Ladd Procedure Research Articles

Three recurrent episodes of malrotation in an infant

Malrotation with midgut volvulus in a newborn is not a rare condition and Ladd's procedure is the recommended surgical treatment. Recurrent volvulus after Ladd's procedure is very rare. We present a case of an infant operated on after birth for malrotation and midgut volvulus with 2 recurrent similar episodes in the following 20 months. We recommend abrasion of the parietal and visceral peritoneal surfaces when recurrence of malrotation occurs.

Outcomes after a Ladd procedure for intestinal malrotation with heterotaxia

Purpose Intestinal rotation abnormalities and complex congenital heart disease associated with heterotaxia coexist. Despite the risk for midgut volvulus, performing a Ladd procedure for asymptomatic malrotation with heterotaxia remains to be controversial because the presumed risk for postoperative complications is thought to exceed the benefits of the operation. The purpose of this study was to review the incidence of complications after a Ladd procedure in asymptomatic patients with heterotaxia to guide recommendations for this patient population. Methods The medical records of all patients with heterotaxia who underwent a Ladd procedure for asymptomatic malrotation between 1984 and 2004 were reviewed. Type of cardiac disease, postoperative complications, and survival were recorded. Results Twenty-two patients (9 boys and 13 girls) with heterotaxia underwent an elective Ladd procedure after their medical stabilization or surgical correction or palliation of their cardiac anomaly. Of these patients, 19 were younger than 1 month at the time of the operation. The remaining 3 patients underwent the operation when they were between 2 and 5 months old. Three of the 22 patients (14%) developed postoperative intestinal obstruction: lysis of adhesions was performed in 1 patient; another patient required a staged bowel resection for a closed loop obstruction; and yet another patient had recurrent midgut volvulus 4 years after an incomplete initial Ladd procedure. All patients survived the initial and secondary procedures. Four deaths, all more than 1 month after the surgery, occurred as sequelae of the underlying cardiac anomaly. Length of follow-up ranged from 1 to 17 years. Conclusions We report on a 14% risk of postoperative bowel obstruction after an elective Ladd procedure, as compared with a small but significant incidence of midgut volvulus in patients with malrotation in the setting of complex congenital heart disease. Our results support the conclusion that an elective Ladd procedure at a time of relative cardiac stability for selected patients with heterotaxia has an acceptably low morbidity and should be considered to prevent midgut volvulus.

Examination: The Ladd's Procedure for Correction of Intestinal Malrotation With Volvulus in Children

AORN JournalVolume 85, Issue 2 p. 309-312 Clinical Examination: The Ladd's Procedure for Correction of Intestinal Malrotation With Volvulus in Children First published: 08 February 2007 https://doi.org/10.1016/S0001-2092(07)60041-6 2.1 The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure. This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume85, Issue2February 2007Pages 309-312 RelatedInformation

Abnormalities of Intestinal Rotation in Patients with Congenital Heart Disease and the Heterotaxy Syndrome

Abnormalities of intestinal rotation (AIR) are seen in association with congenital heart disease and heterotaxy syndrome. The prevalence of these abnormalities and recommendations for management are unclear. Our objective was to determine the prevalence of screening for AIR by elective imaging among our group and prophylactic vs. emergent surgical intervention for AIR in patients with congenital heart disease and heterotaxy syndrome. From October 1988 through October 2000, we identified 74 patients with congenital heart disease and heterotaxy syndrome, 44 (59%) asplenia, 30 (41%) polysplenia. Abdominal imaging was performed in 34 patients (45%). Twenty-four (32%) were found to have AIR. Of 34 patients imaged, 22 (65%) were found to have AIR. Two patients not imaged were found to have AIR: one at autopsy, and the other, incidentally during other abdominal surgery. Because imaging was performed based on individual cardiologist's practice style that did not change over the period of the study and rarely secondary to symptoms, it is likely that the prevalence of AIR in the patients that were not electively imaged would be similar. There was no statistical difference in the presence of AIR between asplenic (34%[15/44]) and polysplenic (30%[9/30]) patients. Of the 22 patients imaged with AIR, 18 underwent Ladd procedure. Five of 12 imaged patients without AIR were found to have other significant gastrointestinal pathologies requiring intervention including gastrostomy tube placement for reflux (3), duodenal web (1), and biliary atresia (1). Of the 40 patients who were not pre-emptively imaged, none suffered acute obstruction solely secondary to AIR. However, in 2 patients intestinal obstruction was suspected and subsequently discovered by imaging and/or laparotomy due to other intestinal anomalies. AIR is common among patients with heterotaxy syndrome and congenital heart disease. We recommend that patients with congenital heart disease and heterotaxy syndrome have routine elective abdominal imaging of their gastrointestinal tract at birth as part of their evaluation.

