Presentation
Sudden onset of abdominal pain.
Patient Data
Dilated and redundant loops of large bowel in the left and mid abdomen. Distortion of the gastric bubble. No small bowel obstruction. Findings suggestive of volvulus or colonic obstruction.
Moderately distended stomach. Dilated, volvulized redundant cecum malpositioned in the left and mid abdomen, with mass effect. No malrotation. No small bowel obstruction. Mesenteric adenopathy. Small amount of free fluid.
Fusion anomaly left kidney with few areas of scarring of the lower pole moiety. No hydronephrosis.
Annotated coronal series following the path of volvulus. Ascending colon, appendix, and terminal ileum are annotated for reference.
OPERATIVE NOTE:
PREOPERATIVE DIAGNOSIS: Abdominal pain concerning for cecal volvulus.
POSTOPERATIVE DIAGNOSIS: Cecal volvulus.
Operation
- Diagnostic laparoscopy.
- Conversion to open exploratory laparotomy.
- Right hemicolectomy.
Procedure/Description
...We then tried to identify the anatomy. We placed the omentum into the left upper quadrant. We initially started to mobilize the duodenum from some flimsy adhesions to the small bowel. However, we were prevented from fully evaluating the small bowel by a large, dilated cecum within the left upper quadrant. It was very difficult to mobilize and showed signs of ischemia, thus, we decided to convert to open.
We made a midline incision starting above the umbilicus to 5 cm below. This was made with the knife and carried down with electrocautery up to subcutaneous tissues to the fascia. Eventually, we were able to exteriorize the cecum. It was quite a redundant cecum. This appeared to volvulized. We untorsed this with 3 turns and inspected the bowel. With the cecum detorsed and mobilized we were able to visualize the ligament of Treitz at the end of the duodenum in its normal position. This was then ran th small bowel to the terminal ileum Again, this was still very dilated. He did have some lateral cecum and right colon attachments. The rest of the colon was inspected. The cecum was extremely dilated, and there was large lymph nodes present within the colonic mesentery.
We divided the terminal ileum approximately 10 cm from the ileocecal valve using a GIA stapler. We then divided the transervse colon at the level at which the diameter was normal. The right colon was then removed. We then made a side-to-side, functional end-to-end stapled anastomosis of the terminal ileum to the transverse colon. The common enterotomy was then made with a blue load 80 mm Covidien stapler. This appeared to be hemostatic. The common enterotomy was then closed with a running 3-0 PDS suture. The mesenteric defect was then closed with a running 3-0 PDS suture as well....
Findings
Large, redundant cecum. Intraoperative findings consistent with cecal volvulus. The patient did have some lateral colonic attachments as well as identifiable ligament of Treitz, not consistent with malrotation. Right hemicolectomy was performed with a side-to-side, functional end-to-end stapled anastomosis.
PATHOLOGY:
Gross: Received fresh is a right hemicolectomy which includes an 11.0 cm terminal ileum in continuity with a 34.0 cm cecum-transverse colon, with an attached 10.5 x 0.8 cm vermiform appendix and mesocolic fat, measuring up to 4.0 cm in length. The cecum is severely dilated to 15.5 cm in circumference. The remainder of the bowel is also markedly dilated, ranging from 12.0 cm in circumference at the ascending colon to 7.5 cm in circumference at the distal margin. The cecal serosa is smooth and congested. The remainder of the serosa has scant, membranous adhesions and is focally congested. The terminal ileum has poorly defined areas of villous mucosa over roughly a 5.0 x 2.0 cm area. The ileocecal valve is slightly dusky. The colonic mucosa is unremarkable. The appendiceal serosa is smooth and glistening. The appendiceal lumen averages 0.6 cm in diameter and is filled with soft fecal material. The appendiceal wall is partially calcified. Lymph nodes are recovered. The distal margin has attached unremarkable omentum (14.0 x 3.0 x 0.2 cm).
Diagnoses:
Right hemicolectomy with 11 cm terminal ileum and 10.5 cm appendix:
- prominently dilated cecum and right colon, consistent with cecal volvulus with transmural congestion and no other significant abnormality.
- congested terminal ileum and appendix with no other significant abnormality.
- mesenteric lymph nodes with dilated sinuses and reactive lymphoid hyperplasia.
- segment of congested, but otherwise unremarkable, omentum.
Addendum: CD3 and CD20 immunostains of the mesenteric lymph nodes confirm the diagnosis of reactive lymphoid hyperplasia.
Case Discussion
Unusual case of cecal volvulus in a pediatric patient. Operative note describes redundant cecum which had volvulized 3 turns. This likely occurred due to congenital lack of peritoneal fixation of the cecum, resulting in increased mobility. A few "flimsy adhesions" were noted in the operative note which may have served as a fulcrum for rotation. The annotated coronal images help to identify the relevant anatomy. Evaluating all three planes can be helpful as the key findings can be more apparent in one than another.
Mesenteric adenopathy can frequently occur when there is congestion/ischemia due to volvulus, as in this case. However, sampling of the lymph nodes was recommended at the time of surgery, as lymphoproliferative disorder is in the differential (final pathology was benign reactive lymphoid hyperplasia).
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