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Colonic Volvulus
KristenKnapp andDanicaN.Giugliano
15
Colonic Volvulus
• Colonic volvulus accounts for approximately 10–15% of
all large bowel obstructions in the United States and may
account for a higher percentage worldwide.
• The most common sites of volvulus are the sigmoid colon
and cecum.
• Cecal volvulus usually occurs in younger patients and
those that are female, and is predisposed by the lack of
xation of the cecum to the retroperitoneum.
• Sigmoid volvulus is often accompanied by chronic constipation and elongation of the colon.
• Symptoms are usually acute, with pain and abdominal
distention as the most common symptoms.
A 56-year-old female with a history of schizophrenia and
depression presents with recurrent onset of cramping abdom-
inal pain and distention.
• Obtain a history including duration of symptoms, character and location of pain, infectious signs and symptoms,
and obstructive signs and symptoms.
– Time of onset
– Past episodes of volvulus
– Characteristics of pain (cramping, colic, constant,
intermittent)
– Associated symptoms:
Obstructive: nausea, vomiting
Infectious: fever, chills
Neoplastic: melena, hematochezia, weight loss
K. Knapp
Department of Surgery, Cooper University Hospital,
Camden, NJ, USA
e-mail: Knapp-kristen@cooperhealth.edu
D. N. Giugliano (
Division of Colon and Rectal Surgery, Department of Surgery,
Cooper University Hospital, Camden, NJ, USA
Cooper Medical School of Rowan University, Camden, NJ, USA
e-mail: giugliano-danica@cooperhealth.edu
*)
– Medical history
– Surgical history
– Patient and family risk factors for malignancy
• Obtain a physical examination
– Abdominal Exam
Palpation- tenderness, masses?
Rebound?
Guarding?
Percussion (distended with air vs uid?)
Distention (soft or hard?)
– Rectal exam
– If peritonitis is present, assume ischemia and/or gangrene
of the colon and emergent exploration is recommended
What diagnostic testing would you like to obtain?
• Lab studies including CBC, BMP, lactate
• Abdominal X-ray (preferably an obstruction series with
upright included) is rst radiographic test
– “Bent inner tube” or “omega sign,” with the apex
pointing to the right upper quadrant, is indicative of
sigmoid volvulus
– “Coffee bean” sign, with the apex pointing to the left
upper quadrant, is indicative of cecal volvulus
• CT scan (Ideally with IV contrast, +/− PO) or contrast enema
study shows bird’s beak deformity on the left side for a sigmoid volvulus and on the right side for a cecal volvulus
What is the initial treatment of a volvulus?
• Decompression and resuscitation: NPO, IVF, foley, antibiotics, and NGT
• Next steps will differ for a sigmoid versus a cecal volvulus
What is the denitive management of sigmoid volvulus?
• Denitive management is exible or rigid endoscopy to
reduce the volvulus
– “Pinwheel” conguration of the mucosa can be seen
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_15
47
48
K. Knapp and D. N. Giugliano
• Leave a long, exible tube in place to provide continue
decompression
• Success rate of detorsion and decompression is 60–80%
and recurrence rates are 20–90%
• The patient can then be bowel prepped for a semi-elective
sigmoid resection with primary anastomosis, preferably
during the same hospital setting
• If the volvulus is unable to be reduced with endoscopy, or
if there is evidence of ischemia then go directory to the
OR for a sigmoid resection with end colostomy
What is the denitive management of cecal volvulus?
• Straight to the OR (endoscopic attempt should not be
performed)
• If the patient is unstable, there is frank perforation or
necrotic bowel, or another reason to suspect a primary
anastomosis would fail, perform a right hemicolectomy,
end ileostomy, and mucus stula
– If gangrene is seen, resect bowel prior to untwisting
mesentery to prevent releasing toxins into circulation
which can cause shock
• Otherwise, a right hemicolectomy and primary anastomosis can be performed
• Cecopexy (recurrence rate 40%) and cecostomy tube
(recurrence rate 14%) are both not recommended as these
roles are unclear
• Not going to the operating room if necrotic bowel seen on
sigmoidoscopy for sigmoid volvulus or if patient has
peritonitis
Bonus Points
• Splenic and transverse colon volvulus presents with
symptoms of large bowel obstruction, either acute or
chronic.
