Is laparoscopic anterior resection of the rectum (LAR) indicated for acute large bowel obstruction due to volvulus in the sigmoid colon?

Laparoscopic Anterior Resection is NOT Indicated for Acute Large Bowel Obstruction Due to Sigmoid Volvulus

For acute large bowel obstruction due to sigmoid volvulus, laparoscopic anterior resection of the rectum is not indicated as first-line treatment. The recommended approach is endoscopic detorsion followed by elective sigmoid colectomy with primary anastomosis during the same admission.1

Initial Management Algorithm

1. Assess for ischemia/perforation:

   • If clinical or radiological signs of ischemia or perforation are present → immediate surgery
   • If no signs of ischemia/perforation → proceed with endoscopic decompression

2. First-line treatment:

   • Flexible endoscopic detorsion (success rate 70-95%)
   • Leave decompression tube in place after successful detorsion 1

3. Definitive management:

   • After successful detorsion: sigmoid colectomy with primary anastomosis during the same admission
   • If detorsion fails or ischemia is present: emergency surgery

Why Laparoscopic Anterior Resection is NOT Indicated

1. Technical limitations:

   • "The role of laparoscopic surgery for volvulus is limited: the absence of fixation of the sigmoid colon and its excessive length often make laparoscopic exposure and dissection difficult." 1

2. Anatomical considerations:

   • Sigmoid volvulus typically involves the sigmoid colon, not the rectum
   • Anterior resection of the rectum is anatomically inappropriate for this condition

3. Preferred surgical approach:

   • Sigmoid colectomy with primary anastomosis is the standard surgical procedure
   • This targets the redundant sigmoid colon that is prone to volvulus

Evidence-Based Recommendations

The 2023 WSES consensus guidelines on sigmoid volvulus management strongly recommend:

1. Initial endoscopic approach: "In patients in whom ischemia or perforation is not suspected clinically and/or radiologically, flexible endoscopy should be performed as a first line to decompress the sigmoid colon." (Strong recommendation, 1C) 1

2. Definitive treatment: "For large bowel obstruction caused by sigmoid volvulus without ischemia or perforation, the best strategy is an endoscopic detorsion procedure followed by same admission surgery that includes a sigmoid colectomy with primary anastomosis." 1

Special Considerations

• High recurrence risk: Without definitive surgery, recurrence rates are 43-75% 1
• Mortality risk: Emergency surgery carries higher mortality (12% for Hartmann's procedure) 1
• Laparoscopic limitations: While some studies report successful laparoscopic sigmoid resection for volvulus 2, the 2019 and 2023 guidelines specifically note limitations of laparoscopy in this setting 1

Pitfalls to Avoid

1. Delaying endoscopic decompression when no ischemia/perforation is suspected
2. Relying solely on endoscopic treatment without definitive surgery (high recurrence rate)
3. Performing inappropriate resection (anterior resection of rectum rather than sigmoid colectomy)
4. Missing associated megacolon - if present, subtotal colectomy is indicated rather than limited sigmoid resection 1

In conclusion, the management of acute sigmoid volvulus should follow a stepwise approach of endoscopic decompression followed by sigmoid colectomy. Laparoscopic anterior resection of the rectum is not the appropriate procedure for this condition.