portion revolves around the sigmoid colon
Undetermined: Inability to identify an active and passive component.
 CONCLUSION

• Sigmoid volvulus is a major cause of intestinal obstruction

with catastrophic outcome, if appropriate intervention is
not instituted.

• Resuscitation ,Endoscopic detorsion and emergency or

elective sigmoidectomy usually with primary anastomosis
or hartmanns procedure usually represents the mainstay
of management.
 REFERENCES
• Sabiston text book of surgery,19th edition

• Schwartz principles of surgery,10th edition

• Farquason operative textbook of surgery

• Bailey and love short practice of surgery

• http//goo.gl/Ptolemyforafrica

• http//goo.gl/Uptodatesurgery2018

• Principles of surgery by BAJA,5th Edition

• Annals of gastroenterology 2017

THANK YOU
FOR YOUR ATTENTION