Laparoscopic Ladd Procedure Research Articles

A case of isolated malrotation without midgut volvulus diagnosed prenatally and treated by laparoscopic surgery

BackgroundMalrotation is a congenital condition that predisposes individuals to midgut volvulus, which can result in significant bowel resection. While most cases of malrotation are diagnosed by the age of 1 year, typically presenting with symptoms related to volvulus or bowel obstruction, some cases remain asymptomatic. In children with visceral malposition, gastroschisis, omphalocele, or diaphragmatic hernia, malrotation may be suspected before symptoms manifest. However, isolated malrotation without midgut volvulus diagnosed prenatally is rare. We herein present a case of isolated malrotation without midgut volvulus that was prenatally diagnosed and successfully treated with laparoscopic surgery.Case presentationA 30-year-old woman (gravida 3, para 1) underwent routine obstetric ultrasound, which revealed increased blood flow in the lower uterine segment and abnormal placental attachment. To rule out placenta percreta, magnetic resonance imaging was performed at 34 weeks of gestation. Incidentally, abnormal fetal intestinal arrangement was noted, with the colon localized in the left hemi-abdomen and the small intestine distributed in the right hemi-abdomen, raising suspicion of malrotation. Postnatal contrast studies confirmed the diagnosis of malrotation without midgut volvulus. Given the risk of midgut volvulus, a laparoscopic Ladd’s procedure was performed on day 6 of life. The postoperative course was uneventful, and the patient was still symptom-free 1 year postoperatively.ConclusionsThis case illustrates that malrotation can be prenatally diagnosed using fetal magnetic resonance imaging. Considering the risk of midgut volvulus, prophylactic Ladd’s procedure should be performed in neonatal period. In cases where malrotation is not complicated by midgut volvulus, a laparoscopic Ladd procedure can be safely performed in neonates.

Intestinal malrotation in the adult population: Diagnosis, management, and outcomes after laparoscopic Ladd procedure

BackgroundThe Ladd procedure is the treatment of choice for patients with intestinal malrotation; however, the long-term outcomes of the laparoscopic Ladd procedure are not well documented. This study aimed to review the presentation, management, and outcomes of adult patients who underwent a laparoscopic Ladd procedure. MethodsA retrospective review was conducted to identify adult patients with malrotation who underwent a laparoscopic Ladd procedure between January 1995 and June 2022 at the Mayo Clinic in Rochester, Minnesota. Patient details and follow-up data were obtained from the electronic medical records. Patients were invited to participate in a structured phone interview to assess symptoms and quality of life (QoL). ResultsA total of 44 patients underwent the laparoscopic Ladd procedure. Of the 44 patients, 42 (95.5 %) were symptomatic, with 7 (16.7 %) presenting with acute symptoms. Moreover, 8 laparoscopic procedures (13.6 %) required conversion to an open procedure. The median estimated blood loss was 20 mL (IQR, 10–50), operative time was 2.3 h (IQR, 1.8–2.8), and hospital length of stay was 2 days (IQR, 2–3). Postoperative ileus was the most common complication (18.0 %). The median follow-up was 8.00 years (IQR, 2.25–13.00), with more than 90.0 % of patients having partial or complete symptom resolution. Of note, 28 patients (63.6 %) completed phone interviews. Moreover, 1 patient (2.0 %) reported a postoperative volvulus. When asked to compare their current symptoms with those preoperatively, 78.6 % of patients noted that they were significantly better. Furthermore, 85.7 % of patients reported that their QoL was significantly better after surgery. Finally, 96.4 % of patients would recommend the procedure to a friend or family member with the same condition. ConclusionThe laparoscopic Ladd procedure is a safe and effective surgical procedure for adult patients with intestinal malrotation.

Massive Chylous Ascites in a 9-Year-Old Girl with Malrotation-A Case Report.