Association of midgut malrotation with intussusception

Background: The cause of intussusuception in most infants is unclear. Intestinal malrotation has been postulated as a possible cause in some infants. Waugh,s syndrome is the association of intestinal malrotation with intussusception.Patients/Methods: Of 18 children with intussusception managed in the Paediatric Surgical Unit of our hospital over a 3-year period, eight had abnormality of intestinal rotation and fixation. Their case notes, operation notes and discharge summary sheets have been retrospectively reviewed.Results: There were five boys and three girls. Their ages ranged from 13 days – 12 months (median 10 months). The main clinical features were bilious vomiting, blood stained diarrhoea and abdominal distension. In two infants, the intussusceptions had prolapsed through the anus at presentation. One neonate had ruptured omphalocoele minor containing a caeco-colic intussusception that had perforated at presentation. Two other infants had mid gut volvulus, one as a simultaneous finding with intussusception while the other one 72 hours after operative reduction of intussusception. All had laparotomy. In six infants, the intussusception was ileo-colic while in two it was caeco-colic. There was no lead point in any infant. Four infants had successful operative reduction while four had bowel resection with end-to-end anastomosis. All had Ladd's procedure. One child died of overwhelming sepsis following resection of gangrenous bowel. Conclusion: Intestinal malrotation may be associated with idiopathic intussusception. It is important to look for this association when managing infants with intussusception. Keywords: Waugh's syndrome, intussusception, malrotation, midgut volvulus, Ladd's procedure Nigerian Journal of Surgical Research Vol. 7(1&2) 2005: 159-161

Minimal Access Surgery in the Neonate

After completing this article, readers should be able to: 1. Review physiologic, anatomic, and technical issues related to minimal access surgery in the neonate. 2. Describe conditions in which minimal access surgery can be used in neonates. Historically, pediatric surgeons were slow to adapt to minimal access surgery (MAS) techniques compared with the adult surgical community. However, MAS now is widely established in infants and children. Differences in size and physiology have necessitated a number of surgical and technological modifications to apply MAS techniques to this population. This review outlines the important differences between children and adults with respect to MAS and provides examples of the use of MAS for diseases seen in infants. ### Physiologic Issues The physiologic response to pneumoperitoneum in children is more pronounced than in adults. Peritoneal insufflation with carbon dioxide has been shown to cause hypercarbia, acidemia, and decreased oxygenation in the pediatric piglet model. (1) In infants, however, there is no detrimental effect on blood pressure, heart rate, or oxygen saturation during short periods of pneumoperitoneum, and elevations in end-tidal CO2 can be counteracted readily by increasing the minute ventilation. (2) Hypercarbia-induced pneumoperitoneum in infants is associated with changes in cerebral blood flow and cardiac output. Nevertheless, laparoscopic procedures have been performed safely with proper anesthetic management in children who have even severe congenital cardiac abnormalities such as hypoplastic left heart syndrome. (3) Hypothermia also can be a concern due to rapid insufflation of unwarmed CO2 gas, mandating the moderation of flow rates. (4) ### Anatomic Issues A number of anatomic factors set children apart from adults and must be accounted for when performing laparoscopic surgery in this age group. Young children and infants have thinner abdominal walls than adults, so extreme care must be exercised when placing trocars. Due to the small size of the abdomen, the working …