– Diagnosis is usually delayed
– Treatment involves surgical exploration with resection
(+/− stoma)
Words ofWisdom
• Colonic volvulus is a common diagnosis in general surgery. It is important to treat these patients as any other
bowel obstruction, including resuscitation and physical
examination. If peritonitis is present, be sure to go straight
to the operating room. If peritonitis is not present, differentiating radiologic ndings for sigmoid volvulus and
cecal volvulus is important, and treatment options differ.
Deciding on a stoma in the operating room depends on the
patient’s overall condition, the condition of the bowel, the
degree of contamination, and the feasibility of the
anastomosis.
Clean Kills
• Not being able to differentiate between a sigmoid and
cecal volvulus based on imaging
• Performing endoscopy on a cecal volvulus instead of
going to the OR
• Performing a cecopexy or cecostomy tube in the case of
cecal volvulus
Bibliography
Score. https://www.surgicalcore.org.
Steele SR, etal., editors. The ASCRS manual of colon and rectal sur-
gery. NewYork: Springer; 2019.
Rectal Prolapse
HannahSoeld andDanicaN.Giugliano
16
A 58-year-old female, G2P2, with a history of hypertension
and chronic constipation presents with the chief complaint of
an intermittent anal bulge for a few months. She has been
experiencing fecal incontinence approximately once per
week. How do you proceed?
• Thorough History:
– Elicit parity history if not given
– Tailor history to attempt to distinguish Grade IV hem-
orrhoids vs. Prolapse (i.e., straining, bleeding, prior
diagnosis of hemorrhoids)
– Obtain colonoscopy history
• Physical Exam:
– Perform an external anal exam as well as a digital rec-
tal exam, assess sphincter tone, and ask patient to bear
down to elicit prolapse if internal tissue not currently
exposed
On a physical exam you see circular folds below the anal
verge (tissue well perfused), how do you manage?
• Attempt reduction if tissue is prolapsed
• Reduction may require using table sugar to coat the prolapse mucosa to reduce edema
• Offer operative repair (perineal or abdominal procedure)
• If vaginal prolapse or bladder prolapse is suspected or
seen, consider discussion with urologist or urogynecologist for possible combined repair
Perineal Rectosigmoidectomy (Altemeier Procedure)
• Prolapsed rectum is excised and anastomosis is performed
(hand-sewn or stapled)
• Fecal incontinence may be exacerbated given loss of rectal reservoir. Levatorplasty may be performed at the time
to improve incontinence symptoms.
• Recurrence rates are up to 20%.
• Traditional approach for elderly patients is the perineal
approach to reduce morbidity, but laparoscopic and
robotic approaches have been proven to be safe in the
elderly.
Transabdominal Rectopexy
• Anchors the rectum to the sacrum and can be performed
open, laparoscopic, or robotic
– Recurrence rates are up to 9%.
– Constipation can be worsened in 50% of patients,
especially if lateral stalks are divided.
– Sigmoidectomy (resection rectopexy) can be per-
formed in combination with rectopexy in patients with
constipation.
– Biologic mesh or synthetic mesh can be used between
the rectum and the sacrum to augment xation. Ventral
rectopexy is often done in a laparoscopic or robotic
manner.
How would you counsel this patient prior to surgery?
H. Soeld
Department of Surgery, Cooper University Hospital,
Camden, NJ, USA
e-mail: soeld-hannah@cooperhealth.edu
D. N. Giugliano (
Division of Colon and Rectal Surgery, Department of Surgery,
Cooper University Hospital, Camden, NJ, USA
Cooper Medical School of Rowan University, Camden, NJ, USA
e-mail: giugliano-danica@cooperhealth.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_16
*)
• Patient is healthy, an abdominal approach is preferred as
there is less risk of recurrence (~5% vs. up to ~30% with
perineal approach).
