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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 - PowerPoint PPT Presentation
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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 58123287@N00 via Flickr
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
*Image by 66317200@N07 via Flickr
*Image by 35230739@N05 via Flickr
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
*Image by 77814749@N00 via Flickr
*Image by 77814749@N00 via Flickr
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
*Image by 65358032@N06 via Flickr