In a hemodynamically unstable patient with sigmoid volvulus and signs of peritonitis, what is the most appropriate next step after resuscitation?

In a hemodynamically unstable patient with sigmoid volvulus and signs of peritonitis, what is the most appropriate next step after resuscitation?

• A. Exploratory laparotomy
• B. Endoscopic detorsion
• C. Observation
• D. Laparoscopic detorsion

Answer: (A)

The key idea is that urgent source control is needed when sigmoid volvulus is accompanied by peritonitis in a hemodynamically unstable patient. After initial resuscitation, the best next step is exploratory laparotomy. Open surgery allows rapid access to the abdomen to assess bowel viability, release any tension, control contamination, and perform definitive resection of nonviable bowel with the appropriate plan for anastomosis or stoma as dictated by the patient’s instability and septic state. Endoscopic detorsion is reserved for stable patients without peritonitis, because it decompresses and untwists the volvulus but does not address possible bowel necrosis or perforation; in the setting of peritonitis and instability, delaying definitive surgery risks ongoing sepsis and death. Observation offers no active management of a potentially necrotic or perforated bowel. Laparoscopic detorsion would still be inadequate in the unstable patient with peritonitis, where rapid, open exploration provides the safest and fastest way to achieve source control and determine the proper surgical plan.

The key idea is that urgent source control is needed when sigmoid volvulus is accompanied by peritonitis in a hemodynamically unstable patient. After initial resuscitation, the best next step is exploratory laparotomy. Open surgery allows rapid access to the abdomen to assess bowel viability, release any tension, control contamination, and perform definitive resection of nonviable bowel with the appropriate plan for anastomosis or stoma as dictated by the patient’s instability and septic state.

Endoscopic detorsion is reserved for stable patients without peritonitis, because it decompresses and untwists the volvulus but does not address possible bowel necrosis or perforation; in the setting of peritonitis and instability, delaying definitive surgery risks ongoing sepsis and death. Observation offers no active management of a potentially necrotic or perforated bowel. Laparoscopic detorsion would still be inadequate in the unstable patient with peritonitis, where rapid, open exploration provides the safest and fastest way to achieve source control and determine the proper surgical plan.