Internal herniation concurrent with ileosigmoid knotting or sigmoid volvulus: Presentation of 12 patients

Internal herniation concurrent with ileosigmoid knotting or sigmoid volvulus is an unusual and complex form of closed-loop obstruction that may result in a fatal outcome unless treated timely and properly. The aim of this article was to review our experience with this condition, with emphasis on the etiopathogenesis, clinicopathologic features, and treatment options.

We conducted a retrospective analysis of medical records of 12 patients treated at 2 university hospitals over a period of 30 years between 1970 and 2000.

In this series, the internal herniation resulted in ileosigmoid knotting in 8 cases, whereas it was concomitant with sigmoid volvulus in 4 cases. The types of internal herniation were identified as transmesenteric through the Treves field in 8 patients and as transomental, intersigmoidal, pericecal, and around omphalomesenteric fibrous cord in 1 patient each. The rate of gangrenous bowel was 100%. En bloc resection for combined gangrene of small bowel and large bowel was the treatment of choice in 7 patients, of whom 5 underwent the Hartmann's procedure and 2 underwent primary sigmoidectomy-anastomosis in addition to primary enterectomy-anastomosis. Primary sigmoidectomy-anastomosis and Mikulicz's procedure were performed in 2 patients for gangrenous sigmoid colon only. Three patients underwent primary enterectomy-anastomosis for gangrenous small bowel only. The morbidity rates and the mortality rate were both 33.3%. The mean length of hospital stay following emergency operations was 11.2 days.

In particular, surgeons who are from developing countries that form the world's "volvulus belt" should be aware of this entity's features and be ready to perform an appropriately selected surgical option for a given patient to accomplish the optimal clinical outcome.