Laparoscopic Ladd's Procedure: Treatment of Choice for Midgut Malrotation in Infants and Children

Amy B Stanfill,Richard H Pearl,Lizabeth J Wallace,Ravindra K Vegunta,Kavitha Kalvakuri

doi:10.1089/lap.2009.0118

Abstract

Rotational anomalies of the midgut encompass a broad spectrum of incomplete rotational events with malfixation of the intestines during fetal development. Ladd's procedure, as a correction of these anomalies, has traditionally been performed by laparotomy. In our institution, the laparoscopic Ladd's (LL) procedure was introduced in May 2004 and soon became the standard approach. A retrospective analysis of all Ladd's procedures in children in our institution between September 1998 and June 2008 was performed. Outcomes between the open (OL) and LL procedures were compared. A total of 156 children underwent Ladd's procedure during the study period. There were 120 open and 36 laparoscopic procedures. Overall, 75% of patients in each group were symptomatic, most commonly with emesis and pain. Duration of surgery was similar in both groups. Time to starting feeds, and amount of time to attain full feeding, was significantly less in the LL group. Postoperative length of stay was significantly less in the patients having LL. Conversion rate to OL from LL was 8.3%. LL can be performed safely in selected patients with no increase in complications. Short-term results are superior to OL and can be achieved without any increase in operative duration.

Highlights

Rotational anomalies of the midgut encompass a broad spectrum of incomplete rotational events with malfixation of the intestines during fetal development
The primitive intestinal tract begins to form at approximately 4 weeks of gestation, and at 10 weeks of gestation, the midgut undergoes a 270-degree counterclockwise rotation around the axis of the superior mesenteric artery (SMA)
Records were reviewed for patient characteristics, findings at operative exploration, postoperative data, complications, and length of follow-up

Summary

Introduction

Rotational anomalies of the midgut encompass a broad spectrum of incomplete rotational events with malfixation of the intestines during fetal development. Ladd’s procedure, as a correction of these anomalies, has traditionally been performed by laparotomy. Short-term results are superior to OL and can be achieved without any increase in operative duration. The term ‘‘malrotation’’ encompasses a broad spectrum of intestinal rotation and fixation anomalies. By week 12, the midgut becomes attached to the posterior abdominal wall via multiple peritoneal reflections providing broad-based stabilization from the ligament of Treitz to the cecum. Variations in this sequence of rotation and fixation of the midgut result in malrotation with a narrowed vascular pedicle, predisposing to torsion or volvulus. Nonischemic obstruction of the duodenum can occur as a result of Ladd’s bands compressing and causing partial obstruction of the duodenum.[1]

Methods

Results

Conclusion