Anomalies of Intestinal Rotation: Laparoscopic Ladd’s Procedure

Anomalies of intestinal rotation, collectively referred to as malrotation, are congenital defects of intestinal rotation and fixation. Normal intestinal embryonic development involves physiologic intestinal herniation and counterclockwise rotation of the midgut around the superior mesenteric vasculature. Rotation can arrest at any stage of this process, resulting in a myriad of rotational anomalies that may remain asymptomatic, cause acute or chronic obstructive symptoms, or present with catastrophic midgut volvulus. Emergent open Ladd’s procedure is the recommended approach in the setting of acute midgut volvulus. Upper gastrointestinal series is the gold standard test for preoperative evaluation of intestinal rotation anomalies in the stable patient without concern for midgut volvulus. Laparoscopy has a controversial, but increasingly recognized role in the diagnosis and treatment of malrotation. Small retrospective series suggest that the laparoscopic approach results in an earlier return of bowel function and shorter hospital stays. The key elements of the Ladd’s procedure are detorsion, division of Ladd’s bands, widening of the small intestine mesentery, appendectomy, and proper reorientation of the bowel. These steps must be preserved in the laparoscopic approach to malrotation. Controversy exists in the optimal management of children with asymptomatic malrotation.