Malrotation leading to massive chylous ascites is rare. A 9-year-old girl was investigated for slowly increasing abdominal distension under a year. She had no vomiting, weight loss, or pain, but was bothered in social situations. Medical investigations, including ultrasound and computed tomography scans, revealed massive ascites. Laparocentesis yielded milk-colored fluid, confirmed as lymph through laboratory analysis. A complete blood count, liver function and hematologic parameters, chyle cytology, bacterial cultures, and polymerase chain reaction for tuberculosis were all within normal limits. She was referred to a tertiary center for vascular anomalies. A dynamic contrast-enhanced magnetic resonance lymphangiography showed normal lymphatic anatomy without leakage or flow obstruction. A whole-body magnetic resonance imaging revealed a central mesenteric rotation. She was referred to a tertiary center for pediatric surgery, where a laparoscopic Ladd's procedure was performed using a new 5 mm pediatric sealing device, along with an appendectomy using a 5 mm stapler. To derotate the bowel, fenestrations were created in compartments containing a substantial amount of chyle and ascites, resulting in the drainage of 2.4 L of fluid. She was discharged the day after surgery and has been in good health for 1 year. We present a video illustrating the Ladd's procedure steps in this patient.

Effect of neuromuscular block on surgical conditions during laparoscopic surgery in neonates and small infants: A randomised controlled trial.

Neuromuscular block (NMB) is routinely used in paediatric and adult anaesthesia to facilitate endotracheal intubation and optimise surgical conditions. However, there are limited data regarding NMB and optimising the conditions for laparoscopic surgery in neonates and small infants. The goal of this study was to determine the effect of NMB on the conditions for laparoscopic surgery in neonates and small infants. A randomised controlled trial. Single-centre Children's Hospital, conducted from November 2021 to December 2022. One hundred and two ASA I-II neonates and small infants aged up to 60 weeks postmenstrual age who were scheduled to undergo an elective laparoscopic Ladd's procedure were included in the study. Patients were randomised into three groups: no NMB group, shallow NMB group and moderate NMB group. Each group was given different doses of rocuronium to achieve the target depth of NMB. The primary outcome was the quality of the surgical conditions evaluated with the Leiden-Surgical Rating Scale (L-SRS) by a blinded surgeon. Secondary outcomes included tracheal intubating conditions and adverse events. The percentage of L-SRS scores of 4 or 5 was similar among the three groups at all the assessment times (P > 0.05 for each time interval). The distribution of L-SRS scores was also similar among the three groups. There were no significant differences in operating condition scores between the groups at any time interval (P > 0.05 for each time interval). The incidence of adverse events during anaesthesia induction was significantly higher in the no NMB group (51.4%) than in the other two groups (13.6% and 14.7%) (adjusted P = 0.012 and adjusted P = 0.003). In particular, clinically unacceptable intubation conditions occurred in 12 patients (34.3%) in the no NMB group, significantly more than in the shallow NMB group (6.1%, adjusted P = 0.012) and moderate NMB group (2.9%, adjusted P = 0.003). There was no statistically significant difference in the incidence of adverse events in the PACU among the three groups (P = 0.103). The depth of NMB was not associated with superior surgical conditions during laparoscopic surgery, but it was associated with a reduction in adverse events during induction and maintenance of anaesthesia in neonates and small infants. Registered at www.chictr.org.cn (ChiCTR2100052296).

Laparoscopic Ladd's procedure for the repair of a right paraduodenal hernia in pediatric patients – A case series

Right paraduodenal hernias are a consequence of midgut malrotation resulting in small bowel encased in a peritoneal-lined hernia sac posterior to the right mesocolon. An indistinct presentation often lends a difficult clinical diagnosis and identification on diagnostic laparoscopy; however, when identified, surgical repair should ensue due to a significant lifetime risk of small bowel incarceration. Two female adolescents (ages 12 and 16-years-old) were referred to Pediatric Surgery clinic for intermittent abdominal pain and frequent emesis with radiographic and endoscopic findings consistent with intestinal malrotation. Patients underwent diagnostic laparoscopy at which time a right paraduodenal hernia was identified. Repair was performed via a laparoscopic hernia reduction and laparoscopic Ladd's procedure with appendectomy. Procedure time was 96–206 minutes. There were no intraoperative or postoperative complications to date. Both patients reported near to complete resolution of abdominal pain and emesis. Laparoscopic paraduodenal hernia reduction and Ladd's procedure with appendectomy is a novel, minimally invasive approach to the repair of right paraduodenal hernia in children.