Minimal access surgery in neonates and infants

Background Minimal access surgery (MAS) in small infants carries an important consideration. The tolerance of these small babies and the assumed physiological effect of MAS, in addition to the required anesthetic and surgical skills, have made it difficult to perform these types of procedures in many international centers. The present article reviews our experience with MAS in neonates and infants in the first year of life. Methods The medical records of all neonates and infants (<1 year) who underwent MAS over a period of 3 years were retrospectively reviewed for demographic information, procedures, operative time, complications, outcomes, and follow-up. Most of the operations were performed with 3-mm instruments and scopes and mean insufflation pressure of 10 mm Hg (range, 4-15 mm Hg). Result Seventy neonates and infants were included in this study: 19 females and 51 males. The weight ranged from 1.3 to 8.2 kg (mean, 4.3 kg). The mean age was 93 days (range, 1 day to 12 months). Twenty-four (34%) were neonates (first 30 days of life). Procedures performed included repair of tracheoesophageal fistula, lobectomy, repair of diaphragmatic or hiatus hernias, pull-through for imperforated anus and Hirschsprung's disease, plication of the diaphragm, Kasai procedure, excision of choledochal cyst, pyloromyotomy, Ladd's procedure, and reduction of intussusceptions. There were 2 conversions, both in neonates with tracheoesophageal fistula. All patients tolerated the procedure very well, with lesser degrees in neonates undergoing thoracoscopic procedures. Two neonates had postoperative hypothermia (<35°C) and 1 neonate had high P co 2 postoperatively. There was 1 mortality and no morbidities. The follow-up ranged from 1 month to 3 years (mean, 19 months). Conclusion Minimal access surgery in neonates and infants is safe and well tolerated. Intraoperative monitoring of end-tidal CO 2 and core temperature is essential in avoiding unwanted effects of performing these procedures, especially in neonates.

Adhesion obstruction following Nissen fundoplication in children.

The incidence of postoperative adhesion intestinal obstruction among 156 children who had undergone Nissen fundoplication for intractable gastro-oesophageal reflux was determined. There were 18 episodes of obstruction in 16 patients (10.3 per cent). The mean interval between fundoplication and adhesion obstruction was 10 months (range 10 days-4 years). Additional procedures performed at the original laparotomy substantially increased the risk of developing obstruction. Relaparotomy for adhesion obstruction was required by 21 per cent of patients who had a Ladd's procedure and 12 per cent who had appendicectomy. Presenting symptoms were not typical of intestinal obstruction because many of these children were unable to vomit. Only three did vomit but all had radiological appearance suggestive of small bowel obstruction. There were two deaths directly related to adhesion obstruction.

Gastro-oesophageal reflux and intestinal malrotation in children

In a series of 74 children undergoing Nissen fundoplication for persistent gastro-oesophageal reflux unresponsive to intensive medical treatment, there was an unexpectedly high incidence (54 per cent, n = 40) of intestinal malrotation. The series was not homogeneous, 25 of the children having reflux as a complication of a serious congenital abnormality (48 per cent incidence of intestinal malrotation), and 49 presenting with 'idiopathic' reflux (57 per cent incidence of intestinal malrotation). Intestinal malrotation is best detected pre-operatively by careful barium radiology, requiring clinicians to be aware of the association. In our experience, in children over the age of 3 months, both an antireflux operation and Ladd's procedure are often necessary to stop gastro-oesophageal reflux when an intestinal malrotation is present.

Recurrent gastrointestinal tract bleeding secondary to jejunal gastric heterotopia

A 4-year-old Latino boy with a history of malrotation, nonobstructing annular pancreas, and a Ladd procedure during infancy presented with recurrent severe gastrointestinal tract bleeding. Investigations revealed a large mass in the proximal small bowel. At laparotomy, the proximal jejunal segment containing the mass was resected. Pathological examinations revealed a large intraluminal polyp composed of ectopic gastric mucosa. The patient presented 10 months later with recurrent bleeding, and subsequent laparotomy demonstrated a newly acquired segment of jejunal polyposis not present at the first operation. The case is presented, along with a plan of patient surveillance and a review of the pertinent literature.

