Rarely, a patient's caecum, his ascending colon and his ileum, may all twist. This can only happen if they are all free to rotate as the result of a rare anomaly of his mesentery, which seems to be more common here in the developing world than it is elsewhere. Twisting causes him sudden severe pain, vomiting, and prostration. His abdomen distends and becomes tender centrally and in his right lower quadrant. Signs of strangulation develop (10.3). X-rays show a huge gas shadow which is not where his caecum should be, but is central, or even in his left upper quadrant where it may mimic his stomach. Unlike a torsion of his sigmoid colon (B, 10-14), this gas shadow does not have two limbs descending into his pelvis. At laparotomy, a huge drum[nd]like structure seems fill his entire abdominal cavity.
VOLVULUS OF THE CAECUM. For the general method for gut obstruction see Sections 10.3 and 10.4.
At laparotomy you will see a tense, blue dilated volvulus. Decompress it (10-9). When you inspect his right lower quadrant, you will find that his caecum is not in its normal place.
Untwist his caecum.
If it is viable, ask your assistant to retract the right side of the abdominal incision. Anchor the patient's caecum to the peritoneum to the right of it with a few seromuscular sutures of 2/0 chromic catgut, passed through one of its taenia. This is of temporary value only, so refer him for a right hemicolectomy later. Or, do a temporary caecostomy, the fibrosis that will follow will keep his caecum anchored. To do this make a small incision over his caecum, insert a Foley catheter, blow it up, draw it back to his abdominal wall and anchor it with some catgut stitches, as in Fig. 66-18.
If it is not viable, and you are skilled, do a right hemicolectomy (66-20). If you are less skilled, exteriorise it, as for an ileocolic intussusception (10.8).
Fig. 10-18 VOLVULUS OF THE CAECUM can only happen if a patient's caecum, his ascending colon and his ileum are all free to rotate, as the result of a rare anomaly of his mesentery, which seems to be more common in the developing world than it is elsewhere. Adapted from a drawing by Frank Netter, with the kind permission of GIBA-GEIGY Ltd, Basle (Switzerland).