Left iliac fossa mini-incision sigmoidectomy for treatment of sigmoid volvulus: Case series of six patients from Qatar

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ContentslistsavailableatScienceDirect

International

Journal

of

Surgery

Case

Reports

jo u r n al ho me p a g e :w w w . c a s e r e p o r t s . c o m

Case

Series

Left

iliac

fossa

mini-incision

sigmoidectomy

for

treatment

of

sigmoid

volvulus.

Case

series

of

six

patients

from

Qatar

Mahmood

Al

Dhaheri

a

_,

_Mohamed

_Abu

_Nada

a

_,

_Walid

_El

_Ansari

b,c,d,∗

_,

_Mohamed

_Kurer

a

_,

Ayman

Abdelhaﬁz

Ahmed

a

a_Department_of_Colorectal_Surgery,_Hamad_General_Hospital,_Hamad_Medical_Corporation,_Doha,_Qatar b_Department_of_Surgery,_Hamad_General_Hospital,_Hamad_Medical_Corporation,_Doha,_Qatar c_College_of_Medicine,_Qatar_University,_Doha,_Qatar

d_School_of_Health_and_Education,_University_of_Skovde,_Skovde,_Sweden

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received14August2020

Receivedinrevisedform3September2020 Accepted3September2020

Availableonline8September2020 Keywords: Volvulus Sigmoidectomy Mini-incision Laparotomy

a

b

s

t

r

a

c

t

BACKGROUND:Midlinelaparotomyisthedeﬁnitivetreatmentforsigmoidvolvulusafterinitial colono-scopicdetorsion.Wesuccessfullyadoptedanothertechniqueatourcenteron6patients,treatingsigmoid volvulusbyleftiliacfossamini-incision.

PRESENTATIONOFCASES:Wereportourexperienceofsixnon-consecutivecasesofsigmoidvolvulus treatedbyleftiliacfossamini-incision.Thecaseswerea33yearoldEgyptianfemale,a21yearold Bangladeshimale,a58yearoldQatarimale,a30yearoldEthiopianmale,a36yearoldUgandanmale, anda58yearoldIndianmale.Thesixcasesareuniqueinthesurgicaltechniqueemployedintheir management.Thisispossiblythesecondcaseseriesofleftiliacfossamini-incisionforsigmoidvolvulus intheMiddleEastandNorthAfricaRegion.

DISCUSSION:Allpatientsunderwentinitialcolonoscopicdetorsionfollowedbysigmoidectomyand anas-tomosis.Theprocedurewassuccessfulintreatingthevolvulusinﬁvepatientswithnocomplication orrecurrenceoverameanfollowupof8months(range:1–36months).Onepatientrequiredfurther laparotomyandresectionwithanastomosisduetoincompletelyremovedsigmoidcolon.

CONCLUSIONS:Leftiliacfossamini-incisionforsigmoidvolvulusissafe,feasible,cosmeticallyappealing andwithlowmorbidity.

1. Background

Sigmoidvolvulusisthemostcommonformofvolvulus, repre-senting3%–5%ofallacuteintestinalobstructions[1].Itoccurswhen aredundantlongsigmoidcolontwistsaroundanelongated nar-rowmesentery.Thereisdebateastowhethersigmoidvolvulusis congenital,acquired,oracombinationofboth[2].However,a high-ﬁberdiet, advancedage,chronicconstipation,previoussurgery, neurologicorpsychiatricconditionsandmegacolonhaveallbeen identiﬁedaspredisposingfactors[2–4].

Most(85%)colonicvolvuluspresentasanacuteobstruction[5], withabouthalfthepatientsreportingasimilarepisodeinthepast [6].Afterinitialcolonoscopicdetorsion,midlinelaparotomywith sigmoidectomyandprimaryanastomosisisthestandarddeﬁnitive management[1].Recently,thelaparoscopicapproachemergedasa

∗ Correspondingauthorat:DepartmentofSurgery,HamadGeneralHospital, HamadMedicalCorporation,Doha,Qatar.

E-mailaddress:welansari9@gmail.com(W.ElAnsari).

minimallyinvasiveoption.However,ithasitstechnicallimitations duetothedistendedbowel,intoleranceofpneumoperitoneumin comorbidpatients,increasedcosts,anditisnotreadilyavailable, particularlyinlowerincomecountries[7].Inordertoaidthe reduc-tionofmorbidity,aleftiliacfossamini-incisionwasﬁrstdescribed in2014[8],associatedwithsigniﬁcantcostsaving,cosmetically appealingscar,potentiallyimprovedrecoveryandlesspain.We adoptedthismini-incisiontechniqueatourhospitalin2016,and sincethenwehaveoperatedon6casesofsigmoidvolvulusata singlecolorectalsurgerycenter.

