Laparoscopy of a splenic flexure volvulus

Abstract

Splenic flexure volvulus (SFV) is a very rare condition that is unlikely to be suspected even when a patient has repeated episodes of abdominal pain and dyschezia. We describe the case of SFV diagnosed and treated laparoscopically in the non-volvulus condition. A 14-year-old boy with no medical history had severe left upper abdominal pain and dyschezia for approximately 1 year. Although contrast enema examination revealed no characteristic findings of volvulus, such as a bird-beak sign, a redundant part of the colon was found to be the site of abdominal pain. We suspected that this part of the colon was the cause of the left upper abdominal pain and performed laparoscopic exploration. The colon at the splenic flexure formed a long loop and was predisposed to twisting; therefore, we performed resection and functional anastomosis of this redundant colon. The postoperative course was uneventful, and the left upper abdominal pain and dyschezia did not recur. Laparoscopic exploration can play a role in patients who are suspected to have recurrent colonic volvulus with radiographic evidence of a redundant portion of the colon, as indicated in our case.

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Accepted Manuscript
Laparoscopy of a splenic flexure volvulus
Yuichi Sesumi, Toshio Sawai, Shohei Maekawa, Hideki Yoshida, Makoto Yagi
PII: S2213-5766(17)30075-1
DOI: 10.1016/j.epsc.2017.07.001
Reference: EPSC 777
To appear in: Journal of Pediatric Surgery Case Reports
Received Date: 18 March 2017
Revised Date: 3 July 2017
Accepted Date: 3 July 2017
Please cite this article as: Sesumi Y, Sawai T, Maekawa S, Yoshida H, Yagi M, Laparoscopy of a splenic
flexure volvulus, Journal of Pediatric Surgery Case Reports (2017), doi: 10.1016/j.epsc.2017.07.001.
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Title: Laparoscopy of the splenic flexure volvulus
Yuichi Sesumi, Toshio Sawai, Shohei Maekawa, Hideki Yoshida, Makoto Yagi
Division of Pediatric Surgery, Department of Surgery, Kindai University Faculty of Medicine, 377-2
Ohno-Higashi, Osaka-Sayama, 589-8511, Japan.
Corresponding author: Yuichi Sesumi, MD.
Division of Pediatric Surgery, Department of Surgery, Kindai University Faculty of Medicine, 377-2
Ohno-Higashi, Osaka-Sayama, 589-8511, Japan
Phone: +81-72-366-0221 (ex 3111), Fax: +81-72-367-7771
E-mail: s.yuichi@surg.med.kindai.ac.jp
Figures: 3 Figures
Keywords: Splenic flexure volvulus; Child; Laparoscopy

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Abstract 1…
Splenic flexure volvulus (SFV) is a very rare condition that is unlikely to be suspected even when a patient 2…
has repeated episodes of abdominal pain and dyschezia. We describe the case of SFV diagnosed and 3…
treated laparoscopically in the non-volvulus condition. A 14-year-old boy with no medical history had 4…
severe left upper abdominal pain and dyschezia for approximately 1 year. Although contrast enema 5…
examination revealed no characteristic findings of volvulus, such as a bird-beak sign, a redundant part of 6…
the colon was found to be the site of abdominal pain. We suspected that this part of the colon was the 7…
cause of the left upper abdominal pain and performed laparoscopic exploration. The colon at the splenic 8…
flexure formed a long loop and was predisposed to twisting; therefore, we performed resection and 9…
functional anastomosis of this redundant colon. The postoperative course was uneventful, and the left 10…
upper abdominal pain and dyschezia did not recur.…Laparoscopic exploration can play a role in patients 11…
who are suspected to have recurrent colonic volvulus with radiographic evidence of a redundant portion of 12…
the colon, as indicated in our case. 13…
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1. Introduction 20…
Colonic obstruction caused by colonic volvulus accounts for 3-5% cases of intestinal obstruction [1] and 21…
is uncommon in children [2–6]. Colonic volvulus occurs most often in the sigmoid colon (60.9% cases), 22…
with the site being the splenic flexure in ≤1.0% cases [7]. We report a case of recurrent splenic flexure 23…
volvulus (SFV) in a 14-year-old patient who was suspected of having a redundant colon at the splenic 24…
flexure, based on radiographic findings, and was diagnosed and treated laparoscopically. 25…
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2. Case report 27…
A 14-year-old boy with no medical history had severe left upper abdominal pain and dyschezia once or 28…
twice per month for approximately 1 year. The left upper abdominal pain had been worsening for 3 29…
months before consultation. He required several hours to defecate due to pain on multiple occasions, and 30…
the pain reduced after defecation. No hematochezia was present. He was referred to our hospital for a 31…
detailed examination. 32…
On physical examination, his general condition was good and he did not show any physical or 33…
psychological developmental problems. When he did not have pain, abdominal radiography was 34…
performed, which showed hoof-shaped loops filled with colonic gas in the left upper quadrant (LUQ) (Fig. 35…
1). Contrast enema examination revealed that the colon in the LUQ was fixed and folded over at the 36…
splenic flexure (Fig. 2).…The part of the colon that was not fixed in a small area formed a long loop and was 37…
prone to twisting. Because this site was identified as the abdominal pain site, we suspected that this 38…

