Su rgica I works hop Br. J. Surg. 1992, Vol. 79, May, 435
Laparoscopic fixation of sigmoid volvulus R . Miller, A. M. Roe, W. K. Eltringham and H. J. Espiner Department of Surgery, Bristol Royal Infirmary, Bristol BS2 8HW, UK Correspondence to: Mr H. J. Espiner
Colonic volvulus accounts for 1-2 per cent of cases of intestinal obstruction in western populations’. If conservative measures fail, colectomy is usually the treatment of choice. A case of laparoscopic fixation for a recurrent sigmoid volvulus is reported.
Surgical technique A 75-year-old man was admitted with a 4-day history of abdominal colic, distension and constipation. Abdominal examination revealed gross distension and obstructed bowel sounds but no tenderness. Plain abdominal radiography showed a sigmoid volvulus and the gut was successfully decompressed using a rigid sigmoidoscope. The following day the distension recurred; the patient again underwent endoscopic decompression and a flatus tube was left in situ. O n removal of this tube after 24 h the patient’s symptoms and signs of obstruction recurred. In view of the patient’s age and poor respiratory function laparoscopic fixation of the colon was performed. Under general anaesthesia, pneumoperitoneum was established and a 10-mm cannula and telescope were introduced at the umbilicus. General inspection of the abdomen revealed a huge sigmoid loop with scarring at its base but no other abnormality. The rectosigmoid junction was identified and the colon was followed carefully with gasping forceps to a point under the right tenth rib. A 5-mm port was established there, and the colon was held at that point while the incision was increased to 3 cm to permit the colon to be brought up into the wound. Several silk seromuscular sutures were placed to fix the colon to the inner layer of the rectus sheath. The outer layer of the rectus sheath and skin were then closed and pneumoperitoneum was re-established. The sigmoid loop was then followed from right to left under the transverse colon and a second point of fixation was fashioned in the left upper quadrant. Finally, a third point of fixation was established in the left iliac fossa. The end result is illustrated in Figure 1 . The patient made an uncomplicated recovery and was discharged on the fourth day after operation. He has been followed up for 14 months, remains asymptomatic, and has had no further episodes of volvulus.
Discussion
Acknowledgements The authors are grateful to Gary James, Department of Medical Illustration, Bristol Royal Infirmary for drawing Figure I .
References
There are several options if endoscopic measures fail to decompress a sigmoid volvulus or frequent recurrence becomes a problem. These include sigmoid resection with primary anastomosis, Hartmann’s procedure, resection with exterior-
0007-1323/92/050435-01
ization of both ends ofcolon and suture fixation sigmoidopexy. The laparoscopic approach offers many advantages over laparotomy as it avoids the morbidity associated with a large abdominal wound. It was particularly suitable in the case presented as the patient was elderly and had poor lung function. These advantages must be weighed against the potential risk of recurrence, which is possibly less likely after resection than suture fixation. In conclusion, it has been shown that laparoscopic fixation for sigmoid volvulus is a practical possibility and merits further evaluation, perhaps in the form of a randomized trial uersus resection and primary anastomosis.
0 1992 Butterworth-Heinemann Ltd
1.
Wertkin M G , Aufses AH Jr. Management of volvulus of the colon. Dis Colon Rectum 1978; 21: 40-5.
Paper accepted 18 December 1991
435
Laparoscopic fixation of sigmoid volvulus R . Miller, A. M. Roe, W. K. Eltringham and H. J. Espiner Department of Surgery, Bristol Royal Infirmary, Bristol BS2 8HW, UK Correspondence to: Mr H. J. Espiner
Colonic volvulus accounts for 1-2 per cent of cases of intestinal obstruction in western populations’. If conservative measures fail, colectomy is usually the treatment of choice. A case of laparoscopic fixation for a recurrent sigmoid volvulus is reported.
Surgical technique A 75-year-old man was admitted with a 4-day history of abdominal colic, distension and constipation. Abdominal examination revealed gross distension and obstructed bowel sounds but no tenderness. Plain abdominal radiography showed a sigmoid volvulus and the gut was successfully decompressed using a rigid sigmoidoscope. The following day the distension recurred; the patient again underwent endoscopic decompression and a flatus tube was left in situ. O n removal of this tube after 24 h the patient’s symptoms and signs of obstruction recurred. In view of the patient’s age and poor respiratory function laparoscopic fixation of the colon was performed. Under general anaesthesia, pneumoperitoneum was established and a 10-mm cannula and telescope were introduced at the umbilicus. General inspection of the abdomen revealed a huge sigmoid loop with scarring at its base but no other abnormality. The rectosigmoid junction was identified and the colon was followed carefully with gasping forceps to a point under the right tenth rib. A 5-mm port was established there, and the colon was held at that point while the incision was increased to 3 cm to permit the colon to be brought up into the wound. Several silk seromuscular sutures were placed to fix the colon to the inner layer of the rectus sheath. The outer layer of the rectus sheath and skin were then closed and pneumoperitoneum was re-established. The sigmoid loop was then followed from right to left under the transverse colon and a second point of fixation was fashioned in the left upper quadrant. Finally, a third point of fixation was established in the left iliac fossa. The end result is illustrated in Figure 1 . The patient made an uncomplicated recovery and was discharged on the fourth day after operation. He has been followed up for 14 months, remains asymptomatic, and has had no further episodes of volvulus.
Discussion
Acknowledgements The authors are grateful to Gary James, Department of Medical Illustration, Bristol Royal Infirmary for drawing Figure I .
References
There are several options if endoscopic measures fail to decompress a sigmoid volvulus or frequent recurrence becomes a problem. These include sigmoid resection with primary anastomosis, Hartmann’s procedure, resection with exterior-
0007-1323/92/050435-01
ization of both ends ofcolon and suture fixation sigmoidopexy. The laparoscopic approach offers many advantages over laparotomy as it avoids the morbidity associated with a large abdominal wound. It was particularly suitable in the case presented as the patient was elderly and had poor lung function. These advantages must be weighed against the potential risk of recurrence, which is possibly less likely after resection than suture fixation. In conclusion, it has been shown that laparoscopic fixation for sigmoid volvulus is a practical possibility and merits further evaluation, perhaps in the form of a randomized trial uersus resection and primary anastomosis.
0 1992 Butterworth-Heinemann Ltd
1.
Wertkin M G , Aufses AH Jr. Management of volvulus of the colon. Dis Colon Rectum 1978; 21: 40-5.
Paper accepted 18 December 1991
435