Surgical management of intestinal malrotation in adults: comparative results for open and laparoscopic Ladd procedures

This study aimed to characterize the clinical features of intestinal malrotation in adults, and to compare the results for the open and laparoscopic Ladd procedures. Between 1984 and 2003, 21 adult patients with a mean age of 36 years (range, 14-89 years) were surgically treated for intestinal malrotation. The clinical data collected included age, gender, presenting symptoms, diagnostic tests, type of operation, operative time, narcotic requirement, time to oral intake, length of hospital stay, and outcome. The groups (open vs laparoscopic) were comparatively analyzed using two-sample t-tests and Wilcoxon rank sum tests. The two groups were similar in terms of age, clinical presentation, and diagnostic tests performed. The most common presenting symptoms were chronic abdominal pain, nausea, and repeated vomiting. Upper gastrointestinal barium studies (UGI/SBFT) were diagnostic for all patients with malrotation as compared with computed tomography (CT) scanning, which was falsely negative in 25% of patients. A total of 21 patients underwent the Ladd procedure, either open (n = 10) or laparoscopic (n = 11). Three laparoscopic procedures were converted to open. Overall, the laparoscopic group resumed oral intake earlier than the open group (1.8 vs 2.7 days; p = 0.092), had a shorter hospital stay (4.0 vs. 6.1 days; p = 0.050), and required less intravenous narcotics on postoperative day 1 (4.9 vs 48.5 mg; p = 0.002). The laparoscopic group underwent a longer operation (194 vs 143 min; p = 0.053). Sixteen of eighteen patients available for follow-up reported complete resolution of symptoms, 2 felt greatly improved. No patient required a second operation related to volvulus or recurrent symptoms. The laparoscopic Ladd procedure is feasible, safe, and as effective as the standard open Ladd procedure for the treatment of adults who have intestinal malrotation without midgut volvulus. Patients also benefit from this minimally invasive approach, as manifested by an earlier oral intake, a decreased need for intravenous narcotics, and an earlier discharge from the hospital.

Recurrent acute pancreatitis caused by malrotation of the intestine and effective treatment with laparoscopic Ladd’s procedure

We herein report a rare case of recurrent pancreatitis caused by malrotation of the intestine. Since the age of 10 years, a female patient showed recurrent epigastralgia and was diagnosed at age 16 years as suffering from acute pancreatitis. Upper gastrointestinal series showed that the duodenal bulb was elongated and rotated caudally. Endoscopic retrograde cholangiopancreatography showed that the descending portion of the duodenum was rotated and occluded the papilla of Vater. Under laparoscopy, the duodenal bulb was tracted caudally by the Ladd's ligament. By incision of this ligament, the entire duodenum was mobilized, with subsequent reduction of the rotation and compression of the pancreatic head. The girl's postoperative course was uneventful, and she has been asymptomatic for the last 3 years. In conclusion, malrotation of the intestine may be a rare cause of recurrent pancreatitis, and laparoscopic Ladd's procedure may be a less invasive and useful treatment.

Heterotaxia syndrome: the role of screening for intestinal rotation abnormalities

Background: Heterotaxia syndrome involves multiple anomalies, including cardiac malformations and intestinal rotation abnormalities. Most authors recommend routine radiological evaluation, with laparotomy and Ladd procedure if a rotation abnormality is found....

