Laparoscopic management Sigmoid Volvulus
Laparoscopy in the management of closed loop sigmoid volvulus
Teena Cartwright-Terry, S Phillips, GL Greenslade*, AR Dixon
Department of Laparoscopic Colorectal Surgery & Anaesthesia*
North Bristol NHS Trust, Frenchay Hospital,
Bristol, UK. www.bristolsurgery.com
Mr Tony Dixon
Consultant Colorectal Surgeon,
Frenchay Hospital, Bristol, BS16 1LE
Aims: Investigate the feasibility and surgical outcome of elective laparoscopic surgery for acute closed loop sigmoid volvulus.
Method: A prospectively electronic database of colorectal laparoscopic procedures identified 9 consecutive patients with sigmoid volvulus managed by colonoscopic decompression followed by same admission laparoscopic recto-sigmoidectomy.
Results: Between January 2001 and February 2007, 9 patients, ASA I (1), II (4), III (4) with sigmoid volvulus were treated: 7 women. Their age distribution was 37–87yrs (median 64 years). The volvulus was the first episode in one patient, the second episode for 4 and the third (or more) for the remainder. Laparoscopy demonstrated that all 9 patients had a redundant sigmoid and shortened mesenteric pedicle with mesenteric fibrosis. The median operation time was 115min (45-145 minutes). No anastomosis was de-functioned. Post-operative analgesia was provided by parenteral paracetamol (8) supplemented by 10mg oral morphine in one instant; a further patient received morphine via patient controlled analgesia for 36hrs. Complications included: ileus (1), myocardial infarct (1) and wound infection (1). There was one death on day 32 from a brainstem infarct. Seven patients had an uncomplicated recovery. The median post-operative stay was 4 days (2-32 days). Social problems delayed discharge in two patients.
Conclusion: Laparoscopic recto-sigmoidectomy in experienced hands, post colonoscopy decompression, is a good option for a selected group of patients with sigmoid volvulus. Surgical complications are minimal and recovery is quick.
Key words: Laparoscopic colorectal surgery, sigmoid volvulus.
Although endoscopic deflation of the sigmoid loop is well established as the initial treatment of choice for a sigmoid volvulus, controversy remains as to whether or not patients should then undergo elective surgery and whether or not this should be resectional. Traditional opinion dictates that resection is mandatory as lesser procedures are associated with a high incidence of recurrence. In cases of megacolon, subtotal colectomy is advised. Elective resection is however, not without risk and caries a mortality approaching 20% with a recurrence of 1.2%1. Whilst, sigmoidopexy is associated with a 50% reduction in 30-day mortality, recurrent volvulus is seen in up to 20%1,2,3 of cases. Percutaneous deflation of the sigmoid loop using a combination of colonoscopy and a percutaneous endoscopic gastrotomy (PEG) kit4, 5,6 has gained some popularity.
The role of laparoscopy in its management is not as yet defined. Two factors however make this an attractive adjunct to the surgical armamentarium. First, the patients are generally elderly and debilitated and as a group would potentially benefit from the minimally invasive approach. Second, the long sigmoid mesocolon lends itself to easy laparoscopic mobilisation of the redundant loop. Furthermore, the shortened base of the mesocolon facilitates a stapled primary anastomosis. At present, reports of its use remain scant within the literature7, 8,9,10 and as a technique it clearly needs more critical appraisal.
We describe our up-to date experience of laparoscopic resection for sigmoid volvulus.
Patients & methods
A prospectively collected, institutionally approved password protected electronic database of all colorectal laparoscopic procedures performed between January 2001 and February 2007 has been used to identify surgical outcomes of 9 consecutive patients who have undergone laparoscopic recto-sigmoidectomy for sigmoid volvulus. All followed an initial endoscopic decompression. Patients with megacolon were excluded. The senior author performed (8) or supervised the surgery.
Patients were placed in the dorsi-lithotomy position using Allen stirrups, arms extended by their side and minimal hip flexion. All received single dose gentamicin (4mg/kg) and metronidazole. The surgeon and camera-operator stand on the patient’s right. The peritoneum was accessed using a cut down via a 12mm port sited in the umbilicus. The peritoneal cavity was insufflated to 12mm Hg and a visual inspection performed. A 300 laparoscope was used. 12 and 5mm threaded disposable ports were placed in the right iliac fossa, approx. 10-12cms apart. Exact port placement was dependent on body habitus.
