Laparoscopic Management of a Primary Small Bowel Volvulus

Abstract

Primary small bowel volvulus in adults is a very rare condition, and it is defined as torsion of all or a large segment of the small intestine and its mesentery in the absence of any preexisting etiologic factors. Proper management of the patients suffering from a strangulated obstruction depends on making an early and accurate diagnosis. Timely treatment is crucial to prevent gangrene. A 49-year-old man who had a history of previous abdominal surgery was admitted to our hospital with complaints of acute abdominal pain. Simple abdominal x-ray showed multiple dilated loops of small intestine in the mid-abdomen. Enhanced abdominal computed tomography showed the distended small bowel loops and longitudinal tapering of the collapsed bowel loops. We carried out diagnostic laparoscopy to confirm the cause of suspected mechanical ileus. It revealed strangulation of the small bowel at the terminal ileum due to clockwise torsion of the bowel loop. There were no adhesions or congenital anomalies in the peritoneal cavity. The torsional segment was spontaneously reduced with minimal handling, and the strangulated portion was resected. The patient was discharged from hospital on postoperative day 6. Primary small bowel volvulus in adults is a very rare malady; if the diagnosis is uncertain, then diagnostic laparoscopy is a valuable tool for making the definitive diagnosis and administering prompt treatment.

A lucky and reversible cause of 'ischaemic bowel'

“…3,4 There are certain risk factors that have been linked to primary SBV, including long mobile mesentery, short mesenteric base, long small bowel, and consumption of a large amount of fibre-rich food after prolonged fasting, with overloading of an empty intestine. 1,3,6 With torsion of the small bowel and its mesentery, the superior mesenteric arterial blood supply is compromised, which results in bowel infarction that usually occurs within 6 hours. 3 The most important clinical feature is persistent abdominal pain with absence of bowel sounds on physical examination.…”

“…3 The most important clinical feature is persistent abdominal pain with absence of bowel sounds on physical examination. [1][2][3][4][5][6][7][8][9] Plain abdominal radiography is of limited diagnostic value. 4 Abdominal CT is the most useful tool for obtaining the correct preoperative diagnosis.…”

“…Volvulus in adults most often occurs in the colon and sigmoid colon (70-80%), and less commonly in caecum (10-20%). 1 Small bowel volvulus (SBV) is rarely encountered in adults. [1][2][3][4][5][6][7][8][9] Intra-operatively, if gangrenous small bowel is found, it needs to be resected and may potentially cause long-term complications, including short bowel syndrome.…”

“…1 Small bowel volvulus (SBV) is rarely encountered in adults. [1][2][3][4][5][6][7][8][9] Intra-operatively, if gangrenous small bowel is found, it needs to be resected and may potentially cause long-term complications, including short bowel syndrome. 2 We report on a patient with primary SBV associated with a perforated duodenal ulcer (PDU), but the patient had a favourable outcome without the need for bowel resection, thereby avoiding the long-term complications associated with extensive bowel resection.…”

“…[1][2][3][4][5][6][7][8][9] The absence of bowel gangrene intra-operatively predicted a favourable outcome for this patient. Strictly, volvulus is defined by more than 180° of rotation, so the intra-operative finding of small bowel twisting around the mesentery root by 180° may signify that the SBV was in the process of partially reversing by itself.…”