Wereportthesesixretrospectivenon-consecutivecasesata singlecentreduetotheuniquenessofthemini-incisionsurgical technique and itsﬁndings, and in orderto debatethepossible advantagesofthistechnique.Thiscaseseriesisinlinewiththe updatedconsensus-basedcaseseries(PROCESS)guidelines[9].

2. Casepresentations

Table1depictsthesummaryofcharacteristicsofthesixpatents. https://doi.org/10.1016/j.ijscr.2020.09.014

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Table1

Summaryofcharacteristicsofthesixpatients.

Characteristic Case1 Case2 Case3 Case4 Case5 Case6

Demographics

Age(years) 33 21 58 30 36 58

Gender Female Male Male Male Male Male

BMI(kg/m2₎ _24.9 _21.32 _23.35 _22.15 _23.54 _28.67

Country Egypt Bangladesh Qatar Ethiopia Uganda India

Presentation Elective,3months

postdelivery

Emergency Emergency Emergency Emergency Emergency

History

Comorbidities Nil Nil Epilepsy,mental

retardation,cataract, hypertension, dyslipidemia

Nil Nil Hypertension

Previoussurgery 3cesareansections Nil Nil Nil Nil Nil

Previous episode/recurrent abdominalpain Recurrent abdominalpain Volvulus5months earlier

Nil Nil Nil Volvulus7months

earlier Pre-operative Allpatientshadsuccessfulcolonoscopicdetorsionanddecompressionwithrectaltubeinsertion

CTﬁndings Notdone Whirlpoolsign Whirlpoolsign Whirlpoolsign Whirlpoolsign Whirlpoolsign

Operative

Procedure Leftiliacfossamini-incisionandsigmoidectomywastechnicallyfeasibleinallpatients

Operativetime(min) 120 90 160 90 90 100

Bloodloss(ml) 20 30 50 20 30 20

Lengthofhospitalstay (days)

4 4 4 4 5 5

Post-operative

Complication/s Nil Nil Persistentvolvulus* Nil Nil Nil

Mortality Nomortalityacrossallpatients,withmeanfollowupof8±SD27months(range:1–36months)

*_Persistent_volvulus_(after₅_days,_during_same_admission)_due_to_incomplete_removal_of_the_redundant_sigmoid_colon.

2.1. Case1

A33yearoldEgyptianfemalewhowas33weekspregnant, pre-sentedtotheemergencydepartmentatourinstitution(Hamad General Hospital, largest tertiary care hospital in Qatar) with abdominal pain,constipation and abdominal distention 2 days. Past history was remarkable for recurrent abdominal pain for around5yearsandpreviouscesareansections.Norelevant fam-ilyhistory.Uponexamination,shewashemodynamicallystable, withdistendedabdomen. Bloodinvestigations were unremark-able. AbdominalX-ray showed severelydilated colon withthe coffeebeansignofsigmoidvolvulus.Shewasadmitted, success-fullyunderwentsigmoidoscopy,detorsionanddecompressionand was discharged home after 3 days. Then, after delivery of the child,shestartedhavingintermittentabdominalpainagain,and3 monthsfollowingtheﬁrstattack,shewasadmittedelectivelyand underwentleftiliacfossamini-incisionsigmoidectomyandwas dischargedonpost-operativeday5.Atonemonthfollowupafter theprocedure,therewerenopost-operativecomplicationsnoted.

2.2. Case2

Apreviouslyhealthy21yearoldBangladeshimalepresentedto theemergencydepartmentatourinstitutionwithabdominalpain fortwodaysassociatedwithconstipationandvomiting.Past his-toryrevealedthathehadanattackofsigmoidvolvulus5months priortothispresentation.Nopasthistoryofsurgery,andno rele-vantfamilyhistory.Uponexamination,hewashemodynamically stable,withdistendedabdomenbutnonperitonitic.Blood inves-tigations were unremarkable. Preoperative CT of the abdomen showeddilatedcolon withthewhirlpool sign, features impres-siveofsigmoidvolvulus.Heunderwentsigmoidoscopy,detorsion anddecompressionwithrectaltube.Onday5postdetorsion,he underwentsigmoidectomyvialeftiliacfossamini-incisionandwas dischargedonpost-operativeday5.Therewerenopost-operative complicationsuponfollowupto36months.