The redundant sigmoid loop was placed and cradled in the pelvis and using gravity as a retractor, the descending colon and root of the sigmoid colon was fully mobilised in a medial to lateral direction using Harmonic (Ethicon EndoSurgery). In general there was no need to fully mobilise the splenic flexure. The inferior mesenteric vessels were ligated between clips (Haem-o-Lok, Wyeth, High Wycombe). The patients were then placed in steep Trendelenburg and the small bowel and sigmoid colon mobilised from the pelvis to allow safe division of the mesorectum. The rectum was then divided using a linear stapler (ATG45 – Ethicon EndoSurgery). The umbilical port was removed and the wound extended (approx 2cm) to allow delivery of the dilated sigmoid loop and its mesentery. The contents of the proximal colon were then decompressed into the sigmoid loop. Where necessary, guarded suction was used to decompress the proximal colon before securing the anvil of a circular stapler (29CDH – Ethicon EndoSurgery) within its lumen. The proximal colon was then returned to the abdomen and the midline closed around the 12mm port using a polydioxanone suture. The anvil was secured to the stapling device introduced through the rectum watching out for the bladder, vagina and any rotation of the bowel. The wounds were finally closed and infiltrated with local anaesthetic. Urethral catheters were removed prior to extubation.
Patients were allowed oral fluids as tolerated, mobilised the same evening and encouraged to take a light diet. Analgesia was provided by intra-operative fentanyl, paracetamol and diclofenac followed by two doses of intravenous paracetamol.
Between January 2001 and February 2007, 9 patients, ASA I (1), II (4), III (4) presented with sigmoid volvulus. There were seven women. Their age distribution ranged between 37 and 87yrs (median 64 years). The volvulus was the first episode in one patient, the second episode in four and the third (or more) for the remaining four individuals. All had undergone prior endoscopic decompression. Laparoscopy demonstrated all 9 patients to have a redundant sigmoid and shortened mesenteric pedicle with mesenteric fibrosis.
The median operation time was 115min (45-145 minutes). There were no intra-operative complications or conversions. No anastomoses were de-functioned. One patient went into acute urinary retention. Post-operative analgesia was provided by parenteral paracetamol (8) supplemented by 10mg oral morphine in one patient; a further patient received morphine via a PCA for 36hrs. Post-operative complications included; small bowel ileus requiring a period of total parenteral nutrition (1), myocardial infarct (1) and a wound infection (1). There was one death on day 32 from a brainstem infarct. Seven of the nine patients had an uncomplicated recovery. The median post-operative length of stay was 4 days (2-32 days). Social problems delayed the discharge of two patients. There were no readmissions.
Laparoscopic colorectal surgery has more than any other laparoscopic procedure created extreme controversy and debate, particularly within the establishment. On reflection this is not surprising given that few specialist surgeons are trained to do it! For those that have been trained, experience and continuous technological innovation has encouraged surgeons to attempt more complex interventions. Our objectives are reduced postoperative pain, early mobilisation, reduced rates of wound sepsis, rapid return of gastrointestinal function, early discharge from hospital, return to normal life and avoidance of incisional hernias. Where there has been no prior incision, laparoscopy offers superior cosmesis.
Open recto-sigmoidectomy for sigmoid volvulus is a major technical challenge with potential for major morbidity and an extended hospital stay. Not forgetting a mortality rate that can approach 20%1. Laparoscopic recto-sigmoidectomy is therefore attractive. It is however a relatively new technique with only a small number of what amounts to little more than case reports7, 8,9 and a solitary series of 14 patients from Taiwan10.
We have demonstrated that laparoscopic resection for decompressed sigmoid volvulus is not only a feasible but also a largely predictable intervention and represents a true alternative to traditional open surgery. Whilst laparoscopic manoeuvres in tortuous and dilated bowel can be difficult, the appropriate use of gravity and the pelvis to cradle the sigmoid can make things relatively straightforward and in our opinion, easier than at laparotomy. However, the fibrosis and neo-vascularisation of the shortened root of the sigmoid colon can make this component of the dissection difficult. The left ureter also tends to lie more medially than one would usually expect. The procedure has minimal morbidity and can result in a short hospital stay, factors to bear in mind given that many of these patients have significant co-morbidity and have a habit of re-presenting on a regular basis.
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