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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

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VOLVULUS

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  1. VOLVULUS DR.M.RAVICHANDRA,M.S ASST.PROF OF SURGERY RIMS,SRIKAKULAM

  2. DEFINITION • A VOLVULUS IS TWISTING OR AXIAL ROTATION OF A PORTION OF BOWEL ABOUT IT’S MESENTRY

  3. 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

  4. TYPES • PRIMARY&SECONDARY • PRIMARY • CONGENITAL MALROTATION OF GUT • ABNORMAL MESENTERIC ATTACHMENTS • CONGENITAL BANDS • SECONDARY • ACQUIRED ADHESION • (OR) STOMA

  5. 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

  6. PREDISPOSING FACTORS • BAND OF ADHESIONS(PERIDIVERTICULITIS) • OVER LOADED PELVIC COLON • LONG PELVIC MESOCOLON • NARROW PELVIC MESOCOLON

  7. 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

  8. *Image by 13304137@N06 via Flickr

  9. *Image by 58123287@N00 via Flickr

  10. PRESENTATION • HX: ABDOMINAL PAIN, DISTENSION,ABSTIPATION,VOMITING OCCURS LATE,HICCOUGH&RETCHING NO FLATUS OR BOWEL MOVEMENTS • EXAM: TYMPANITIC ABDOMEN, DISTENSION, MILD TENDERNESS, PALPABLE MASS

  11. SIGMOID VOLVULUS • “BENT INNER TUBE” APPEARANCE • DILATED SIGMOID LOOP WITH LIMBS POINTING TOWARDS THE RLQ

  12. ZACHARY COPE • THOUGH SOMETIMES IN A PERSON WHO IS FAT THE 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

  13. SIGMOID VOLVULUS • “COFFEE BEAN” APPEARANCE WITH THE TWO TWISTED LOOPS WITH A CENTRAL DOUBLE WALL COMPONENT

  14. *Image by 66317200@N07 via Flickr

  15. *Image by 35230739@N05 via Flickr

  16. BARIUM ENEMA • CONTRAINDICATED IN PATIENTS WITH FREE AIR ON AXR, CLINICAL SIGNS OF PERITONITIS, OR SUSPICION FOR NECROSED BOWEL • BIRD’S BEAK • CAN DECOMPRESS

  17. 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

  18. 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

  19. DELAYED RESECTION WITH PRIMARY ANASTOMOSIS • MORTALITY RATE 8% • OPERATIVE MORTALITY RELATED TO VIABILITY OF BOWEL • VIABLE 12% VS NONVIABLE 53% MORTALITY

  20. 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

  21. 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

  22. 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

  23. X-RAYS • “COMMA” SHAPED • CONVEXITY TOWARD RIGHT AND DOWNWARD • BE - RISK OF PERFORATION WITH GETTING AIR/CONTRAST TO RIGHT COLON

  24. *Image by 77814749@N00 via Flickr

  25. C.T OF CAECAL VOLVULUS *Image by 77814749@N00 via Flickr

  26. MANAGEMENT • DECOMPRESSION WITH COLONOSCOPE • LESS SUCCESSFUL THAN WITH SIGMOID VOLVULUS • EMERGENT OPERATION IF SIGNS OF VASCULAR COMPROMISE

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. *Image by 65358032@N06 via Flickr

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