2.3. Case3

A 58 yearold Qatarimale living ina residential homewith medicalhistoryofmentalretardation,cataract,hypertension, dys-lipidemia,andepilepsycontrolledbymedication.Thepatienthad pasthistory ofchronic constipationwhich wasusuallyrelieved by rectal enema. History taken from the accompanying nurse indicatedthathehadconstipationandprogressiveabdominal dis-tentionfor three days.Over the2 days prior tothe admission toourhospital,thepatienthadbecomeirritableand uncooper-ative, andthis wasattributed tohisabdominalpain. Hisblood investigationswereunremarkable.PreoperativeCToftheabdomen showeddilatedcolonwithtwistedmesenteryandthewhirlpool sign,featuresremarkableofsigmoidvolvulus.Heunderwent sig-moidoscopy,detorsionanddecompressionwithrectaltube.Eight days postdetorsion, heunderwent sigmoidectomy vialeft iliac fossa mini-incision. Post operatively, although he did not pass motionsorflatus,hewasstartedonsurgicalfluid,afterwhichhe developedgradualabdominaldistentionoverpostoperativedays 3 and4.Hence apostoperativeCT oftheabdomenwas under-taken and again showed features of sigmoid volvulus. A rectal tube wasinsertedand the distention partiallyimproved. How-ever,heagaindevelopeddistensionandconstipationforwhichhe underwentexploratorymidlinelaparotomyonpost-operativeday 5.Intraoperatively,therewasdilatedcolondistal tothe anasto-moticsite,withabanddiscoveredextendingfromleftcolontothe smallbowelmesenteryaroundwhichtheremainingsigmoidwas twisted.Thisbandwasdivided,andsigmoidectomyofthe remain-ingsigmoidandprimaryanastomosisweredone.Thepatienthad asmoothpost-operativecoursewithopenbowelandwasstarted onregulardietonpost-operativeday4.Onfollowup,hewaswell until29monthspost-surgery,afterwhichhepresentedagainwith abdominaldistensionandconstipationbutpassingflatus.CTofthe abdomenshoweddilatedcolonandsmallintestinewithtransient pointat theanastomoticsite.Heunderwentcolonoscopy anda stricturewasfoundattheanastomoticsitewhichwastreated endo-scopicallywithserialCRETM_Balloon_dilatation_in_three_intervals_up

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to16.5cm.Onfollowup,todate,hewaswellandpassingmotion onbulklaxativeintermittently.

2.4. Case4

A30yearoldEthiopianmalewithnomedicalillnesspresented toouremergencydepartmentwithcolickyabdominalpain and constipationfor3days.Nopasthistoryofsurgery,andnorelevant familyhistory.Uponexamination,hewashemodynamicallystable withdistendedabdomen.Bloodinvestigationswereunremarkable. PreoperativeCToftheabdomenshoweddistensionofcolonwith thewhirlpoolsign, featuresremarkableof sigmoidvolvulus. On thesamedayheunderwentsigmoidoscopy,detorsionand decom-pressionwithrectaltube.Onday3postdetorsion,heunderwent sigmoidectomyvialeftiliacfossamini-incisionandwasdischarged onpost-operativeday4.Atonemonthfollowup,therewereno post-operativecomplications.

2.5. Case5

A36yearoldUgandanmalepresentedtoouremergency depart-mentwith colickyabdominal pain for onedayassociated with vomitingandpassageofloosemotionsfor3days.Nohistoryof medicalillnessorprevioussurgery,andnorelevantfamilyhistory. Uponexamination,hewashemodynamicallystablewithdistended abdomen.Bloodinvestigationswereunremarkable.Preoperative CT of theabdomenshowed twisting of thesigmoidaround its mesenterywith the whirlpool sign, and a massivelydistended proximalcolonwithanair-ﬂuidlevel.Onthesameday,he under-went sigmoidoscopy, detorsion and decompression with rectal tube.Onday5postdetorsionheunderwentsigmoidectomyvia leftiliacfossamini-incision andwasdischarged onpost opera-tiveday5.Attwomonthsfollowup,therewerenopost-operative complications.

2.6. Case6

A58yearoldIndian malewithpresentedtoouremergency departmentwithabdominalpainandabdominaldistentionthat developedgraduallyoverthepastweek.Hehadhistoryofsigmoid volvulus7monthspriortothispresentation,medicalhistory of hypertensioncontrolledwithmedication,andnorelevantfamily history.Uponexamination,hewashemodynamicallystablewith distendedabdomen.Bloodinvestigationswereunremarkable. Pre-operativeCToftheabdomenshowedtwistingofthevesselsand mesenteryofthesigmoidcolon,consistentwithwhirlpoolsign.On thesameday,heunderwentsigmoidoscopy,detorsionand decom-pressionwithrectaltube.Onday5postdetorsion,heunderwent sigmoidectomyvialeftiliacfossamini-incisionandwasdischarged onpost-operativeday5.Atsevenmonthsfollowup,therewereno post-operativecomplications.