Congenital Intestinal Malrotation in Newborns: Laparoscopic Ladds Procedure versus Open Laparotomy

To assess the efficacy and safety of laparotomic or laparoscopic Ladd's procedure in newborns with congenital malrotation. Descriptive study. Department of Pediatric Surgery, Ganzhou Maternal and Child Health Care Hospital, Ganzhou JiangXi province, China, from January 2015 to December 2021. The clinical data of newborns with malcorrection were retrospectively analysed. Patients were divided into laparotomy group (64 cases) and laparoscopy group (30 cases), according to the surgery they had been subjected. The patients who had the severe malformations, underwent the laparoscopic Ladd's procedure at the first 10 cases, and had found bowel necrosis during operation were excluded. The general data such as lengths of operation, intraoperative blood loss, time-to-diet, lengths of hospital stay, and postoperative complications were compared between the two groups. Crude comparisons showed that the laparoscopy increased the lengths of operative time (70.0 vs. 110.0 minutes, p <0.001) but decreased the postoperative complications (25.0% vs. 6.7%, p=0.035). The intraoperative blood loss, time-to-diet, and lengths of hospital stay between the two groups were not statistically significant (p=0.109, 0.065, and 0.858 respectively). The intestinal volvulus in the two groups (43.8% vs. 80.0%, p=0.001) had statistical differences. Using modified Poisson regression analysis, adjusting for confounding differences of midgut volvulus, lengths of operation time and intraoperative blood loss, and laparoscopic Ladd's showed a significant decrease in postoperative complications (RR=0.13,95%CI 0.03-0.54, p=0.005). Laparoscopic Ladd's procedure is feasible to treat neonatal malrotation and is associated with lower postoperative complications of newborns with congenital malrotation. Newborns, Congenital malrotation, Laparoscopy, Laparotomy, Complications.

Laparoscopic Versus Open Ladd's Procedure for Intestinal Malrotation in Infants and Children: A Systematic Review and Meta-Analysis.

Aim: To compare clinical outcomes in infants and children with intestinal malrotation who were treated by laparoscopic or open Ladd's. Methods: PubMed, EMBASE, and Cochrane library were searched for studies comparing laparoscopy with open Ladd's for intestinal volvulus through January 5, 2021. Search terms were confined to Title/Abstract: "Intestinal Volvulus" OR "Intestinal malrotation" AND "Laparoscopy" AND "Laparotomy." Randomized controlled trials (RCTs) and retrospective studies comparing laparoscopy with open Ladd's in neonates, infants, or children were included. Outcomes evaluated included operative time, time to full feeds, length of hospital stay, rate of conversion, reoperation, overall postoperative complications, postoperative adhesive small bowel obstruction, and postoperative volvulus. Pooled odds ratios (OR) were calculated for dichotomous variables; pooled mean differences (MDs) were measured for continuous variables. Results: Fourteen studies were included, comprising 444 patients who underwent laparoscopic approach and 1422 patients who underwent open procedure. Laparoscopy group had shorter operative time (MD = -14.44 minutes, 95% confidence interval [CI] = -20.79 to -8.09, P < .00001), hospital stay (MD = -4.57 days, 95% CI = -7.58 to -1.56, P = .003), and time to full feeds (MD = -3.00 days, 95% CI = -3.80 to -2.19, P < .00001). Laparoscopic Ladd's procedure had less overall postoperative complications (OR = 0.35, 95% CI = 0.19-0.65, P = .0009), less postoperative adhesive small bowl obstruction (OR = 0.37, 95% CI = 0.19-0.74, P = .005), and more postoperative volvulus (OR = 2.97, 95% CI = 1.23-7.13, P = .02). There was no difference in incidence of reoperation rate (OR = 2.04, 95% CI = 0.96-4.33, P = .06). Conclusion: Laparoscopic procedure is superior to open Ladd's in operative time, hospital stay, time to full feeds, overall postoperative complication, and postoperative adhesive small bowel obstruction. However, more RCTs with adequate follow-up are needed to overcome the limitations of our study.

