Br. J. Surg. Vol. 63 (1976) 961-962

Mesocoloplasty for sigmoid volvulus : a preliminary report R. N. T I W A R Y A N D S . P R A S A D * SUMMARY

A technique of mesocoloplasty for the prevention of recurrence of sigmoid volvulus is described. The maneuvre is simple, and does not open the gut. It can be performed confidently by junior doctors undergoing surgical training and appears to be an eminently safe technique as a routine procedure in any emergency service.

SIGMOID volvulus is a very common cause of lower colonic obstruction in India. Banerjee (quoted by Tambaku, 1970) reported its incidence in Bihar to be as high as 50 per cent. Andersen (1956) observed that 60 per cent of intestinal obstructions occurring in western India were due to sigmoid volvulus, and Shankaran (1972) found that in southern India it was responsible for 50 per cent of cases of acute obstruction. Sigmoid volvulus commonly occurs in people over 50 years of age. A wide pelvis and lax abdominal wall muscles make it uncommon in women. Patients generally belong to the poorer classes. On average the period between the onset of symptoms and presentation is 3 4 days. Generally, these patients give a history of similar attacks which had either resolved spontaneously or after conservative management. Some patients require more than one operation for this condition (Patalay, 1972). In all the patients the sigmoid colon is redundant, the mesosigmoid is long with a very narrow base and in the majority there is a mesocolic fibrous band running from the base towards the apex of the mesosigmoid (Sinha, 1969). A loaded sigmoid colon generally rotates on the axis of this mesocoiic fibrous band. The movement is facilitated by a long mesocolon which has a very narrow base (Fig. 1). Therotation usually takes place in a clockwise direction. When the rotation is partial (180"), spontaneous derotation can occur, or it may be relieved by passing a flatus tube beyond the twist. However, recurrent attacks often occur (Andersen, 1956) even after laparotomy and derotation. Forward (1 966) reported a recurrence rate of 31 per cent, and Sutcliffe (1968) one of 60 per cent within 1 year. In one of these attacks the rotation becomes more acute and conservative management fails. The colon becomes ischaemic, and soon gangrene develops with rupture due to the high intracolonic pressure. Faecal material escapes into the peritoneal cavity, usually with fatal results. Andersen (1956) reported 100 per cent mortality in patients with gangrenous sigmoid volvulus, while Patalay (1972) had a mortality of 83 per cent in his series.

Fig. 1. Redundant sigmoid colon with a long mesocolon and a narrow base. The dotted line shows the incision for mesocoloplasty running through the mesocolic fibrous hand.

Fig. 2. Appearance of the sigmoid after mesocoloplasty. The base of the mesosigmoid has been broadened and the mesocolon has been shortened. The mesocolic fibrous band has been removed. The final appearance of the incision following interrupted stitching is shown.

Clearly, as Wilson et al. (1956) have stated, the successful management of this condition depends upon early diagnosis before gangrene occurs, the early relief of acute obstruction and the prevention of recurrence. Various operative manaeuvres aimed at prevention of recurrence have been advocated (Bhargava, 1947; Patalay, 1972; Tahiliani, 1972). Owings (1952)

* Department of Surgery, Rajendra Medical College Hospital, Ranchi, India. 961

R. N. Tiwary and S. Prasad

favoured elective sigmoid resection, while Dean and Murry (1952), Andersen (1956), Shankaran (1962), Sutcliffe (1968), Sinha (1969) and Tambaku (1970) advocated primary sigmoid resection with end-to-end anastomosis. In our experience most of our patients are reluctant to undergo a second operation once the acute crisis is over and fail to keep their appointment. Primary sigmoid resection is a major procedure, requiring considerable experience which is not always available in an emergency service. Better skills and facilities are mandatory before primary resection can be performed as a routine procedure for sigmoid volvulus. We have therefore adopted a technique of mesocoloplasty which is simple, does not open the colon, can be undertaken with confidence by surgical staff undergoing training and is quick to perform. Operative procedure In the present study there were 12 patients with sigmoid volvulus. After adequate resuscitation, under general anaesthesia, a left lower paramedian incision was made and the volvulus was delivered and reduced. A flatus tube was passed and the distended sigmoid was decompressed. The viability of the sigmoid was confirmed. Attention was then directed to the mesocolic fibrous band on the lateral leaf of mesosigmoid and a longitudinal incision was made in the band, starting from the root of the mesosigmoid and extending to its apex, and the entire fibrous band was excised. The lateral leaf on either side of the incision was mobilized for 2.5-3 cm, separating it from the blood vessels and taking adequate care not to traumatize them. Using 2/0 intestinal catgut the longitudinal incision was stitched in a transverse axis using interrupted stitches. A similar procedure was then carried out on the medial leaf of the sigmoid mesocolon. Before closing the abdomen the sigmoid was inspected for any discoloration. The procedure in effect shortened the long mesosigmoid, broadened the root of the mesosigmoid and removed the mesocolic fibrous band which provided the axis on which the sigmoid rotated (Fig. 2). Postoperatively, the patients were kept on intravenous infusions and nasogastric


suction until the return of bowel movements. The stitches were removed after 10 days and the patients were discharged home after 2 weeks. The period of follow-up on these patients varies from 1 to 18 months. So far there has been no recurrence, nor has any patient complained of undue constipation. Acknowledgement We are grateful to Dr B. Singh, Superintendent, Rajendra Medical College Hospital, for permitting us to publish this series. References (1956) Volvulus in western India. A clinical study of 40 cases with particular reference to the conservative treatment of pelvic colon volvulus. Br. J. Surg. 44, 132-143. BHARGAVA K. P. (1947) Clinical aspects of acute intestinal obstruction. Ind. J . Surg. 9, 60-65. DEAN G. 0. and MURRY J. w. (1952) Volvulus of sigmoid colon. Ann. Surg. 138, 830-840. FORWARD A. D. (1966) Hypokalemia associated with sigmoid volvulus. Surg. Gynecol. Obstet. 123, 3542. of the sigmoid colon. owiNcis J . c. (1952) Vo~vuh~s Ann. Surg. 135, 839. PATALAY v. E. (1972) Volvulus of sigmoid colon. h d . . I Surg. . 34, 157-1 63. SHANKARAN v. (1962) Volvulus in south India. Ind. J . Surg. 24, 785-790. SINHA R. s. (1969) A clinical appraisal of volvulus of the pelvic colon. Br. J . Surg. 56, 838-840. SUTCLIFFE M. M. L. (1968) VOIVUhlS Of the sigmoid colon. Br. J . Surg. 55, 903-910. TAHILIANI N. (1972) Anterior sigmoidopexy for prevention of recurrence in sigmoid volvulus. Ind. J. Surg. 34, 195-198. TAMBAKU N. s. (1970) Primary resection of sigmoid for an acute sigmoid volvulus. Ind. J . Surg. 32, 155159. WILSON H. and DUNAVANT w. D. (1965) Volvulus of the sigmoid colon. Surg. Clin. North Am. 45, 1245-1251. ANDERSEN D. A.

Mesocoloplasty for sigmoid volvulus: a preliminary report.

A technique of mesocoloplasty for the prevention of recurrence of sigmoid volvulus is described. The manoeuvre is simple, and does not open the gut. I...
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