• There is a 15% risk of new onset constipation and a 50%
risk of worsening constipation.
• Other complications include bleeding, infection, ureteral
injury, mesh erosion, anastomotic leak or stricture, recto-
49
50
H. Soeld and D. N. Giugliano
vaginal stula, chronic pain, sacral discitis, and continued
fecal incontinence.
What if on the physical exam you observed a rosette of
prolapsed tissue, how would you manage?
• These are Grade IV prolapsed hemorrhoids; do not offer
prolapse repair. Discuss options for treatment of hemorrhoids including banding if internal, topical treatments,
and surgical excision.
Clean Kills
• Misdiagnosing grade IV hemorrhoids as rectal prolapse
• Attempting to reduce a strangulated prolapse
Bonus Points
• A Delorme procedure is a perineal procedure for short
segment full-thickness rectal prolapse. During this procedure, the mucosa is stripped and the rectal wall is placated
using suture. Recurrence rates are 16–30%.
• Recurrent rectal prolapse can be challenging. If resection
rectopexy was performed at the initial operation, perineal
rectosigmoidectomy may cause ischemic section in the
distal bowel.
Words ofWisdom
• Rectal prolapse most often occurs with chronic constipation and more commonly in women who are older.
Circular folds are seen on examination. Prolapse is often
able to be reduced and strangulation rarely occurs.
Surgical excision is recommended and can include perineal and abdominal approaches. Though a perineal
approach has been traditionally used for elderly patients
with comorbidities, minimally invasive abdominal
approaches have proven to be safe and effective in this
population.
Bibliography
Score. https://www.surgicalcore.org/modulecontent.aspx?id=164957.
Score. https://www.surgicalcore.org/modulecontent.aspx?id=146744.
Steele SR, etal., editors. The ASCRS manual of colon and rectal sur-
gery. NewYork: Springer; 2019.
Appendiceal Cancer
LeahSteinmetz andDanicaN.Giugliano
17
Epithelial Lesions
• Adenocarcinoma, mucocele, mucinous cystadenoma
(LAMN), mucinous adenocarcinoma, and signet ring cell
carcinoma
• Mucoceles are benign lesions
• LAMN’s morphologically resemble adenomas
• Adenocarcinomas are divided into mucinous and nonmucinous adenocarcinomas
– Right hemicolectomy is the operation of choice for
adenocarcinomas
– Signet ring cell carcinoma is a rare but aggressive type
of mucinous adenocarcinoma with rapid dissemination
within the peritoneal cavity and poor prognosis
A 31-year-old man undergoes a laparoscopic appendec-
tomy for acute appendicitis and the pathology comes back with
a 2.1cm adenocarcinoma of the appendix. What do you do?
• All adenocarcinoma of the appendix, regardless of size,
requires surgical resection of the primary tumor with
resection of the associated lymph node basin (in this case,
right hemicolectomy).
• 2/3 of these lesions are found incidentally after an appendectomy or ileocolectomy
• 5-year survival rate is 100% for stage I and 14% for stage
IV
Non-epithelial Lesions
• Carcinoid, lymphoma, leiomyoma, leiomyosarcoma,
Kaposi sarcoma
Appendiceal Carcinoid Tumors
• 75% of carcinoids are located at the tip of the appendix,
10% mid-appendix, and 10% at the base
• 80% of carcinoids are less than 1cm in size, 14% between
1 and 2cm, and 6% are greater than 2cm
• Ki67 is used to determine the proliferation capacity of
these types of tumors
• Staging is based on the size of the tumor
• 5-year survival rate for local disease is 95% and is 31%
for distant disease
A 31-year-old man undergoes a laparoscopic appendec-
Mixed Lesions
• Goblet cell carcinoids or can be referred to as mucinous
adeno-neuroendocrine carcinoma
• Behave like adenocarcinoma
L. Steinmetz
Department of Surgery, Cooper University Hospital,
Camden, NJ, USA
D. N. Giugliano (
Division of Colon and Rectal Surgery, Department of Surgery,
Cooper University Hospital, Camden, NJ, USA
Medical School of Rowan University, Camden, NJ, USA
e-mail: giugliano-danica@cooperhealth.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_17
*)
tomy for acute appendicitis and the pathology comes back
with a 2.1cm carcinoid at the base of the appendix. What do
you do?