Laparoscopic Ladd Procedure for Malrotation in Newborns and Infants

Laparoscopic approach for malrotation has become more popular for neonates and in cases with volvulus, but its safety and efficacy remains controversial. This study reviewed laparoscopy outcomes in neonate/infant malrotation. Medline/PubMed and Lilacs databases were reviewed. Data from studies published in English/Spanish between 1995 and 2019 were collected. Results are presented as percentages and means/medians; logistic regression was used to study possible associations. Nineteen papers offered 99 neonates/infants with median age and weight of 10.5 days and 3.5 kg, respectively. Ladd's procedure was performed in 95 (96%) patients and bands' division in 4 (4%); appendectomy was not included in 16 (16.2%) patients, and cecopexy was not performed in all cases. Volvulus was reported in 39 (39.4%) patients. There were 11 conversions (11.1%) and 10 recurrences of symptoms (10.1%) that required reintervention. An association was found between volvulus and recurrence (P = .05) and the need for conversion (P < .01). There were 10 (10.1%) minor complications and no mortality. The median follow-up was 10 months. Laparoscopic approach to malrotation is feasible and safe in hemodynamically stable neonates/infants without intestinal necrosis and is associated with 11% conversion rate and 10% reinterventions. The presence of volvulus is associated with recurrence and conversion. Laparoscopic Ladd's procedure with appendectomy and without cecopexy is the commonly practiced approach that is associated with minor complications.

Laparoscopic Ladd Procedure for the Management of Malrotation and Volvulus

Introduction: While laparoscopic Ladd procedure is commonly performed in patients with asymptomatic malrotation, a paucity of data exists on children with volvulus or with low weight (≤3 kg). Our purpose was to evaluate the safety and efficacy of the laparoscopic Ladd procedure in these complex patient populations. Methods: A retrospective review of patients undergoing operation for malrotation from 2008 to 2018 was performed. Specific subgroup analysis was performed comparing outcomes after open and laparoscopic approaches in patients presenting with acute volvulus or in low-weight (<3 kg) patients. Results: Out of 110 patients, 38 (35%) presented with volvulus and 72 (65%) without volvulus. In patients with volvulus, 16 (42%) underwent laparoscopy and 22 (58%) had an open procedure. More patients in the open group had a preoperative diagnosis of volvulus (63.6% vs. 12.5%, P = .002). Operative time was longer in the laparoscopic group (87 vs. 61 minutes, P = .029), with 7 patients being converted to an open procedure (44%). Days to regular diet, hospital length of stay, and recurrent volvulus were similar between groups. In patients weighting <3 kg, 10 patients underwent laparoscopy and 10 patients had an open procedure. Demographics, operative time, postoperative outcomes, and complications were similar between groups. One person in the laparoscopic group was converted to open. Conclusion: Laparoscopic management of malrotation, even in the presence of volvulus and low patient weight, is safe and effective, with low rates of recurrent volvulus. If exposure is suboptimal, conversion to open in patients with volvulus should be considered.

Laparoscopic 'steering wheel' derotation technique for midgut volvulus in children with intestinal malrotation.

Introduction:Since the first description by William Ladd, the Ladd's procedure has been the surgery of choice for the correction of malrotation. The laparoscopic Ladd's procedure is becoming popular with the advent of minimal access surgery and is described in the literature. Various techniques of the Ladd's procedure have been described but none of them describes the stepwise technique for derotation of volvulus which is the most difficult and confusing part of the surgery. We describe ‘steering wheel’ technique for easy derotation of volvulus associated with malrotation.Method:A total of 62 patients were diagnosed to have an intestinal malrotation between 2010 and 2017. All cases which had complete non-rotation with a midgut volvulus were reviewed. Out of these, 48 patients were operated with open technique and 14 patients were subjected to the laparoscopic correction.Technique:Using three-port technique, stepwise derotation of volvulus is done which simulates the rotation of steering of car at an acute turn and has been described in four simple steps. This technique also stresses the importance of the release of Ladd's band before derotation.Results:Of 62 patients diagnosed with malrotation, 14 (22.6%) patients underwent the laparoscopic Ladd's procedure. The mean age was 26 + 8 months, mean weight was 10 + 2 kg and included eight males (57%) and six females (43%). There was only one (7.14%) conversion to open technique, due to a huge dilatation of duodenum causing difficulty in dissection in a patient with malrotation without volvulus. The laparoscopic Ladd's procedure took an average time of 70 ± 15 min.Conclusion:The laparoscopic ‘steering wheel’ derotation technique is easy and provides a stepwise description of the laparoscopic derotation of volvulus associated with malrotation in children.

Reoperation after Ladd's procedure in the neonatal period.