3. Surgicaltechnique:leftiliacfossamini-incision sigmoidectomy

Afterinitialcolonoscopic detorsionand decompressionwith insertionofrectaltube,patientswererestartedonoralfluids.Once patientscantolerateoralfluids,allpatientsshouldhavemechanical bowelpreparationandfullcolonoscopytocheckforany pathol-ogy.Onceconfirmationisavailablethatthereisnopathologyin thecolonotherthanthevolvulus,leftiliacfossamini-incision sig-moidectomyandprimaryanastomosisisundertakenlater.

Theprocedureswereperformedbyconsultantswithexperience incolorectalsurgeryofatleast5years.Undergeneralanesthesia, thepatientinsupineposition,aleftiliacfossaskinincisionofabout 5cmwasundertaken(mirrorimageofMcBurneyincision)(Fig.1).

Fig.1.Leftiliacfossamini-incisiononpostoperativeday4(Shortarrow:umbilicus, Longarrowleftanteriorsuperioriliacspine).

Fig.2.Exteriorizationofthesigmoidcolonshowingthemini-incisioninleftiliac fossa.

Theexternalobliqueaponeurosiswasdividedalongitsﬁbersand themuscleswereseparated.Theperitoneumwascarefullyopened withscissors.Thedilatedredundantcolonwasexteriorizedand carefullyinspectedforviability(Fig.2).Acriticalstepwastoensure theretrievalofthewholeredundantcolonproximallyanddistally untiltherectosigmoidjunction,inordernottoleaveanyredundant colonicsegmentwhichcouldlaterpredisposetorecurrenceofthe volvulus(Fig.3).Oncethesigmoidwasexteriorized,the mesen-terywasthendividedinaVshapemanner,andcolonicresection oftheredundantsigmoidcolonwasundertakenleavingawell vas-cularizedproximaland distalpartofthecolonforanastomosis. Re-establishmentoftheintestinalcontinuitywasdonebysideto sideanastomosisusingGIAlinearstapler80[8].

4. Discussion

The initial assessment of sigmoid volvulus comprises an appraisal of signs of perforation, gangrene or peritonitis. For patientswithsignsofperforationorgangrene,animmediate mid-linelaparotomyshouldbeperformed[10]. Forpatientswithout

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Fig.3.Exteriorizationofthewholeredundantsigmoidcolon.

peritonitis,primarytherapyiscolonoscopicdetorsionusinga flex-ibleendoscope,wheresuccessfuldetorsionisachievedin upto 80–90%ofcases[4,6],andmaintainedwiththeinsertionofa rec-taltubeand concomitantresuscitationof thepatient.Detorsion anddecompressionaloneisfrequentlyfollowed bya significant recurrencerate[4,10].Hence,definitiveearlysurgeryshouldbe performed.

Deﬁnitivesurgicalmanagementofpatientswithout peritoni-tisfollowingsuccessfulendoscopicdecompressioniscontroversial. Theclassicaldeﬁnitivesurgicalapproachhasbeenmidline laparo-tomy and sigmoid colectomy with primary anastomosis [10]. But such approach has the disadvantage of colonic resection andpossibleanastomoticleakage.Hence,non-resectionalsurgical approaches,aimedatdecreasingsuchmorbidity havealsobeen described. These include open, laparoscopicor endoscopic sig-moidopexy, as wellas extraperitonealizationof the sigmoidor meso-sigmoidoplasty[11–14].Thesethreealternativeshavebeen usedwithvariablesuccesses,butsuchapproacheshaveamajor drawbackintermsofhigherrecurrencerateofthevolvulus[15].To date,nolargerandomizedcontrolledtrialshavebeenconductedto comparetheeffectivenessofsigmoidcolectomywithprimary anas-tomosisvssigmoidopexy,extraperitonealizationofthesigmoidor meso-sigmoidoplasty.

Thelaparoscopicapproachhasbeenincreasinglydescribedfor sigmoidvolvulusandisgenerallyassociatedwithimproved mor-bidity[16–19].However,someauthorsclaimthatlaparoscopyfor sigmoidvolvulusisunwarrantedasitistechnicallydifﬁcultand toocostly[7,18].Inordertosimplifythetechnicaldifﬁcultiesof laparoscopiccolectomyinsigmoidvolvulus,itwasproposedthat laparoscopybeusedonly tohelpexteriorize thesigmoidcolon throughamini-incisionwithoutpreliminarydissection[17].

