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

For acute large bowel obstruction due to sigmoid volvulus, laparoscopic anterior resection of the rectum is not recommended as the primary approach due to technical difficulties and increased risks. 1

Optimal Management Algorithm for Sigmoid Volvulus

Initial Assessment and Management

1. Endoscopic decompression should be the first-line treatment for uncomplicated sigmoid volvulus

   • Success rate: 70-95% with 4% morbidity 1
   • Allows conversion from emergency to elective situation
   • Contraindicated if signs of peritonitis, bowel ischemia, or perforation are present

2. Urgent surgical intervention is required when:

   • Endoscopic decompression fails
   • Signs of bowel ischemia or perforation are present
   • Patient presents with peritonitis or septic shock

Definitive Surgical Management

For Uncomplicated Sigmoid Volvulus (after successful decompression)

• Sigmoid colectomy with primary anastomosis during the same admission is the treatment of choice 1
• Open approach is preferred over laparoscopic for sigmoid volvulus because:
  • The absence of fixation of the sigmoid colon makes laparoscopic exposure difficult
  • Excessive length of the sigmoid colon complicates laparoscopic dissection 1
  • Limited evidence supports laparoscopic approach in emergency settings 1

For Complicated Sigmoid Volvulus (ischemia/perforation)

• Urgent sigmoid resection without detorsion to prevent release of endotoxins 1
• Hartmann procedure (sigmoid resection with end colostomy) is recommended for:
  • Non-viable colon
  • Presence of peritonitis
  • Hemodynamically unstable patients
  • High-risk patients 1

Important Clinical Considerations

Technical Challenges with Laparoscopy in Sigmoid Volvulus

• Massively dilated bowel limits visualization and working space
• Redundant sigmoid colon with poor fixation makes exposure difficult
• Risk of iatrogenic injury is increased during manipulation of distended, friable bowel

Patient-Specific Factors

• For elderly or high-risk patients who cannot tolerate major surgery:
  • Consider percutaneous endoscopic colostomy (PEC) as an alternative 1
  • Reserved only for patients in whom established surgical interventions present prohibitive risk

Special Circumstances

• Concomitant megacolon: Subtotal colectomy rather than sigmoid resection alone is recommended to prevent recurrence 1
• Pregnancy: Requires multidisciplinary approach with treatment depending on gestational age 1

Common Pitfalls to Avoid

1. Delaying surgical intervention after successful endoscopic decompression

   • Recurrence rates up to 71% without definitive surgery 1
   • Elective surgery should be performed during the same admission

2. Attempting laparoscopic anterior resection in the emergency setting

   • Increased technical difficulty
   • Higher risk of anastomotic leak compared to open approach 1

3. Performing detorsion only without resection

   • Associated with 18-48% recurrence rates
   • Higher morbidity (30-35%) and mortality (11-15%) 1

While some limited evidence suggests that elective laparoscopic sigmoid resection may be feasible after successful decompression in carefully selected patients 2, the current guidelines do not support laparoscopic anterior resection as the standard approach for acute large bowel obstruction due to sigmoid volvulus, particularly in the emergency setting.