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

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

Laparoscopic anterior resection of the rectum is not recommended as the primary treatment for acute large bowel obstruction due to sigmoid volvulus. 1

Initial Management Algorithm

1. First-line treatment: Endoscopic decompression

   • Flexible endoscopy is preferred over rigid sigmoidoscopy for decompression 1
   • Success rate: 60-95% of cases
   • Allows assessment of colonic viability
   • A decompression flatus tube should be left in place after successful detorsion

2. When endoscopic decompression fails OR signs of ischemia/perforation exist:

   • Proceed to emergency surgery
   • Open sigmoid colectomy with either:
     • Primary anastomosis (if patient stable, no peritonitis)
     • Hartmann procedure (if patient unstable, peritonitis present)

Why Laparoscopic Anterior Resection is Not Indicated

The 2019 World Journal of Emergency Surgery guidelines specifically state: "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

Additionally, the 2023 WSES consensus guidelines reinforce that while laparoscopic surgery may be considered in select cases, there are significant technical challenges:

1. The redundant, twisted sigmoid colon makes visualization difficult
2. The risk of intestinal injuries is higher with laparoscopy in obstructed bowel
3. Some studies show a twofold increase in anastomotic leaks with laparoscopic approaches 1

Proper Management Pathway

For Stable Patients Without Signs of Ischemia/Perforation:

1. Initial treatment: Endoscopic decompression
2. Definitive treatment: Elective sigmoid colectomy during same admission
   • Open approach is generally preferred
   • Laparoscopic approach only in highly selected cases by experienced surgeons

For Unstable Patients or Those With Signs of Ischemia/Perforation:

1. Emergency surgery: Open sigmoid resection
   • Hartmann procedure preferred if patient unstable or peritonitis present
   • Primary anastomosis if patient stable and bowel viable

Special Considerations

• High-risk patients: For those unfit for surgery, percutaneous endoscopic colostomy (PEC) may be considered as an alternative to prevent recurrence 1
• Concomitant megacolon: Requires subtotal colectomy rather than limited sigmoid resection 1
• Mortality risk factors: Age >60 years, shock on admission, history of previous volvulus episodes 1

Pitfalls to Avoid

1. Delaying surgical intervention after successful endoscopic decompression (recurrence rates of 43-75% without definitive surgery)
2. Attempting laparoscopic surgery in patients with extremely redundant sigmoid colon
3. Performing detorsion without resection (recurrence rates of 18-48%)
4. Underestimating the technical difficulty of laparoscopic surgery in the setting of volvulus

While some case reports describe successful laparoscopic approaches for sigmoid volvulus 2, these represent highly selected cases and do not reflect the standard of care recommended by current guidelines for acute large bowel obstruction due to sigmoid volvulus.