ABSTRACT

Sigmoid volvulus (SV) arises from the twisting of the sigmoid colon around itself and tends to recur. The optimal treatment is an elective sigmoidectomy following endoscopic detorsion. In this field, laparoscopic sigmoid colectomy (LSC) with natural orifice specimen extraction (NOSE) is the most recent approach. In this paper, my comments pertain to LSC with NOSE for SV.

Dear Sir,

I read with great pleasure the article by Uylaş et al. (1) on laparoscopic sigmoid colectomy (LSC) with natural orifice specimen extraction (NOSE) for Sigmoid volvulus (SV); it reports one of the largest series in this field. Although SV is uncommon in Western populations, Eastern Anatolia, our practice area, is an endemic region for SV (2). As a consequence, our SV series, comprising 1,096 patients treated over 59 years (from June 1966 to July 2025), is the largest published SV series in the world (3). Among 763 patients (93.8%) with viable bowel in our series, 638 cases (83.6%) underwent successful endoscopic detorsion. Elective sigmoid colectomy was performed in 124 patients (19.4%; 95 open and 29 laparoscopic procedures), with no mortality, a morbidity rate of 1.3%, and no recurrences. However, we have no cases treated with LSC and NOSE in this series.

LSC with NOSE represents the most recent advancement in the treatment of SV. However, a database search of the literature in Web of Science (3), under the heading “sigmoid volvulus” and covering the last 80 years (1945–2025), revealed only a few (ten) SV cases treated with LSC with NOSE. Among those, the largest series, presenting 16 patients, was reported by Chen et al. (4). Due to the rarity of such cases, some controversy remains regarding this subject.

First, all reports, including the discussed paper, describe elective cases treated with endoscopic detorsion, and the results of LSC with NOSE are uncertain in emergency SV cases. Similarly, the outcomes of this procedure in children, elderly individuals, pregnant women, and morbidly obese individuals are unclear (1, 4, 5).

Second, there are some controversies regarding the technical approach. Some practitioners use laparoscopic procedures alone, while others prefer robotic surgery. Although the authors used four 5- and 12-mm trocars in the present paper, instruments reported in the literature are generally heterogeneous, including different numbers and sizes of trocars. Similarly, the authors used the transanal extraction route for small specimens; however, they suggested the transvaginal route for larger ones. Although the authors preferred splitting the specimens, total specimen extraction remains an alternative technique (1, 4, 5).

Third, following the resection, the choice of anastomotic technique remains controversial. Although the authors generally used side-to-end anastomosis, with one case employing a side-to-side procedure, other anastomotic techniques, including end-to-end and end-to-side procedures are also possible. On the other hand, the authors placed a rectal device for three days. Although rectal tubes may discharge the gas and preserve the anastomosis, their use is widely debated (1, 4, 5).

Finally, as demonstrated by the authors, both relatively prolonged operative time and relatively increased cost remain controversial issues in LSC with NOSE for SV (1, 4, 5).

I appreciate the authors’ didactic presentation, and I wonder about the authors’ opinion on my comments. It is clear that prospective studies are needed to standardize LSC with NOSE for SV.