VOLVULUS

VOLVULUS

DR.M.RAVICHANDRA,M.S

ASST.PROF OF SURGERY

RIMS,SRIKAKULAM

DEFINITION

A VOLVULUS IS TWISTING OR AXIAL ROTATION OF A PORTION OF BOWEL ABOUT IT’S MESENTRY

VOLVULUS

OBSTRUCTION CAUSED BY TWISTING OF THE INTESTINES MORE THAN 180 DEGREES ABOUT THE AXIS OF THE MESENTERY

1-5% OF LARGE BOWEL OBSTRUCTIONS SIGMOID ~ 65% CECUM ~25% TRANSVERSE COLON ~4% SPLENIC FLEXURE

TYPES

PRIMARY&SECONDARY PRIMARY

CONGENITAL MALROTATION OF GUT ABNORMAL MESENTERIC ATTACHMENTS CONGENITAL BANDS

SECONDARY ACQUIRED ADHESION (OR) STOMA

SIGMOID VOLVULUS WORLDWIDE - UP TO 50% OF

OBSTRUCTION INDIA, AFRICA, E. EUROPE

MORE COMMONLY SEEN IN ELDERLY PATIENTS IN WESTERN SOCIETIES

RISK FACTORS CHRONIC CONSTIPATION PSYCHIATRIC PROBLEMS NON-WESTERN SOCIETIES

HIGH RESIDUE DIET

PREDISPOSING FACTORS

BAND OF ADHESIONS(PERIDIVERTICULITIS)

OVER LOADED PELVIC COLON LONG PELVIC MESOCOLON NARROW PELVIC MESOCOLON

THE ACUTE ABDOMEN IN RHYME.ZACHARY COPE,1881-1974

SOMETIMES A BOWEL-COIL GETS OUT OF PLACE

BY TWISTING ROUND A NARROW BASE WITH GRADUAL STRANGULATING OF

THE BLOOD SUPPLY AND DANGER THAT THE AFFECTED

COIL WILL DIE THIS IS AVOLVULUS WHICH YOU

SHOULD LEARN IS FROM THE LATIN-VOLVERE-TO-TURN

*Image by 13304137@N06 via Flickr

http://www.flickr.com/people/13304137@N06

http://www.flickr.com/


PRESENTATION

HX: ABDOMINAL PAIN, DISTENSION,ABSTIPATION,VOMITING OCCURS LATE,HICCOUGH&RETCHING NO FLATUS OR BOWEL MOVEMENTS

EXAM: TYMPANITIC ABDOMEN, DISTENSION, MILD TENDERNESS, PALPABLE MASS

SIGMOID VOLVULUS

“BENT INNER TUBE” APPEARANCE

DILATED SIGMOID LOOP WITH LIMBS POINTING TOWARDS THE RLQ

ZACHARY COPE

THOUGH SOMETIMES IN A PERSON WHO IS FATTHE DIAGNOSIS IS NOT CLEAR AS THAT

TIS THEN YOU GET HELP FROM PLAIN XRAY

WHICH GAS WITHIN THE GUT SHOWED WELL DISPLAY

SO THAT THE COIL YOU SEE IN THE RADIOGRAM

REACHING FROM PELVIS TO THE DIAPHRAGM

SIGMOID VOLVULUS

“COFFEE BEAN” APPEARANCE WITH THE TWO TWISTED LOOPS WITH A CENTRAL DOUBLE WALL COMPONENT



BARIUM ENEMA

CONTRAINDICATED IN PATIENTS WITH FREE AIR ON AXR, CLINICAL SIGNS OF PERITONITIS, OR SUSPICION FOR NECROSED BOWEL

BIRD’S BEAK CAN

DECOMPRESS

MANAGEMENT OF CHOICE

ENDOSCOPIC DECOMPRESSION RIGID OR FLEXIBLE

PROCTOSIGMOIDOSCOPE INSERTED INTO RECTUM

GUSH OF AIR/FECES --> SUCCESSFUL DECOMPRESSION

RECTAL TUBE SUCCESSFUL IN 85-90% OF

CASES RECURRENCE RATE >60% DECREASED RISK FOR BOWEL

NECROSIS IF TREATED EARLY COLON ISCHEMIA,

PERFORATION ELECTIVE RESECTION

OPERATIVE MANAGEMENT FOR SIGMOID VOLVULUS

ELECTIVE RESECTION SAME ADMISSION

EMERGENT LAPAROTOMY OPERATION DEPENDS ON

VIABILITY OF THE BOWEL RESECTION AND

ANASTOMOSIS HARTMANN RESECTION EXTERIORIZATION

RESECTION (PAUL MICKULISZ PROCEDURE)

DETORSION DETORSION WITH

COLOPEXY PERCUTANEOUS

COLOSTOMY PERCUTANEOUS

SIGMOIDPEXY

DELAYED RESECTION WITH PRIMARY ANASTOMOSIS MORTALITY RATE 8%

OPERATIVE MORTALITY RELATED TO VIABILITY OF BOWEL VIABLE 12% VS NONVIABLE 53% MORTALITY

AN ANECDOTE

A FRAGILE LADY IN HER MID 80S SUFFERED ONE EPISODE AFTER ANOTHER BUT EACH TIME SHE WAS THOUGHT UNFIT FOR AN ELECTIVE OPERATION ON A BENIGN CONDITION. AFTER HER 12TH VOLVULUS SHE HAD PROVED HER CASE AND WAS SUBJECTED TO SIGMOIDECTOMY FROM WHICH SHE RECOVERED UNEVENTFULLY AND WAS DISCHARGED AFTER 5 DAYS

