LAUSR

We present the case of a 70-year-old gentleman who was referred to our Surgical Emergency Unit with signs and symptoms of large bowel obstruction on a background of long-standing constipation. Computed tomography confirmed sigmoid volvulus. Endoscopic decompression was unsuccessful. Although there were no findings suggestive of ischaemia or perforation, abdominal dissention and absolute constipation persisted. He underwent diagnostic laparoscopy and untorting of his sigmoid colon. In view of multiple medical comorbidities and a strong wish of the patient to avoid a stoma, the decision was taken not to perform a resection but to a laparoscopic sigmoidopexy. The sigmoid colon was fixed over its entire length to the abdominal wall with permanent metal tacks (Protack, Covidien) in an effort to prevent future volvulus. The patient made an uneventful recovery and was discharged on the third postoperative day. He presented again 5 months later with an identical clinical picture of abdominal distension, pain, vomiting, and absolute constipation. Computed tomography again confirmed the presence of a sigmoid volvulus. Tube decompression was initially successful, but the volvulus reoccurred just 4 days later. In view of recurrence, the decision was taken to perform another endoscopic desufflation, but followed by immediate laparoscopic sigmoid resection and primary anastomosis. At the time of laparoscopy, the following view was encountered (Image 1). The patient made and uneventful recovery and was discharged home on the day five post-operatively. He was asymptomatic at routine follow-up (24 months). The procedure of (temporary) sigmoidopexy with metal tacks is often utilized as part of laparoscopic ventral mesh rectopexy, and occasionally metal tacks are not removed at completion of the procedure. The concern is that, especially in a thin abdominal wall, these could predispose to chronic pain. In this case, after sigmoidopexy, the patient experienced a pulling pain that only occurred at reaching for the top