Staged repair of giant omphalocele in the neonatal period

Background/Purpose The aim of this study was to analyze the outcome of giant omphalocele repaired in the neonatal period. Methods Twelve consecutive (1997-2004) neonates with giant omphalocele (defect >6 cm with liver herniation) were reviewed. A silo of Prolene mesh (Ethicon) was attached to the fascia and the defect was closed without opening the amniotic sac after sequential reduction. In 2 neonates with ruptured omphalocele a plastic sheet was inserted below the mesh. Data are reported as median and range. Results Gestational age was 38 weeks (range, 32-40 weeks) and birth weight was 2.9 kg (range, 1.0-3.1 kg). The final closure was achieved at 26 days (range, 16-62 days). Three neonates (25%) died before final closure (causes: ruptured omphalocele, lung hypoplasia, cardiac anomalies, and intestinal failure). In the 9 surviving neonates, mechanical ventilation was required for 8 days (range, 2-20 days), hospital stay was 42 days (range, 23-73 days), and full enteral feeding was achieved on day 12 (range, 4-53 days). Complications included wound infection in 5 neonates and midgut volvulus in 1. Prophylactic Ladd's procedure was performed laparoscopically at a later stage in 4 children. At laparoscopy, intraperitoneal adhesions were minimal and the central liver did not preclude the operation. The 9 survivors are all well after 46 months (range, 12-67 months). Conclusions Giant omphalocele can be safely repaired in the neonatal period without opening the amniotic sac. Intestinal malrotation should be excluded and Ladd's procedure can be performed laparoscopically at a later stage.

Surgical treatment of malrotation after infancy: a population-based study

Purpose Because malrotation most commonly presents in infants, treatment recommendations for older children (>1 year) have been based on data obtained from small case series. The purpose of this study was to use a large national database to determine the clinical significance of older children presenting with malrotation to develop treatment recommendations for this group. Methods Records of children undergoing a Ladd's procedure were identified in the Kids' Inpatient Database, an administrative database that contains all pediatric discharges from 27 states during 2000. Patient characteristics, associated diagnoses, operations performed, and mortality were evaluated. Discharge weighting was used to obtain a national estimate of the number of children older than 1 year treated for malrotation. Results Two hundred nineteen older children (>1 and <18 years) undergoing a Ladd's procedure were identified in the database. One hundred sixty-four (75%) of these patients were admitted for treatment of malrotation, whereas most of the remaining 55 patients (25%) were admitted for another diagnosis and underwent a Ladd's procedure incidental to another abdominal operation. Seventy-five patients underwent a Ladd's procedure during an emergency admission. Thirty-one patients had volvulus or intestinal ischemia, 7 underwent intestinal resection, and 1 patient died. Based on case weightings, it was estimated that 362 older children underwent a Ladd's procedure for symptoms related to malrotation in 2000 in the United States (5.3 cases per million population). Conclusions These findings provide support for performing a Ladd's procedure in older children with incidentally found malrotation to prevent the rare but potentially devastating complications of this anomaly.

Late presentation of malrotation: An argument for elective repair

Introduction. Midgut malrotation is not commonly diagnosed in adults. We reviewed our experience and present one of the largest reported series of operative repair of malrotation in adolescents and adults. Methods. Retrospective review of medical records that carried the diagnosis of anomaly of intestinal fixation or malrotation was performed in our health system between September 1993 and February 2004. Results. Since 1993, we treated 32 patients with varying degrees of malrotation whether the presentation be acute, chronic, or incidental with a Ladd Procedure. Ages ranged from 11 to 83 years old (mean 33), with a slight male preponderance (56% male). Symptoms were present from less than one day to most of a lifetime. Patients presented with acute abdominal pain (50%), nausea and vomiting (59%), constipation (50%), abdominal distention (41%) and chronic abdominal pain (25%). Initial work-up included CAT scan (28%), UGI study (38%), and plain films (47%) prior to surgery. Twenty-eight percent of patients were found to have midgut malrotation incidentally during an operation for another reason. All patients underwent Ladd’s procedure. Complications occurred in 22% of the incidental group, 25% in the elective group, and 60% of the nonelective/nonincidental group. Prolonged postoperative ileus (4 days) occurred in 28% of patients; however, patients that had their malrotation repaired electively had a lower rate of prolonged ileus: 11% in the incidental group, 25% in the elective group, and 40% in the nonelective/nonincidental group. Average length of stay was 7.6 days. Symptoms attributed to malrotation resolved in all cases. There were no second-look operations and no mortalities. Conclusion. Intestinal malrotation is an important entity to consider in nonpediatric patients with vague abdominal complaints. When symptoms progress to acute abdominal pain, postoperative complications are greater. Based on our experience with late presentation of intestinal malrotation, we recommend elective Ladd’s procedure, which can be performed safely.

