Management of Cecal Volvulus with Viable Cecum
For a viable cecum diagnosed with volvulus during an operation for small bowel obstruction, right hemicolectomy is the procedure of choice. 1
Rationale for Right Hemicolectomy
- Right hemicolectomy is the definitive treatment for cecal volvulus as it eliminates the risk of recurrence by removing the affected segment 1
- In cecal volvulus, endoscopy has no therapeutic role, unlike sigmoid volvulus where endoscopic detorsion may be attempted 1
- Surgical intervention is the only option for cecal volvulus, with right hemicolectomy being specifically indicated as the procedure of choice 1
Alternative Procedures and Their Limitations
Cecopexy
- While cecopexy (surgical fixation of the cecum) has been used historically, it is considered less effective than resection 2
- Cecopexy has higher recurrence rates compared to definitive resection 2, 3
- May be considered in select cases with minimal distension and no evidence of ischemic changes, but is not the preferred approach 4, 3
Tube Cecostomy
- Tube cecostomy carries higher morbidity compared to resection and primary anastomosis 2
- Associated with increased risk of wound infection due to enterotomy 3
- Considered a more morbid option than definitive resection 2
Resection with Ileostomy and Mucous Fistula
- This staged approach is typically reserved for cases with perforation, peritonitis, or hemodynamic instability 1
- Not the first choice for a viable cecum as primary anastomosis can safely be performed 1
Clinical Considerations
- The viability of the cecum is a critical factor in determining the surgical approach 3
- For viable cecum, resection with primary anastomosis (right hemicolectomy) provides the best long-term outcomes 1
- Cecal volvulus has a high risk of recurrence if not definitively treated with resection 2, 5
- Mortality increases significantly if gangrene supervenes, emphasizing the importance of definitive treatment 2, 3
Surgical Approach
- Laparoscopic or open right hemicolectomy can be performed based on surgeon expertise and patient factors 4
- The procedure involves resection of the terminal ileum, cecum, ascending colon, and hepatic flexure with primary ileocolic anastomosis 6
- This approach addresses the underlying anatomical abnormality that predisposes to cecal volvulus 5, 6
Right hemicolectomy remains the gold standard for treating cecal volvulus with viable bowel as it provides definitive treatment with the lowest risk of recurrence and complications.