The Knotty Ladd-Laparoscopic Repair of Intestinal Malrotation in Adult

Introduction: Intestinal malrotation is one of the rare causes of intestinal obstruction secondary to failure of normal embryologic 270° anticlockwise rotation around the superior mesenteric vessels. Adult intestinal malrotation prevalence is unknown; however, computed tomography screening has revealed 0.17% prevalence.1 Surgical treatment may be required and entails widening the mesenteric pedicle to prevent future volvulus and obstruction rather than correcting the malrotation. The Ladd's procedure is the standard corrective measure for intestinal malrotation. Seymour and Anderson documented seven adult patients with malrotation who underwent a laparoscopic Ladd's procedure. These patients were discharged on postoperative day (POD) one through three with substantial improvement in six patients and slight improvement in one patient.2 Frasier et al reported a significant difference in hospital length of stay that favored the laparoscopic approach over an open approach.3,4 This video presents an adult intestinal malrotation treated laparoscopically for chronic abdominal pain and subacute intestinal obstruction. Materials and Methods: An 18-year-old girl presented with abdominal pain and vomiting for 2 days. As per the history she had been having similar episodes three to four times per year since childhood causing nutritional impairment with a body mass index of 15. The current episode was resolved nonoperatively and computed tomography revealed intestinal malrotation. The patient was taken for a laparoscopic Ladd's procedure. The patient was positioned supine and the abdomen was entered through a 12-mm infraumbilical port and two 5-mm working ports. An adhesiolysis was performed with division of the Ladd's bands and intermesenteric bands. The duodenum was kocherized and straightened followed by widening of the base of the mesentery, an appendectomy, placement of bowel in nonrotation. Results: Total operative time was 40 minutes with an estimated blood loss of 10 mL. There were no complications, and the patient was advanced to a diet on POD 1 and discharged on POD 2. At the patient's 5-month follow-up, she was tolerating diet without pain and a weight gain of 12 kg. Conclusion: The laparoscopic Ladd's procedure can be done safely in adults with adequate satisfaction, minimal postoperative pain and early hospital discharge. The laparoscopic method requires long-term follow-up to document its efficacy. No competing financial interests exist. Authors' Contributions: S.K. wrote the first draft of the article, collected data, and managed the literature searches. A.K. was the operating surgeon and scientific advisor. N.G. and A.K.G. read and approved the final article. All the authors mentioned in the title page have read and gone through the article and attest the legitimacy and validity of the data, and approved it. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. This procedure and video do not contain any resources that may cause plagiarism and patent-related issues in future. Authors did not have any commercial associations during the past 3 years that might create a conflict of interest in connection with the video. Source and place of study: The preoperative work-up, operative procedure, and postoperative follow-ups were carried out in a government/public-run tertiary care hospital. There were no special fundings or financial assistances from third parties. Runtime of video: 9 mins 44 secs