However,inourexperience,weobservedthatthereisnoneed foreitheralongincisionorlaparoscopy,asinpatientswith volvu-lus,thesigmoidcolonisquitelong,redundantandrathereasily broughtoutoftheabdominalcavity.Hence,weagreewithothers [8]thatleftiliacfossamini-incisionwithoutlaparoscopyis sufﬁ-cient.Inourinitialexperiencewithsixpatientsduringthepast 2.5years,theprocedurewasstraightforward,andtechnicallyless challengingthan thelaparoscopicapproach. In agreement, oth-ershavesupportedthatthatleftiliacfossamini-incisionwithout laparoscopyhasexcellentresultsand couldalsobeundertaken underlocalanesthesia[8,20,21].Furthermore,intherareeventof failedexteriorization(e.g.,inobesepatients)ofwhichwedidnot encounterany,theprocedurecouldbeconvertedtotheopenor laparoscopicapproach.

Oursixpatientswhounderwentleftiliacfossamini-incision sigmoidectomyandprimaryanastomosisfortreatmentofsigmoid volvuluswereallsatisﬁedandpleasedwiththesmallincisionthat wascosmeticallyappealing.Fromthesurgeons’ side,there was minimalblood loss,decreasedlengthofhospital stayand post-operativeanalgesiawhichminimizedthecosts.Weobservedno complicationswiththismini-incision surgicalapproach, in con-trasttomidlinelaparotomywhichgenerallycarriesa10–30%risk ofincisionalherniaasalatecomplication[22–26].

Oneofourpatients(Case3)hadtobere-operated4daysafter theindexprocedurebyamidlinelaparotomy,duepersistenceof thevolvulusbecausetheredundantsigmoidcolonwasnot com-pletelyresected.Here,wehighlightthecriticalstepofretrieving thewholeredundantproximalanddistalcolon.Thisisanimportant pointinthelearningcurveoftheprocedure.

5. Conclusion

In this case series, we highlightsigmoidectomy for sigmoid volvulusbyleftiliacfossamini-incisionasapossiblealternative totheclassicalmidlinelaparotomy.Itissafe,feasible,cost effec-tive,haslowmorbidity,andcosmeticallyappealing.Althoughthe majorityofourpatientswereyoung,sigmoidectomyforsigmoid volvulusbyleftiliacfossamini-incisioncouldbeevenmore advan-tageousforolderpatientswithmultiplemorbiditiesasitcanbe undertakenunderlocalanesthesia.Weencouragethepracticeof suchtechnique,howeverthereisaneedforheadtoheadrigorous comparisonswithmidlinelaparotomyandlaparoscopy.

DeclarationofCompetingInterest

Theauthorsreportnodeclarationsofinterest. Funding

Nothingtodeclare. Ethicalapproval

ApprovedbyMedicalResearchCenter,HamadMedical Corpo-rationreferencenumber(MRC-01-20-086).

Consent

Itwasnotpossibletoobtainwritteninformedconsentfromthe patients.Mostpatientsprobablytravelledoutofthecountryafter surgery.Theheadofoursurgicalteamhastakenresponsibilitythat exhaustiveattemptshavebeenmadetocontactthepatientsortheir familiesandthatthepaperhasbeensufﬁcientlyanonymizednot tocauseharmtothepatientsortheirfamilies.Acopyofasigned documentstatingthisisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Authorcontribution

MahmoodAlDhaheri:Conceptualization,Datacuration, Inves-tigation,Projectadministration,Writing-originaldraft,Writing -review&editing.MohamedAbuNada:Datacuration, Investiga-tion,Methodology,Writing-review&editing.WalidElAnsari:Data curation,Methodology,Writing-originaldraft,Writing-review& editing.MohamedKurer:Datacuration,Investigation, Methodol-ogy,Writing-review&editing.AymanAbdelhaﬁz:Datacuration, Methodology,Validation,Writing-originaldraft,Writing-review &editing,Writing-review&editing.Allauthorsreadandapproved theﬁnalmanuscript.

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Registrationofresearchstudies researchregistry5909.

https://www.researchregistry.com/register-now#home/ registrationdetails/5f36449b945da30018d17556/.

Guarantor

ProfDrWalidElAnsari. Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed. Acknowledgement

Theauthorswishtoacknowledgethepatientsincludedinthis report.

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