DR. M. Ravichandra,M. S



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DR.M.RAVICHANDRA,M.S

  • DR.M.RAVICHANDRA,M.S

  • ASST.PROF OF SURGERY

  • RIMS,SRIKAKULAM


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

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



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

  • 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


PRIMARY&SECONDARY

  • PRIMARY&SECONDARY

  • PRIMARY

    • CONGENITAL MALROTATION OF GUT
    • ABNORMAL MESENTERIC ATTACHMENTS
    • CONGENITAL BANDS
  • SECONDARY

    • ACQUIRED ADHESION
    • (OR) STOMA


WORLDWIDE - UP TO 50% OF OBSTRUCTION

  • 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


BAND OF ADHESIONS(PERIDIVERTICULITIS)

  • BAND OF ADHESIONS(PERIDIVERTICULITIS)

  • OVER LOADED PELVIC COLON

  • LONG PELVIC MESOCOLON

  • NARROW PELVIC MESOCOLON



SOMETIMES A BOWEL-COIL GETS OUT OF PLACE

  • 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







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

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

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



“BENT INNER TUBE” APPEARANCE

  • “BENT INNER TUBE” APPEARANCE

  • DILATED SIGMOID LOOP WITH LIMBS POINTING TOWARDS THE RLQ



THOUGH SOMETIMES IN A PERSON WHO IS FAT

  • THOUGH SOMETIMES IN A PERSON WHO IS FAT



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

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







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

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

  • BIRD’S BEAK

  • CAN DECOMPRESS



ENDOSCOPIC DECOMPRESSION

  • 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


ELECTIVE RESECTION

  • 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

  • DELAYED RESECTION WITH PRIMARY ANASTOMOSIS

    • MORTALITY RATE 8%
  • OPERATIVE MORTALITY RELATED TO VIABILITY OF BOWEL

    • VIABLE 12% VS NONVIABLE 53% MORTALITY


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

  • 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



LESS COMMON THAN SIGMOID 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

  • 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


“COMMA” SHAPED

  • “COMMA” SHAPED

  • CONVEXITY TOWARD RIGHT AND DOWNWARD

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







DECOMPRESSION WITH COLONOSCOPE

  • DECOMPRESSION WITH COLONOSCOPE

    • LESS SUCCESSFUL THAN WITH SIGMOID VOLVULUS
  • EMERGENT OPERATION IF SIGNS OF VASCULAR COMPROMISE



DETORSION ± APPENDECTOMY

  • DETORSION ± APPENDECTOMY

  • CECOPEXY/LAPAROSCOPIC CECOPEXY

  • CECOSTOMY

  • RESECTION

    • RIGHT COLECTOMY WITH PRIMARY ANASTOMOSIS


DETORSION ± APPENDECTOMY

  • 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


LESS COMMON AREA FOR VOLVULUS(4%)

  • 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



PREDISPOSED BY ARRESTED ROTATION OF GUT WITH A RESULTANT NARROW MESENTERY OF SMALL BOWEL & CAECUM

  • 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



OCCURS IN LOWER ILEUM

  • 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



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

  • 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



TRANSVERSE COLON MOVES UPWARDS TO LIE UNDER THE LEFT HEMIDIAPHRAGM

  • 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



TREATMENT

  • 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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