51
52
L. Steinmetz and D. N. Giugliano
Alternate Scenario
A 31-year-old man undergoes a laparoscopic appendectomy for acute appendicitis and the pathology comes back
with a 4cm carcinoid at the base of the appendix. What do
you do?
Overall workup of known appendiceal carcinoid lesions
• Tumors <1cm: no staging unless identied as high-grade
malignant
• Tumors between 1 and 2cm: additional screening
– Plasma chromogranin A level corresponds to tumor
load and levels >5000 μg/L correlate with poor
outcomes.
• Tumors >2cm, incomplete resections, evidence of metastatic disease, or goblet cell tumors: further investigation
needed
– Must determine plasma chromogranin A levels and
24-h urinary levels of 5-hydroxyindoleacetic acid
Surgical Treatment ofAppendiceal Lesions
• Appendectomy alone
– Carcinoid tumor size <2 cm within tip or body of
appendix
– Low grade-carcinoid
– Single histology carcinoid tumor
– No mesoappendiceal invasion
• Right hemicolectomy
– Carcinoid >2cm anywhere in appendix
– Any size carcinoid at base of appendix
– Carcinoid 1–2 cm anywhere in appendix with any of
the following:
Mesoappendiceal invasion
High grade
Positive margins
– Carcinoid 1–2cm anywhere in appendix with angioin-
vasion and mixed histology (goblet cell carcinoid,
adenocarcinoid)
– Conrmatory diagnostic testing: 24-h urine for
5-hydroxyindoleacetic acid levels (5-HIAA) and chromogranin A levels (CgA)
– Somatostatin receptor scintigraphy (octreotide scan)
for localization
– Computed tomography (CT) angiogram for liver and
lymph node involvement
• Medical Therapy
– Symptomatic carcinoid tumors: Somatostatin and
interferon-α for palliating symptoms
– Advanced cases: Chemotherapy with streptozotocin,
doxorubicin, and 5-FU
• If liver metastases are seen treatment options include:
– Enucleation, multiple resections, or lobectomy
– Selective embolization
• Radiofrequency ablation
• In carcinoid syndrome:
– Only 10% of patients have carcinoid tumors
– Symptoms independent from each other include cuta-
neous ushing, diarrhea, right cardiac valvular, and
asthma
– Caused by the release of serotonin and other vasoac-
tive amines from neuroendocrine tumors
Clean Kills
• Not returning to OR for right hemicolectomy after appen-
diceal adenocarcinoma is found after a routine
appendectomy
• Forgetting the characteristics that determine the surgical
treatment of appendiceal carcinoid tumors
• Failing to perform the appropriate cancer operation with
resection of accompanying mesentery/lymph nodes
• Failing to recognize the carcinoid syndrome when
present
Bonus Points
A 62-year-old woman with GERD on omeprazole presents to the ED with abdominal pain and nausea. Her symptoms have been associated with diarrhea for the past
3months. Computed tomography (CT) scan shows a 4cm
mass in the body of the appendix. The appendix is removed
without issue. Pathology returns several days later demonstrating a 1.5 cm tumor with polygonal cells containing
polygonal eosinophilic cells in addition to mucin containing cells. What do you do?
• Diagnosis: Likely carcinoid
• Next best step: Urinary 5-HIAA
• Preoperative workup:
• Cytoreductive surgery and HIPEC can be performed in
cases of peritoneal dissemination
• Referral should be placed to specialized centers with
expertise in cytoreduction surgery
• Adequate staging and PCI score are needed prior to surgery, with best outcomes for patients with PCI score less
than 16–20
• Cytoreductive surgery aims to remove tumor implants
less than 2 mm in size and includes omentectomy with
stripping of all parietal peritoneal surfaces
• Heated chemotherapeutic drugs are circulated throughout
the abdominal cavity and is most commonly mitomycin-c
• Morbidity may exceed 50%
17 Appendiceal Cancer
53
Words ofWisdom
Most appendiceal lesions are found incidentally.
