Sigmoid Volvulus Surgery Prefinal

1. SIGMOID VOLVULUS
GENERALISED ABDOMINAL PAIN
AN OVRVIEW
Collin Zachariah
Prefinal MBBS

2. SIGMOID VOLVULUS
✔ Different causes for generalized abdominal pain
✔ Anatomy of sigmoid colon
✔ Epidemiology
✔ Etiology- Risk Factors
✔ Pathology
✔ Case History
✔ Clinical features- Symptoms & Signs
✔ Differential diagnosis
✔ Investigations
✔ Treatment
✔ Mindmap
✔ Diagnostic Algorithm
✔ Treatment Algorithm

3. SIGMOID VOLVULUS
D/D for Generalised Abdominal Pain

4. Anatomy of Sigmoid Colon
Sigmoid Colon is a hindgut structure
Relations :
Anterior- Urinary bladder,Uterus and upper Vagina
Posterior-Rectum,Ileum and Sacrum
A/S - Sigmoidal artery (br. of IMA)
V/S- Sigmoidal veins (drains into IMV)
N/S- Nerves from inferior mesenteric plexus
Sympathetic-Lumbar splanchnic nerves
Parasympathetic- Pelvic splanchnic nerves
Lymphatic drainage- drain into inferior mesenteric nodes

5. SIGMOID VOLVULUS
Epidemiology
✔ Volvulus occurs when a segment of colon
undergoes twisting along its own mesentery
(mesenterio-axial) resulting in obstruction.
✔ Twisting of 180 degrees results in clinical
obstruction, and further twisting to 360 degrees
causes strangulation with venous gangrene,
ischemia, and eventual perforation.
✔ It is a closed loop obstruction
✔ Common in elderly and those who are taking
neuro-psychiatric drugs
✔ Sigmoid volvulus accounts for 5% of large bowe
obstruction in developed countries. and
10% to 50% in developing countries
✔ This is because of intake of high-fibre diet in
these countries
✔ Patients are often institutionalized and debilitate
due to underlying neurologic or psychiatric
disease and have a history of constipation

6. SIGMOID VOLVULUS
ETIOLOGY-Risk Factors
✔ Higher incidence in developing countries (attributed to
high fiber diets)
✔ Seen mostly in elderly, institutionalized male with
chronic neuropsychiatric conditions
✔ Long pelvic mesocolon
✔ Narrow attachment of pelvic meso-colon
✔ Overloaded pelvic colon- constipation
✔ A loop of bowel fixed at its apex by adhesions.

7. SIGMOID VOLVULUS
PATHOLOGY
✔ The loop of sigmoid colon usually
undergoes twisting in an
anticlockwise direction from one half
to three turns.
✔ As the volvulized segment enlarges,
it becomes trapped in the confines of
the abdominal wall and is unable to
spontaneously detorse.

9. SIGMOID VOLVULUS
Clinical Features- Symptoms & Signs
SYMPTOMS
✔ Abdominal pain (initially left-
sided, later diffuse)
✔ Enormous abdominal
distension (left iliac fossa and
then whole of abdomen)
✔ Obstipation
✔ Hiccough, retching
✔ Vomiting- late feature
SIGNS
✔ Tympanic abdomen
✔ Tyre-like consistency of abdomen
is diagnostic
✔ Empty rectal vault (on digital rectal
exam)
✔ Just distension of abdomen
without tenderness
✔ Viable bowel
✔ Generalised tenderness with
rebound tenderness
✔ Gangrenous bowel
✔ Rigid abdomen
✔ Bowel perforation

10. SIGMOID VOLVULUS
Clinical Features- Symptoms & Signs

11. SIGMOID VOLVULUS
DIFFERENTIAL DIAGNOSIS
✔ Colorectal carcinoma causing
obstruction
✔ Toxic megacolon
✔ Colorectal strictures
✔ Hirschsprung's disease
✔ Caecal volvulus
✔ Paralytic ileus
✔ Ileosigmoid knotting
✔ Ogilvie's disease (colonic pseudo-
obstruction)- Dysfunction of Sacral para-
sympathetic nerves
✔ Acquired megacolon
✔ Giant colonic diverticulum

12. SIGMOID VOLVULUS
INVESTIGATIONS
✔ Blood tests : CBC, Serum Electrolytes
✔ RFT: Blood urea&Creatinine
✔ AXR- Erect is diagnostic
- Coffee-bean appearance
- Bent-inner tube sign
-Omega sign
- Frimann-Dhal sign

13. SIGMOID VOLVULUS
INVESTIGATIONS
✔ Barium Enema:
- Bird’s beak appearance
- Ace of spade sign
✔ Upper end of Barium column
tapers into spirally-twisted
distal sigmoid colon

14. SIGMOID VOLVULUS
INVESTIGATIONS
✔ CT Abdomen:
- whirl sign, which represents
tension on the tightly twisted
mesocolon by the afferent and
efferent limbs of the dilated colon.

15. SIGMOID VOLVULUS
TREATMENT
Indication: Young patients without
signs of Ischemia
✔ Rigid/Flexible Sigmoidoscopy-
negotiate obstruction and
decompress proximal bowel
✔ Risk of recurrence >50%
✔ To prevent recurrence
-Percutaneous endoscopic
sigmoidopexy (Non-resectional)
- Mesosigmoidoplasty
-Sigmoid colectomy( Resectional)
Indication: Old patients with signs of
Ischemia
Exploratory laparotomy
✔ If bowel is viable
- Sigmoidopexy/Sigmoidectomy
✔ If bowel non-viable
- Paul-Mickulicz double barrel
colostomy
- Hartman’s procedure
✔ Never do primary anastomosis in an
emergency scenario for fear of
anastomotic leakage
CONSERVATIVE OPERATIVE
RESUSCITATION
-I.V.Fluids
-Antibiotics
-Bladder
Catheterisat
ion

16. SIGMOID VOLVULUS
TREATMENT
Paul-Mickulicz Double barrel
Colostomy
Hartman’s temporary End-
Colostomy

17. SIGMOID VOLVULUS

18. SIGMOID VOLVULUS
DIAGNOSTIC ALGORITHM

19. SIGMOID VOLVULS
TREATMENT ALGORITHM