To investigate (1) the indications for reoperation after neonatal Ladd's procedure, (2) the type of reoperation and (3) its outcome. We reviewed all neonatal Ladd's procedures in our hospital from 2003 to 2017 and the outcomes of reoperation in these patients. 252 neonates had Ladd's procedure: 59 were laparoscopic (23.4%) and 193 open (76.6%). 15 (6.0%) required reoperation with no difference between laparoscopic and open (p = 0.12). Overall, the indications for reoperation were: adhesive intestinal obstruction (n = 10, 4.0%), recurrent midgut volvulus (n = 4, 1.6%), and missed diagnosis of associated anomaly (n = 1, 0.4%). The incidence of recurrent midgut volvulus was higher after laparoscopic Ladd's procedure (3/59; 5.1%) compared to open Ladd's procedure (1/193; 0.5%) (p = 0.04). Adhesive intestinal obstruction developed after both open (8/193, 4.1%) or laparoscopic Ladd's procedure (2/59, 3.3%). The duration of reoperation and the length of post-operative hospital stay were 63.4 ± 27.1min and 10.1 ± 5.2days, respectively. After reoperation, there were no post-operative complications. All children were well at follow-up (6months-14years). In neonates, laparoscopic Ladd's procedure compared to the open Ladd's procedure is associated with a significantly higher risk of recurrent volvulus. The risk of developing this potentially dangerous complication after laparoscopic Ladd's procedure raises doubts about the effectiveness and safety of the laparoscopic approach in neonates.

Laparoscopic Ladd's procedure for malrotation in infants and children is still a controversial approach

BackgroundOpen Ladd's procedure is the gold standard for the correction of intestinal malrotation and laparoscopic approach remains controversial. This study aimed to evaluate our experience in laparoscopic management of malrotation. MethodsSingle center retrospective study including patients who underwent a laparoscopic assessment of intestinal malrotation with correction if appropriate between 2007 and 2017. ResultsSixty-five patients (median age 7 months) had a laparoscopic assessment with and without correction of malrotation. Forty-five (69%) were symptomatic, including 16 (25%) with a midgut volvulus. The procedure was completed laparoscopically in 55 (86%) patients in 110 min (30–190). Conversions happened more frequently at the beginning of the experience. With a follow-up of 12.5 months (8 days–5.3 years), morbidity rate was 15% and 4 (6%) patients underwent a redo surgery, all in the first 5 months after surgery, compared with 3/53 (6%) in a contemporaneous group undergoing open Ladd's. ConclusionThis is the largest series reported so far of the laparoscopic management of malrotation. Laparoscopic Ladd's procedure is reliable but still exposes to open conversion which may be in part owing to a learning curve. A low conversion threshold is important in cases with volvulus. The redo rate is similar to that of the open procedure. Level of evidenceLevel III retrospective comparative treatment study.

Is less more? Laparoscopic versus open Ladd's procedure in children with malrotation

BackgroundWith the advent of minimally invasive techniques, laparoscopic Ladd's procedure is increasingly used to treat children with malrotation, yet evidence regarding its safety and efficacy is lacking. We hypothesize that operative and postoperative outcomes with the open technique are superior to the laparoscopic Ladd's procedure. MethodsWe conducted a 5-y retrospective chart review of all patients who underwent Ladd's procedure at our institution from 2010-2015. Exclusion of patients included those with concomitant conditions, such as poor gut perfusion, significant reflux, tracheoesophageal fistula, failure to thrive requiring concomitant gastrostomy, and biliary atresia. Kruskal–Wallis and Mann–Whitney tests were used where appropriate. ResultsBetween 2010 and 2015, of 130 patients who underwent Ladd's procedure, 77 met inclusion criteria. Sixty-two patients underwent initial open surgery, 15 patients underwent laparoscopy, seven of which were converted to open. Patients undergoing open surgery were younger compared to the laparoscopic groups. Thirty-three of the 77 malrotation patients (43%) presented with volvulus, 27 underwent open surgery, four had laparoscopic converted to open procedures, and two patients underwent laparoscopic Ladd's without incident. Laparoscopy resulted in increased operative time and clinic visits. Patients undergoing laparoscopic to open surgery had longer operative times, time to resume diet, and length of hospital stay. No difference was noted in complications among the groups. ConclusionsAlthough minimally invasive approaches are becoming increasingly used, no evidence supports laparoscopic superiority over open Ladd's procedure. We found that open surgery was associated with shorter operating times and fewer clinic visits. Furthermore, laparotomy remains the favored procedure for patients presenting with volvulus.