Treatment for appendiceal lesions depends on diagnosis.
All appendiceal adenocarcinomas that are not metastatic
at time of diagnosis should be treated with a right hemicolectomy. If appendiceal carcinoid is diagnosed, the size
and location of the tumor, and extent of disease, will
drive the extent of surgery (appendectomy versus right
hemicolectomy).
Bibliography
Score. https://www.surgicalcore.org
Steele SR, etal., editors. The ASCRS manual of colon and rectal sur-
gery. NewYork: Springer; 2019.
Small Bowel Obstruction
JohannaLou andKahyunYoon-Flannery
18
Way Question May BeAsked?
A 56-year-old woman with a history of hypertension, laparoscopic appendectomy as a child, and three Cesarean sections
presents to the Emergency Department with 2days of abdominal pain. Her appetite has been poor, and she has only had one
small liquid bowel movement this week without any atus in
the last 24h. This morning, her pain worsened with new nausea
and vomiting, which prompted her to come to the hospital.
How toAnswer?
Full History
• Anorexia +/− nausea, vomiting
• Changes in bowel habits: constipation, obstipation, passage of atus
• Location and quality of pain
• Important to obtain surgical history
• Inammatory bowel disease can cause mechanical
obstruction from strictures
• Signicant unintentional recent weight loss may indicate
obstruction from malignancy
• B symptoms may be related to small bowel lymphoma
Full Physical Exam
• Nonspecic abdominal pain
• Peritonitis is a sign of bowel compromise
• Abdominal distention +/− tympany
• Evaluate for hernias—incarcerated hernias containing
small bowel require intervention
J. Lou
Department of Surgery, Cooper University Hospital,
Camden, NJ, USA
e-mail: lou-johanna@cooperhealth.edu
K. Yoon-Flannery (
Cooper University Hospital, Cooper Medical School of Rowan
University, Camden, NJ, USA
e-mail: Yoon-Flannery-Kay@CooperHealth.edu
*)
Diagnostic Tests
• Labs: mild leukocytosis, anemia if a bleeding mass is
present
• Signicant leukocytosis or bandemia may indicate bowel
compromise
• Contraction alkalosis from emesis
• Hypokalemia and hypochloremia
• May have metabolic acidosis if bowel is compromised
• May have mild Cr elevation, elevated hematocrit or acute
kidney injury if signicant emesis
• Abdominal X-ray: upright lms will show air-uid levels
with dilated loops of small bowel
• CT scan: dilated stomach, dilated loops of small bowel,
decompression distal colon, may have a transition point in
the pelvis
• If suspected partial obstruction from adhesive disease,
can obtain small bowel follow-through with water- soluble
contrast and serial lms to follow passage of contrast
Surgical Treatment
• If no signs of strangulation or bowel ischemia, can attempt
non-operative management
• NPO, IVF
• Nasogastric tube for decompression
• Failure to clinically improve after 48h will likely need
operative intervention
• Operative approach is through a midline laparotomy
• Place a foley to decompress the bladder
• Enter away from prior incisions if possible with sharp dissection to avoid bowel injury
• All adhesions should be divided and small bowel inspected
in its entirety
• Enterotomies can be repaired if edges are viable and
<50% circumferential
• Ischemic bowel or extensive damage should be resected
• If resection is necessary, preserve as much small bowel as
possible
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_18
55
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J. Lou and K. Yoon-Flannery
Common Curveballs
• Obstruction from bowel-containing hernia
• Can begin with incision over the hernia
• If possible strangulation, do not reduce bowel before full
inspection
• Maintain high index of suspicion for Crohn’s
• Creeping fat, bowel wall thickening (esp terminal ileum),
brotic strictures, ulcerations
• Intussusception
• Examine carefully for any masses or lead points
Malignancy
• Obtain 5–10cm margins proximally and distally for margins with high ligation for nodes
• Internal hernia
• Can occur from adhesions
• Bariatric surgery
• Paralytic ileus
• Will affect large and small bowel
• Stone just proximal to ileocecal valve may be due to gallstone ileus
• Inspect gallbladder for cholecystoenteric stula
• Proximal enterotomy and milking stone out for retrieval
• If suspect Crohn’s, resecting multiple segments instead of
strictureplasty
• If gallstone ileus, failure to inspect entire bowel for multiple stones
Summary
SBO can be due to extraluminal compression (adhesions,
hernia), intrinsic bowel wall malignancies, or intraluminal obstruction (bezoar, stones, etc.). Management can be
proven challenging due to the unique variations in presentation and etiology. Partial SBOs from adhesive disease may be managed non-operatively initially. Early
surgical intervention should be considered for complete
obstruction or in the setting of bowel compromise.
