What is the operative technique for performing a sigmoidopexy in an older adult with recurrent sigmoid volvulus and viable colon?

Sigmoidopexy Should Not Be Performed as a Definitive Treatment for Recurrent Sigmoid Volvulus

The World Journal of Emergency Surgery explicitly recommends avoiding non-resectional procedures such as sigmoidopexy, mesosigmoidoplasty, or simple detorsion alone due to their high recurrence rates, and instead strongly advocates for sigmoid resection during the index admission after successful endoscopic decompression. 1

Why Sigmoidopexy Is Not Recommended

The 2023 WSES consensus guidelines make clear that after successful endoscopic decompression of uncomplicated sigmoid volvulus, sigmoid resection should be offered and preferably performed during the index admission because without resection, the chance of recurrence remains high and quality of life may be impaired. 2

Key Evidence Against Sigmoidopexy:

• Recurrence rates after conservative management alone range from 45-71% overall, with 63% recurring within just 3 months 1
• Mortality after conservative treatment ranges from 9-36%, significantly higher than surgical resection 1
• The entire length of redundant colon must be removed to prevent recurrence—fixation procedures fail because they don't address the underlying anatomical redundancy 1
• Non-urgent sigmoid resection carries low morbidity and mortality (0-12%), making it safer than repeated episodes of volvulus 1

When Sigmoidopexy Techniques May Be Considered (Rare Exception)

Sigmoidopexy should only be considered in patients with prohibitive surgical risk who absolutely cannot tolerate sigmoid colectomy. 1 This is a last-resort option, not a standard treatment.

Endoscopic Sigmoidopexy Technique (For High-Risk Patients Only):

Patient Selection Criteria:

• American Society of Anesthesiologists physical status classification ≥3 OR Barthel index <30 3
• Multiple comorbidities making elective surgery prohibitive 4, 5
• Exclude patients with intestinal necrosis, perforation, or peritonitis—these require immediate surgical resection 3

Procedural Steps:

1. Preoperative bowel preparation is performed 4

2. Colonoscopic decompression and assessment:

   • Insert colonoscope to visualize and decompress the volvulus site 4
   • Confirm adequate decompression and viable bowel 4

3. Identification of fixation sites under fluoroscopic guidance:

   • Identify 5-10 fixation points (average 8.8 sites) along the sigmoid colon 3
   • Use transmitted colonoscopic illumination and finger pressure on the abdominal wall to identify optimal puncture sites 3

4. Percutaneous fixation technique:

   • Perform exploratory puncture with 23-gauge needle under local anesthesia 3
   • Make small skin incision 3
   • Deploy T-fasteners or 2-shot anchor devices to suture sigmoid colon to anterior abdominal wall 4, 3
   • Alternative: Place pigtail Chait catheters through the anchors 5

5. Multiple fixation points:

   • Repeat fixation at 5-10 sites to prevent rotation 3
   • In laparoscopic-assisted technique, perform adhesiolysis and detorsion before placing 2 percutaneous endoscopic colostomy tubes 6

Outcomes and Complications of Sigmoidopexy:

Efficacy (Short-term):

• Technical success rate: 93-100% 3, 5
• No recurrence during 10-12 month follow-up in small series 6, 3, 5

Complications:

• Major complication rate: 10% (including peritonitis, pneumoperitoneum) 1, 4, 5
• Minor complication rate: 37% (subcutaneous emphysema, tube-related issues) 1, 3
• One death reported from underlying comorbidities post-procedure 4

Critical Pitfalls to Avoid

1. Do not perform sigmoidopexy in surgical candidates—the recurrence risk and mortality with conservative management far exceed the low morbidity of elective sigmoidectomy 1, 7

2. Do not use sigmoidopexy if megacolon is present—these patients require subtotal colectomy, as sigmoid colectomy alone has an 82% recurrence rate 1

3. Never attempt sigmoidopexy in emergency situations with peritonitis, ischemic bowel, or hemodynamic instability—proceed directly to emergency laparotomy with sigmoid resection 1

4. Recognize that sigmoidopexy is palliative, not curative—it does not address the underlying redundant sigmoid anatomy that predisposes to volvulus 8

The Correct Algorithm for Sigmoid Volvulus Management

For viable colon after successful endoscopic decompression:

• Elective sigmoid colectomy during the same admission (laparoscopic or open based on surgeon expertise) 2, 1
• No stoma creation required in non-emergency setting 1
• This approach prevents the 45-71% recurrence rate and reduces mortality from 9-36% to 0-12% 1

Only if truly prohibitive surgical risk:

• Consider endoscopic sigmoidopexy as described above 1, 5
• Accept the 10% major complication rate and understand this is a compromise 1