Sonographic Findings of Midgut Malrotation With Volvulus: A Case of Upper Intestinal Obstruction in a Neonate

Midgut malrotation is a congenital condition resulting from incomplete normal intestinal rotation after physiologic gut herniation. While it can remain asymptomatic over an entire lifetime, midgut volvulus is most likely to occur during early life. While an upper gastrointestinal series is the imaging modality of choice for definitive diagnosis, sonography is a safe and effective modality capable of indicating midgut malrotation, especially in pediatric patients. This case study illustrates the sonographic findings associated with intestinal malrotation with volvulus and discusses the etiology, signs, symptoms, and treatment of the condition. In addition, the sonographic findings are correlated with upper gastrointestinal results, which confirmed midgut malrotation. The diagnosis of volvulus secondary to midgut malrotation was confirmed by a laparoscopic Ladd procedure performed to treat the neonate.

Laparoscopic Ladd'S Procedure in Children: Challenges, Results, and Problems.

Background:Laparoscopic correction of malrotation in children is challenging. Authors review their experience with indications, results and problems of laparoscopic correction of malrotation.Materials and Methods:This is a retrospective study of 41 cases of children who were diagnosed as Intestinal malrotation on clinical and radiological evaluation.Results:Successful laparoscopic Ladd's procedure was accomplished in 35 cases. There were six conversions to open surgery. The mean hospital stay was 4 days (range 3-12days). Restoration of complete feed was achieved on an average of 3 days (range 2-4days). Post-operative recurrence of symptoms was seen in nine cases. Of which, five cases had incomplete correction, three cases had duodenal kinking due to adhesive intestinal obstruction and one had intra luminal duodenal obstruction. All patients underwent open surgery for recurrent symptoms.Conclusion:Laparoscopic Ladd's procedure is feasible in children with intestinal malrotation with or without associated volvulus. However, some of them need conversion to open surgery due to difficult local anatomy. For persistent symptoms, they may require redo surgery, which may be due to incomplete correction, adhesive obstruction or intraluminal obstruction.

A Case of Adult Intestinal Malrotation Diagnosed Preoperatively with Computed Tomography and Treated with a Laparoscopic Ladd Procedure

A Case of Adult Intestinal Malrotation Diagnosed Preoperatively with Computed Tomography and Treated with a Laparoscopic Ladd Procedure

Laparoscopic diagnostic finding in atypical intestinal malrotation in children with equivocal imaging studies.

Background:Atypical presentation of intestinal malrotation provide a diagnostic and therapeutic dilemma for the surgeon to answer the question is it wisdom to operate or not? Upper gastrointestinal (UGI) contrast study is essential for diagnosis; however, 'soft’ radiologic findings place the responsibility of excluding malrotation directly on the surgeon. Recently, minimally invasive surgical techniques would be able to accomplish the identical evaluation and treatment of this group of patients.Patients and Methods:A total of 40 patients (25 male, 15 female), age of 2-14 years, presented with symptoms of chronic abdominal pain, intermittent upper intestinal obstruction, recurrent bilious vomiting and failure to thrive. On clinical examination, none of the patients had signs of acute abdominal emergency. UGI contrast study was done and it was equivocal. All patients underwent laparoscopic evaluation.Results:A total of 36 patients (90%) were found on laparoscopy to have a discrepant finding of chronic intestinal malrotation. With narrow mesenteric base which put them at significant risk of midgut volvulus. Two patients (5%) were found to have chronic appendicitis with extensive adhesion at the right iliac fossa, one patient (2.5%) has annular pancreas and one patient has negative laparoscopic exploration. Laparoscopic findings of chronic intestinal malrotation includes, huge dilated stomach and the first part of duodenum, ectopic site of caecum central in the abdomen or under the liver, medial and low position of duodenojejunal junction, congested mesenteric veins with lymphatic oedema, generalised mesenteric lymphadenopathy, reversed relation of superior mesenteric artery and vein, right-sided small bowel.Conclusion:Laparoscopic diagnostic finding permits direct evaluation and treatment of undocumented malrotation in children, with equivocal UGI contrast study. Furthermore, laparoscopy provides an excellent opportunity to assess the base of the mesentery. Those children with a narrow base should undergo laparoscopic Ladd procedure to avoid catastrophic midgut volvulus.