Words ofWisdom
“Never let the sun rise or set on a bowel obstruction” is the
tradition that surgeons have been taught for generations
(Diaz et al. 2021). While some recent articles have challenged this notion, early intervention is considered the mainstay of proper treatment algorithms, and will be for purposes
of your board exam.
Clean Kills
• Not running the entire small bowel
• Failure to assess blood supply if concerned for viability
• Failure to inspect for enterotomies
• Missed intraluminal lesions
Bibliography
Diaz A, Ricci KB, Rushing AP, Ingraham AM, Daniel VT, Paredes
AZ, Baselice HE, Oslock WM, Heh V, Strassels SA, Santry
HP. Re-examining “never letting the sun rise or set on a bowel
obstruction” in the era of acute care surgery. J Gastrointest Surg.
2021;25(2):512–22. https://doi.org/10.1007/s11605- 019- 04496- 3.
Epub 2020 Feb 10.
Mesenteric Volvulus
KeshavKooragayala andMaureenMoore
19
Concept
While this often is found in newborns with malrotation, older
children and adults can also present with this nding. In the
adult population, malrotation is often secondary to adhesions, tumors, bariatric surgery, or a Meckel’s diverticulum.
Way Question May BeAsked?
A 34-year-old female patient presents with acute onset right
lower quadrant pain over the last month. She reports intermittent nausea and vomiting, along with severe episodes of
abdominal pain. Her surgical history includes a diagnostic
laparoscopy for endometriosis.
How toAnswer?
Full History
• Focused history of presenting symptoms of bowel
obstruction
• Character of emesis (bilious, nonbilious)
• Prior surgical history
• Medical history
• History of any newborn medical history, including bowel
obstructions or history of intussusception
• History of bariatric surgery (Gastric bypass associated
with internal hernia with volvulus of small bowel within
the mesentery of the jejunojejunostomy or the roux limb
and the transverse colon mesentery (Peterson’s defect)
Full Physical Examination
• Abdominal exam
• Evaluation of prior surgical scars
• Vital signs
Diagnostic Tests
• Laboratory workup (CBC, BMP, Lactic acid)
• Urinalysis
• CT with IV and/or PO contrast
– Whirl sign: swirl of mesenteric soft tissue and fat
attenuation
• Upper GI study with small bowel follow through could be
used to conrm malrotation or in children as rst test
– Bird’s beak obstruction, with abnormal positioning of
duodenal bulb
Surgical Management
• Pre-operative uid resuscitation, NGT decompression
• Correction of electrolyte abnormalities
• Surgical management is within the mainstay of small
bowel volvulus
• Laparoscopic or laparotomy based on clinical scenario
– If Patient is hemodynamically unstable or unable to
tolerate insufation-> open surgery
• Goal of surgery: detorsion of small bowel, resection of
ischemic bowel, and management of underlying etiology
• Tumor-> resection with appropriate mesenteric margin
with reconstruction
• Adhesive disease→enterolysis
K. Kooragayala · M. Moore (*)
Department of Surgery, Cooper University Hospital,
Camden, NJ, USA
e-mail: kooragayala-keshav@CooperHealth.edu;
Moore- maureen@cooperhealth.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_19
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