Abstract
Dolichosigmoid is a recognized risk factor for sigmoid volvulus, particularly in elderly or bedridden patients. Although endoscopic decompression is the first-line treatment, recurrent cases require surgical resection. We report a laparoscopic-assisted sigmoidectomy using single-incision laparoscopic surgery and two-fire functional end-to-end anastomosis. A 3.5–4.0 cm transumbilical incision allowed laparoscopic inspection and exteriorization of the redundant sigmoid colon. Reconstruction was performed extracorporeally, enabling accurate determination of the anastomotic site and straight, tension-free bowel alignment. Post-reconstruction laparoscopic inspection confirmed a stable anastomosis without torsion or mesenteric tension. Although follow-up periods were short, all patients remained recurrence-free. This technique may reduce wound-related morbidity, facilitate early postoperative mobilization, improve intraoperative assessment, and reduce stapler-related costs. It represents a simple and reproducible surgical option for elective treatment of sigmoid volvulus in elderly or high-risk patients. Further accumulation of cases and long-term outcome evaluation are needed to establish its efficacy and durability.
Introduction
A redundant sigmoid colon predisposes patients to sigmoid volvulus, particularly in elderly, bedridden individuals or those with neurological or psychiatric disorders [1, 2]. Although endoscopic reduction is typically the first-line treatment, surgical intervention is indicated in recurrent or refractory cases.
Definitive management involves resection of the redundant segment; however, there is no consensus regarding the optimal extent of resection or the most appropriate method of reconstruction.
Herein, we describe a laparoscopically assisted sigmoid resection using single-incision laparoscopic surgery (SILS) combined with a simplified two-fire functional end-to-end anastomosis (FEEA).
Materials and methods
Patient and surgical technique
This technique was applied in four elective cases (Table 1).
Summarize of four cases.
| Case 1 | Case 2 | Case 3 | Case 4 | |
|---|---|---|---|---|
| Age | 70 | 75 | 77 | 83 |
| Gender | Male | Male | Male | Male |
| Underlying disease | Cerebral infarction | Parkinson disease | Prostate cancer | Cerebral infarction |
| ASA-PS | 3 | 3 | 2 | 3 |
| Surgical approach | SILS | SILS | SILS | SILS |
| Length of midline wound (cm) | 4.0 | 4.0 | 3.5 | 3.5 |
| Operative time (min) | 89 | 88 | 72 | 71 |
| Blood loss | Minimal | Minimal | Minimal | Minimal |
| Postoperative complications | – | – | Intestinal paralysis Hyponatremia | – |
| Length of stay (day) | 10 | 11 | 16 | 11 |
| Recurrence | No | No | No | No |
| Duration of follow up (month) | 25 | 22 | 11 | 10 |
As a representative example (Case 4), an 83-year-old man presented with recurrent sigmoid volvulus following multiple prior endoscopic reductions.
A 3.5-cm transumbilical incision was created, and SILS was used to inspect the abdominal cavity, confirming the location of the dilated sigmoid colon and the absence of adhesions or active torsion (Fig. 1). The redundant sigmoid colon was then exteriorized through the umbilical incision (Fig. 2a). Resection and reconstruction were performed using a simplified two-fire FEEA technique. The resection line was planned such that the entry hole was positioned at skin level, allowing for safe and controlled extracorporeal manipulation. The mesentery was divided close to the bowel wall to preserve central vascular supply.
Operative findings. (a) The long sigmoid colon was located on the right side of the abdominal cavity. (b) No intra-abdominal adhesions or mesenteric torsion were observed.
Operative findings. (a) The sigmoid colon was elevated outside the body. (b, c) The entry hole was set at the skin level just above the wound. Resection and reconstruction were performed using two-fire functional end-to-end anastomosis. (d) Post-reconstruction photograph.
Because mesenteric dissection was limited to the peripheral side, perfusion to the remaining bowel was considered sufficient, and routine indocyanine green fluorescence assessment was not deemed necessary in these elective cases.
The entry hole was closed while simultaneously completing the resection using a second stapler firing (Fig. 2b–d). Care was taken to ensure proper alignment and to minimize tension at the anastomosis.
After reconstruction, laparoscopy was resumed to confirm the integrity and orientation of the anastomosis and to ensure the absence of tension (Fig. 3). The incision in the abdomen is then closed, and the surgery is concluded (Fig. 4). The total operative time was 71 min with minimal blood loss.
The anastomosis site as seen in the abdominal cavity following resection of the excess sigmoid colon.
After closure of the wound.
The postoperative course was uneventful, and the patient was discharged on postoperative Day 8. Follow-up computed tomography (CT) demonstrated resolution of the redundant sigmoid colon (Fig. 5), with no recurrence observed at 10 months.
CT findings. (a) Preoperative CT demonstrating a markedly redundant sigmoid colon with sigmoid volvulus. (b, c) Postoperative CT demonstrating resolution of the redundant sigmoid colon, with the residual sigmoid colon appearing almost straightened. Arrows indicate the anastomotic site.
