eP111 - Left-lower Quadrant Incision Sigmoid Colectomy: The Preferred Approach for Sigmoid Volvulus in a Lower Middle-income Country

Purpose/Background: Colonic volvulus, most often involving the sigmoid (50-80% of cases), occurs when a redundant colon twists around a narrow mesenteric attachment causing luminal obstruction and compromised vascular perfusion. The initial treatment for sigmoid volvulus without bowel ischemia or perforation is endoscopic detorsion. This has been found to be successful in up to 95% of cases. A recurrence may be seen (43-75%) if no subsequent intervention is done. It is, therefore, recommended to perform a sigmoidectomy after the acute phase of volvulus.Methods/Interventions: A review of records was conducted at the Philippine General Hospital (PGH) from January 2022 to September 2023. This included all patients diagnosed with sigmoid volvulus who underwent a sigmoidectomy through a left-lower quadrant (LLQ) incision after endoscopic detorsion and decompression. Patient profile and intraoperative outcomes were documented.The surgeries were performed by General Surgery residents, under the supervision of a Colorectal Surgery trainee or consultant. In supine position, a LLQ incision (Fig 1A) of about 5 cm in length was made up to the external oblique aponeurosis (EOA). The EOA was then divided along its fibers, and the muscles separated. The peritoneum was opened, followed by application of a wound protector. The redundant sigmoid colon was delivered out of the abdomen (Fig 1B). The mesentery was divided, and the marginal arteries were ligated (Fig 1C). Intestinal continuity was re-established with a side-to-side stapled anastomosis. The abdominal wall was then closed in layers.Results/Outcomes: In the past year, six patients underwent sigmoidectomy for volvulus through a LLQ incision. Majority were males (83%; 5:1, M:F), with ages ranging from 41 to 87 years (median 65 yrs). Four had comorbidities (i.e. leukemia, metabolic syndrome, hypertension, schizophrenia). Five had prior successful endoscopic detorsion. Upon confirmation that there was no other bowel pathology, the patients were scheduled for surgery. One patient previously underwent manual detorsion and sigmoid loop colostomy at a local hospital that had no endoscopic equipment. All patients were enrolled in the Enhanced Recovery After Surgery (ERAS) program.The estimated blood loss ranged from 50 to 100 mL (mean 75 mL), and the operative time ranged from 60 to 140 mins (mean 100 mins). Numerical rating scale (NRS) on Day 1 ranged from 0 to 2. Return of bowel function was noted 2 days postoperatively. Postoperative length of stay ranged from 3 to 4 days. Two patients had superficial surgical site infection. No mortalities were reported. In addition, the hospital cost was reduced by an average of $1,652.Conclusion/

Discussion: A midline laparotomy has been the traditional surgical approach. A trend favoring the use of laparoscopy, with its inherent advantages have been established in recent years. However, laparoscopy may not be suitable for all patients especially those at risk of cardiopulmonary compromise. In some areas in LMICs, there remain to be limited availability of laparoscopy. Moreover, it requires a higher degree of dexterity and surgical proficiency. To offset the disadvantages of a midline laparotomy and laparoscopy, a LLQ incision may be a viable option for patients with sigmoid volvulus. Exteriorization of the redundant bowel is technically feasible and easy with this approach. As seen in this series, even those in early stages of training can confidently perform the procedure. It is considered safe, less technically demanding, cost-efficient, and cosmetically acceptable.Figure 1(A) The left lower quadrant incision is made at the junction of the middle and outer thirds of the line adjoining the umbilicus and the left anterior superior iliac spine. (B) The redundant sigmoid colon is exteriorized, with a wound protector in place. (C) The mesentery was divided, and the marginal arteries were ligated. (Philippine General Hospital, 2022)