Twist of Fate: Intestinal Non-Rotation and Intermittent Volvulus in an Adult Treated with Laparoscopic Lysis of Laddʼs Bands

Abstract

Purpose: Intestinal malrotation or non-rotation is well described in infants and children, but rare in adults. Most adults with intestinal malrotation are asymptomatic, and the anomaly is discovered incidentally. In the rare symptomatic adult with intestinal malrotation or non-rotation, mid-gut volvulus can be life-threatening. We describe an adult with symptomatic intestinal non-rotation treated successfully with laparoscopic lysis of Ladd's bands. Methods: The clinical course of a patient diagnosed with congenital non-rotation is described. She was studied by CT scans, small bowel follow-through x-rays, endoscopy, and obstructive series during symptomatic episodes. Results: A 45 year old female complained of intermittent episodes of severe abdominal pain, associated with nausea, vomiting and abdominal distension, since her teenage years. They would last 45 minutes to several hours, and would spontaneously subside. Severe episodes necessitated emergency room visits, where obstructive series would occasionally reveal small bowel dilation with air-fluid levels. A CT scan revealed that all her colon was on the left side of the abdomen. Her small bowel was on the right side of her abdomen, as seen on CT scan and by small bowel follow-through x-rays. On CT scan, the superior mesenteric artery was on the right side of the superior mesenteric vein, contrary to normal anatomy. The third and fourth portions of the duodenum were entirely anterior to the superior mesenteric artery, rather than posterior to it, and occurred in the right upper quadrant, rather than the left. At laparoscopy, Ladd's bands were seen, as well as a narrow mesenteric pedicle. Ladd's bands were lysed, appendectomy performed, and the non-rotated positions of the small and large bowel were left as is. The patient did well without recurrence of symptoms in follow-up. Conclusion: Symptomatic adult intestinal malrotation or non-rotation is rare, but can be associated with life-threatening mid-gut volvulus and intestinal infarction. Laparoscopic lysis of Ladd's band can successfully treat this rare but potentially life-threatening condition in adults.