Rotação gastro-esplênica inversa com ausência de rotação do intestino médio

We present a case of duodenal malrotation associated with microgastria, inverted splenic rotation and retrogastric spleen, treated succesfully by a Ladd's procedure, hiatal reconstruction and partial fundoplication.

Intestinal obstruction due to malrotation * Authors' response

Mr Awan and his colleagues (July 2004 JRSM1) report a case of malrotation in an adult. As they point out, this condition is much more often encountered in childhood. Paediatric surgeons would not agree that the operation done in this case, with an attempt to restore normal anatomy, was the correct one. The standard operative procedure is based on that described by Ladd 70 years ago—detorsion of the volvulus, division of adhesions, broadening of the small-bowel mesentery and positioning of the duodenum down the right side of the abdomen and the caecum into the left iliac fossa. There was a brief vogue in the 1960s for stabilization, as performed by Awan and colleagues, but this was never accepted by the paediatric surgical community; indeed a study by Shier et al.2 in 1987 confirmed that it has a higher morbidity than the Ladd procedure.

Introduction

This study sought to determine the reliability of wound classification guidelines when applied to neonatal operations.This study is a cross-sectional web-based survey of pediatric surgeons. From a random sample of 22 neonatal operations, participants classified each operation as “clean,” “clean-contaminated,” “contaminated,” or “dirty or infected,” and specified duration of perioperative antibiotics as “none,” “single preoperative,” “24 hours,” or “>24 hours.” Unweighted κ score was calculated to estimate interrater reliability.Overall interrater reliability for wound classification was poor (κ = 0.30). The following operations were classified as clean: pyloromyotomy, resection of sequestration, resection of sacrococcygeal teratoma, oophorectomy, and immediate repair of omphalocele; as clean-contaminated: Ladd procedure, bowel resection for midgut volvulus and meconium peritonitis, fistula ligation of tracheoesophageal fistula, primary esophageal anastomosis of esophageal atresia, thoracic lobectomy, staged closure of gastroschisis, delayed repair and primary closure of omphalocele, perineal anoplasty and diverting colostomy for imperforate anus, anal pull-through for Hirschsprung disease, and colostomy closure; and as dirty: perforated necrotizing enterocolitis.There is poor consensus on how neonatal operations are classified based on contamination. An improved classification system will provide more accurate risk assessment for development of surgical site infections and identify neonates who would benefit from antibiotic prophylaxis.

Minimally Invasive Surgery in Neonates: Ten Years' Experience

Background: This study reviews ten years' experience in our institution with minimally invasive surgery in infants. It evaluates the feasibility, safety, and efficacy of performing advanced endoscopic procedures in infants under 5 kg. Methods: From October 1992 through October 2002, 846 infants weighing 1.1 to 5.0 kg underwent 881 procedures using minimally invasive techniques. The majority of the procedures were performed using 3 mm instruments and 2.7 or 4 mm scopes. Procedures include Nissen fundoplication, pyloromyotomy, colon pull-through, patent ductus arteriosus (PDA) closure, Ladd's procedure, colon resection, congenital diaphragmatic hernia repair, tracheoesophageal fistula repair, and exploration. Results: Ninety-eight percent of procedures were completed successfully endoscopically. There were two intraoperative complications and no mortality. Days to discharge for patients admitted for their specific procedure were Nissen 1.1, PDA 1.3, pyloromyotomy 1, pull-through 2.6. Conclusions: This study...