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folded colon was the cause of the left upper abdominal pain; we then performed laparoscopy. A skin 39…
incision was made just below the umbilicus, and a 5-mm trocar was inserted. Under laparoscopic 40…
guidance, two 5-mm trocars were placed, i.e., one in the right upper abdomen and the other in the left 41…
lower abdomen. 42…
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Fig. 1 An abdominal radiograph showing hoof-shaped loops filled with colonic gas in the left upper 45…
quadrant (white arrow). 46…

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Fig. 2 Contrast enema examination showing that the redundant colon was fixed and folded over at the 48…
splenic flexure. 49…
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In comparison with the descending colon, the transverse colon appeared slightly dilated, and the colon 51…
had a long and redundant part between the splenocolic and phrenocolic ligaments and was prone to 52…
twisting (Fig. 3). Therefore, we deduced that the left upper abdominal pain had occurred at the time of the 53…
volvulus. We performed resection of this redundant colon and functional end-to-end anastomosis with 54…
stapling devices. The operation time was 3 hours 18 minutes. There were no intraoperative complications. 55…
Although oral diet was started on postoperative day 3, the patient recovered without complication and was 56…
discharged on post-operative day 8. He had no recurrence 50 months after the operation. 57…
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Fig. 3 Laparoscopic findings showing redundant colonic loop (white arrows) between the splenocolic and 60…
phrenocolic ligaments. 61…
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3. Discussion 63…
Colonic volvulus can be caused by the following three factors: congenital factors, physiological factors, 64…
and mechanical factors [8]. Congenital factors include abnormalities in the fixation of the intestine, such 65…
as intestinal malrotation and shortening of the fixed part of the colon. Physiological factors include chronic 66…
constipation caused by several pathologies including congenital lack of enteric plexus, psychiatric 67…
disorder, and pregnancy. Mechanical factors include submucosal hematoma of the colon and abnormal 68…
location of the colon due to adhesion and surgery. SFV is rare with a colonic volvulus because this part of 69…
the colon has restricted mobility due to attachment of the ligaments, such as the splenocolic, gastrocolic, 70…
and phrenocolic ligaments, and retroperitoneal fixation of the descending colon [5,9]. In our case, we 71…
considered that the volvulus was caused by congenital factors. The patient had no history of surgery, 72…
intestinal rotation abnormality, or chronic constipation, but the redundant colon was observed at the site of 73…

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splenic flexure. Because splenocolic, gastrocolic, and phrenocolic ligaments were not absent and the 74…
colon, except for the redundant part, was fixed, we concluded that this redundant colon was causing the 75…
volvulus. 76…
The initial symptoms of SFV include abdominal colic seizures as well as those of the sigmoid volvulus, 77…
followed by vomiting and abdominal distension [10,11]. The diagnosis is mainly made on the basis of 78…
these clinical symptoms and findings on abdominal radiography and contrast enema examination. On 79…
contrast enema examination, narrowing with a bird-beak sign at the distal part of the splenic flexure is 80…
usually observed [12]. Since the sensitivity and specificity of the contrast enema examination depend on 81…
the clinicians performing the procedure, it has also been recommended recently that CT scanners 82…
continue to be used in complicated or unclear cases because of the widespread availability of fast CT 83…
scanners [13]. Our patient presented with no characteristic findings at the time of the examination, but it 84…
was considered that the repeated abrupt abdominal colic seizures occurred due to the volvulus and 85…
subsequent reduction of the volvulus of the redundant colon. In fact, it has been reported that symptoms 86…
occur repeatedly due to intermittent SFV [14,15]. 87…
Treatment of colonic volvulus includes endoscopic detorsion and surgery. Joergensen et al. reported 88…
endoscopic detorsion for the first time, and determined that it is associated with a high recurrence rate 89…
and the risk of perforation [16,17]. Surgical colon resection is the most useful procedure for preventing 90…
recurrence; when the involved segment develops necrosis, colon resection is essential [18]. For patients 91…
at high risk, colon reduction or fixation is recommended, but this is not commonly performed because of 92…

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the high recurrence rates in such cases [6]. In our case, the volvulus was not observed during 93…
laparoscopic observation; however, resection of the redundant colon was performed to prevent 94…
recurrence. 95…
In particular, we could diagnose and treat SFV laparoscopically when no acute findings such as 96…
abdominal pain, abdominal distension, and bird-beak sign were observed during contrast enema 97…
examination in the present case. In reported cases of SFV, the treatment approach was based on these 98…
findings at the time of examination, even in cases involving repeated episodes of abdominal pain, as was 99…
present in our case [14,15]. In addition, this patient required a long time to defecate. It is hypothesized 100…
that the dyschezia occurred from the abdominal pain due to colonic volvulus as he was able to defecate 101…
when the abdominal pain had subsided, which corresponded with reduction of the volvulus. 102…
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4. Conclusion 104…
Because SFV is a very rare condition, it is unlikely to be suspected even when a patient has repeated 105…
episodes of abdominal pain. Laparoscopic exploration should be considered in patients with recurring 106…
abdominal pain of unknown origin and radiographic evidence of a redundant mobile colonic portion, prone 107…
for volvulus. Laparoscopic partial colectomy is feasible in these patients. 108…
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4.…Reference
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Highlights
•  rare case of splenic flexure volvulus (SFV) was diagnosed and treated
laparoscopically.
• we could diagnose  in the non-volvulus condition.

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There are no conflicts of interest to declare.