Simultaneous laparoscopic repair of intestinal malrotation and ileal duplication

Abstract An 8-year old boy was referred for chronic, frequent bilious vomiting and intermittent abdominal pain. Intestinal malrotation was diagnosed by upper gastrointestinal study (UGI) and laparoscopic Ladd's procedure was performed. Ladd's bands were laparoscopically dissected out, and the mesentery was dissected to be broaden. After performing Ladd's procedure, an ileal duplication cyst was found 30 cm proximal to the terminal ileum, which was extracted through the umbilical port site and was totally resected. Three years postoperatively, the patient has had no further symptoms.

Malrotation with Isomerism: Laparoscopic Ladd Procedure

Introduction: Isomerism is a rare congenital condition in which one side of the body is a mirror image of the opposite side of the body. Abdominal manifestations include abnormal stomach positioning with possible malrotation of the intestines.1 If malrotation occurs, a laparoscopic Ladd procedure is performed. Materials and Methods: This video shows a laparoscopic Ladd procedure done in a 9-month-old male with right-sided isomerism and asymptomatic intestinal malrotation. Access to the right lower quadrant was achieved by a modified Hasson technique with a Step™ trocar (Auto-Suture) placed through a 5 mm incision in the umbilicus. Pneumoperitoneum was established using 5 L/minute of carbon dioxide under 12 mm Hg of pressure. A 30° telescope camera was inserted into the peritoneal cavity for proper observation. Next, two 3 mm incisions were made in the lower right and left abdominal quadrants. A 3 mm port was placed on the right and a 5 mm port was placed on the left with Step trocars (Auto-Suture). Important structures were immediately identified. The liver was located in the center of the abdomen and the spleen was absent, suggestive of right-sided isomerism. The attachment between the splenic flexure of the colon and the left lateral abdominal wall was divided. The colon was then reflected downwards, exposing the centrally located stomach. Duodenal loops were released from the Ladd bands, allowing for observation of the pancreas lying inside of the C-loop of the duodenum. While looking for the distal portion of the jejunum, it was discovered that the entire jejunum was trapped retroperitoneally, creating a mesocolic hernia. Using hook diathermy, the entire bowel was released down to the ileocecal region, which was in its normal anatomical location in the right lower quadrant. The appendix appeared normal. Using hook diathermy, the mesentery of the appendix was taken down. The appendix was ligated with two 3′0 Vicryl ties, resected, and removed through a port site. All of the small bowel was placed on the right side of the abdomen, and all of the large bowel was placed on the left. Finally, the stomach was insufflated to rule out an intrinsic duodenal obstruction. Air passed easily into the stomach and across the duodenum, confirming patency. The bowel appeared completely viable. Ports were withdrawn after desufflating the pneumoperitoneum. The umbilical port site was closed with 2-0 Vicryl UR-6 single suture. All other port sites were closed with Dermabond glue. Results and Conclusions: There were no postoperative complications. The patient began tolerating feeds on post-operative day #3 and was discharged on post-operative day #4. No competing financial interests exist. Runtime of video: 5 mins 51 secs

Laparascopic Ladd's procedure as treatment alternative, when parenteral or prolonged hospital nutrition is not an option for superior mesenteric artery syndrome

ObjectivesSuperior mesenteric artery syndrome (SMAS) is an uncommon cause of duodenal obstruction in pediatric patients. It is extremely rare in young infants. The classic treatment for SMAS has been an open or laparoscopic duodenojejunostomy when conservative medical therapy failed to resolve the obstruction. We herein reported 3 cases of SMAS in infants treated by laparoscopic Ladd's procedure. The advantages and feasibility of laparoscopic Ladd's procedure applied for SMAS in infants were discussed. MethodsThree cases of infants with SMAS subjected to laparoscopic Ladd's procedure in our hospital were collected from January 2014 to December 2015. The patients' age, operative time, postoperative hospital observation, resumption of full diet, and postoperative complications were analyzed. ResultsThe median age at operation was 8 months (range, 6–9 months). The mean body weight was 7.9 kg (range, 6.5–8.8 kg). The mean operative time was 66.7 min (range, 65–75 min). The mean postoperative hospital stay was 4.3 days (range, 4–5 days) and the follow-up was 20.7 months (range, 12–34 months) without any specific postoperative complications. ConclusionBased on our reports, laparoscopic Ladd's procedure is a reliable and practicable minimally invasive surgery for in infants with SMAS.