Discussion
This approach offers several practical advantages in the management of redundant sigmoid colon.
First, the use of SILS minimizes surgical access trauma through a small umbilical incision. Previous studies have demonstrated that laparoscopic colorectal surgery is associated with reduced postoperative pain, earlier mobilization, faster recovery of bowel function, and a lower incidence of surgical site infection compared with open surgery [3–6]. Most patients in our series were elderly and had significant comorbidities, including neurological disorders. In this population, a minimally invasive approach may facilitate postoperative recovery by reducing surgical trauma, postoperative pain, and enabling earlier mobilization, while potentially decreasing the risk of postoperative ileus and wound-related complications. These benefits may be particularly relevant in patients with dolichosigmoid, who often exhibit impaired colonic motility and delayed postoperative recovery [7]. Additionally, the elongated sigmoid colon can be sufficiently exteriorized through a small incision, allowing extracorporeal resection without the need for extensive mobilization. If necessary, an additional port can be added without compromising the minimally invasive nature of the procedure.
Second, laparoscopic visualization enables accurate intra-abdominal assessment, including evaluation of adhesions, torsion, and bowel orientation, which may be difficult to achieve through a limited open approach alone. In Case 4, e.g. laparoscopic manipulation allowed for safe and controlled mobilization of the sigmoid colon from the right to the left abdomen (Fig. 1). In our series, the total operative time ranged from 71 to 89 min. Because the laparoscopic component was limited to intra-abdominal inspection and confirmation, the duration of laparoscopic manipulation itself was relatively short. These findings suggest that the addition of laparoscopy does not substantially prolong the overall operative time while enabling the procedure to be performed through a smaller incision.
Third, the simplified two-fire FEEA technique allows reconstruction with fewer stapler firings compared with conventional two-step methods. Previous studies have suggested that reducing the number of stapler firings does not compromise clinical outcomes [8], while potentially improving procedural efficiency and reducing cost. Furthermore, minimizing staple lines may theoretically reduce potential weak points in the anastomosis. In addition, compared with hand-sewn anastomosis, stapled techniques have been shown to provide comparable clinical outcomes with shorter operative time and greater reproducibility [9–11], which may be advantageous in minimally invasive settings.
Fourth, previous studies have reported recurrence of sigmoid volvulus even after surgical resection [12–14]. Inadequate resection length and residual redundancy are considered potential contributing factors. In the present technique, extracorporeal manipulation allows precise adjustment of the resection length and bowel alignment, which may reduce residual redundancy and the need for additional fixation procedures. This simplified approach may also contribute to shorter operative time.
Although this technique is based on a conventional FEEA concept, its application in a SILS-assisted extracorporeal setting represents a practical and rational adaptation for redundant sigmoid colon.
This approach may be best suited for elective cases with adequate bowel decompression and limited contamination, whereas emergency situations with ischemia or perforation may require conventional open or multiport approaches.
An additional practical observation was that the redundant segment could be readily delivered through the small umbilical incision in all cases. This finding suggests that the excessively mobile portion of the sigmoid colon may be selectively identified and resected extracorporeally. Although speculative, such an approach may reduce the need for additional fixation procedures while preserving a physiologic bowel configuration. This technique appears to be particularly suitable for patients with a markedly redundant sigmoid colon, in whom a tension-free anastomosis can be achieved without extensive mobilization of the left colon. Such anatomical characteristics are also considered to predispose patients to sigmoid volvulus, making this approach especially relevant in this clinical setting. Cases requiring extensive mobilization may not be ideal candidates for this technique.
Several limitations should be acknowledged. This study includes a small number of cases with a heterogeneous and relatively short follow-up period, limiting evaluation of long-term outcomes such as recurrence or anastomotic complications. Further studies with larger cohorts are required.
Conclusion
SILS-assisted sigmoid resection using a simplified two-fire FEEA technique is a feasible and reproducible option for the management of redundant sigmoid colon.
This approach enables precise resection and tension-free reconstruction while maintaining the benefits of minimally invasive surgery. Further investigation is required to establish its long-term outcomes and clinical role.
Acknowledgements
The authors would like to thank Satoe Takanaga for her assistance in collecting background information. The authors also would like to thank FORTE Science Communications (www.forte-science.co.jp) for English language editing.
Author contributions
Y.Y. drafted the manuscript. All authors obtained informed consent and performed surgery. Y.M. supervised the study. All authors read approved the final manuscript.
Conflicts of interest
None declared.
Funding
This study was supported by grants from JSPS KAKENHI (24 K19391) to Y.M.
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Ethics approval and consent to participate
Although this study is presented as a case report, it includes an institutional review; therefore, ethical approval was obtained from the Institutional Review Board of Okayama University (approval number: 2004–-028). The study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from the patient for publication of this case report and accompanying images.
Statements and declarations
The authors have no financial conflicts of interest relevant to the publication of this manuscript.
Consent for publication
Written informed consent was obtained from the patients for publication of this case and any accompanying images.