CECAL VOLVULUS

LESS COMMON THAN SIGMOID VOLVULUS PARIETAL PERITONEUM FAILS TO CONNECT

WITH THE CECUM AND RIGHT COLON PRESENT IN ABOUT 10% OF POPULATION

INCREASED MOBILITY OF BOWEL, RESULTING IN IT FOLDING ON ITS AXIS OR UPWARD

TORSION OCCURS PROXIMAL TO CECUM RISK FACTORS:

DISTAL OBSTRUCTION, PREGNANCY, ADHESIONS, CONGENITAL BANDS, PROLONGED CONSTIPATION, METEORISM (AIR IN INTESTINES) THAT OCCURS WITH NON-PRESSURIZED AIR TRAVEL

HX: ABDOMINAL PAIN, COLICKY DISTENTION

AXIAL TORSION TYPE TWIST 180-360 DEGREES

ON LONGITUDINAL AXIS OF ASCENDING COLON (DISTAL ILEUM AND ASCENDING COLON)

ASSOCIATED WITH BOWEL COMPROMISE, ISCHEMIA, AND PERFORATION

CECAL BASCULE CECUM FOLDS

ANTERIORLY ON ASCENDING COLON

MAY RESULT IN INTERMITTENT OBSTRUCTIVE SYMPTOMS

X-RAYS

“COMMA” SHAPED CONVEXITY

TOWARD RIGHT AND DOWNWARD

BE - RISK OF PERFORATION WITH GETTING AIR/CONTRAST TO RIGHT COLON



C.T OF CAECAL VOLVULUS

MANAGEMENT

DECOMPRESSION WITH COLONOSCOPE LESS SUCCESSFUL

THAN WITH SIGMOID VOLVULUS

EMERGENT OPERATION IF SIGNS OF VASCULAR COMPROMISE

OPERATIVE MANAGEMENT FOR CECAL VOLVULUS

DETORSION ± APPENDECTOMY

CECOPEXY/LAPAROSCOPIC CECOPEXY SUTURE R COLON TO

LATERAL PARACOLIC GUTTER OR USE LATERAL PERITONEAL FLAP

CECOSTOMY RESECTION

RIGHT COLECTOMY WITH PRIMARY ANASTOMOSIS

RESULTS DETORSION ± APPENDECTOMY

HIGH RATE OF RECURRENCE (NOT COMMONLY DONE ANYMORE)

CECOPEXY DO NOT NEED TO HAVE PREPPED BOWEL RECURRENCE 25%

CECOSTOMY ± CECOPEXY COMBINED PROCEDURE MORE EFFECTIVE IN

PREVENTING RECURRENCE RESECTION

PRIMARY ANASTOMOSIS UNLESS PERITONEAL CONTAMINATION IS PRESENT

TRANSVERSE COLON VOLVULUS LESS COMMON AREA FOR VOLVULUS(4%) ASSOCIATED WITH MOBILE RIGHT COLON,

DISTAL OBSTRUCTION, CHRONIC CONSTIPATION, CONGENITAL MALROTATION OF THE MIDGUT

USUALLY NOT DIAGNOSED PREOPERATIVELY

NO CHARACTERISTIC RADIOLOGICAL FINDINGS EXCEPT COLONIC DILATATION

RESECTION OF TRANSVERSE COLON HIGH RATE OF RECURRENCE IF TREATED WITH

DETORSION ALONE

VOLVULUS NEONATARUM PREDISPOSED BY ARRESTED ROTATION OF GUT

WITH A RESULTANT NARROW MESENTERY OF SMALL BOWEL & CAECUM

SYMPTOMS – VOMITINGS,ABDOMINAL DISTENTION, & DEHYDRATION

AXR REVEALS SIGNS OF DUODENAL OBSTRUCTION LAPAROTOMY REVEALS DISTENDED STOMACH &

COILS OF INTESTINE TORSION IS IN CLOCKWISE DIRECTION OPERATION REDUCTION BY UNTWISTING &

DIVISION OF ANY SECONDARY OBSTRUCTIVE LESIONS LIKE TRANSDUODENAL BAND OF LADD

VOLVULUS OF SMALL INTESTINE OCCURS IN LOWER ILEUM PRIMARY & SECONDARY PRIMARY

SPONTANEOUS IN AFRICANS FOLLOWING CONSUMPTION OF LARGE VOLUME OF

VEGETABLE MATTER SECONDARY

WEST ADHESIONS PASSING TO PARIETIES/FEMALE PELVIC

ORGANS TREATMENT - REDUCTION OF TWIST & TREAT

UNDER LYING CAUSE

VOLVULUS OF STOMACH

ROTATION OF STOMACH AROUND THE AXIS AND 2 FIXED POINTS THE CARDIA & THE PYLORUS

2 TYPES HORIZONTAL(ORGANO AXIAL) M.C VERTICAL(MESENTERIO AXIAL)

USUALLY ASSOCIATED WITH A DIAPHRAMATIC DFEFECT AROUND ESOPHAGUS AND THERE IS PARAESOPHAGEAL HERNIATION

VOLVULUS OF STOMACH CONTD…

TRANSVERSE COLON MOVES UPWARDS TO LIE UNDER THE LEFT HEMIDIAPHRAGM

DURING THIS PROCESS IT TAKES STOMACH ALONG WITH IT

STOMACH& COLON BOTH ENTER THE CHEST THROUGH THE EVENTRATION OF DIAPHRAGM

CHRONIC- DIFFICULTY IN EATING ACUTE MAY PRESENT WITH ISCHAEMIA

VOLVULUS OF STOMACH CONTD…

TREATMENT BOTH OPEN&LAP REDUCTION OF SAC & CONTENTS CLOSURE OF DEFECT IN DIAPHRAGM

WITH MESH SEPARATE STOMACH FROM TRANS.

COLON PERFORM ANTERIOR GASTROPEXY


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VOLVULUS