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| LETTER TO THE EDITOR |
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| Year : 2022 | Volume
: 2
| Issue : 2 | Page : 83-84 |
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Ladd procedure in intestinal malrotation
Rathnaswami Arunachalam
Department of Surgical Gastro Enterology, SRM Medical College Hospital and Research Centre; Department of Surgical Gastro Enterology, Madras Medical College and Government General Hospital, Chennai, Tamil Nadu, India
| Date of Submission | 25-Feb-2022 |
| Date of Decision | 28-Feb-2022 |
| Date of Acceptance | 08-Mar-2022 |
| Date of Web Publication | 23-Mar-2022 |
Correspondence Address:
Rathnaswami Arunachalam
Department of Surgical Gastro Enterology, SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ghep.ghep_8_22
How to cite this article:
Arunachalam R. Ladd procedure in intestinal malrotation. Gastroenterol Hepatol Endosc Pract 2022;2:83-4 |
Dear Editor,
I read with interest the case series of acute abdomen with midgut malrotation presenting in adulthood published in the January 2022 issue of GHEP,[1] and wish to offer a few comments. Malrotation of the gut is diagnosed by locating the duodenojejunal junction not crossing the superior mesenteric vessels to the left side and by abnormal superior mesenteric artery (SMA) and superior mesenteric vein (SMV) orientation, the SMV being to the left of the artery. Duodenal and proximal jejunal twisting and obstruction occurs often due to the abnormally located duodenojejunal junction, not fixed by Treitz ligament. Malrotation usually presents acutely due to midgut volvulus in infants. Malrotation in adults may be associated with a number of chronic nonspecific symptoms, some of which could be due to recurrent reversible volvulus or rarely due to compression by bands that run from the right posterior abdominal wall to cecum crossing the duodenum anteriorly. When a patient with malrotation presents acutely, it is due to midgut volvulus unless proved otherwise. Such patients should be operated upon immediately to avoid catastrophic outcomes. Patients with malrotation may present with unrelated problems. If they develop acute appendicitis, the unusual location of the appendix causes diagnostic dilemma. Duodenal obstruction, or rarely perforation, is due to (recurrent reversible) volvulus, and rarely due to bands or intrinsic duodenal pathology such as duodenal stenosis. Patients diagnosed with malrotation should be advised surgery – Ladd's procedure – even if their symptoms are nonspecific to prevent future impending volvulus. The present case series must be viewed against this background.
The first patient reported, a 32-year-old woman with 2 days of abdominal pain, had no previous symptoms of abdominal angina or pain but was diagnosed to have acute SMA thrombosis. Acute onset of thrombosis without previous minor symptomatology would be quite uncommon. In this patient with a diagnosis of acute SMA thrombosis, the malrotation was just incidental as stated by the authors. There is no mention in the report of whether arterial thrombectomy or bypass was considered or attempted.
In the second case, the patient presented with acute appendicitis and was managed by appendicectomy. The Ladd's bands were released and the mesenteric base widened to prevent future volvulus. Here again, malrotation was an incidental anomaly.
The diagnosis in the third case was “band obstruction” which was released during surgery. Neither computed tomography nor the operative description mentions the presence or absence of volvulus. The 48 h wait before surgery suggests that volvulus was absent in the patient.
In the fourth case of duodenal perforation (with midgut malrotation) just closure of perforation, without Ladd procedure which could not be done, may not prevent future abdominal symptomatology.
The authors use the term Ladd's procedure for the surgical intervention carried out in their patients. It must be clarified that Ladd's procedure involves several steps, of which the first step, i.e., counterclockwise detorsion of the bowel, was not carried out in the patients described in this series. The Ladd procedure, first described in 1936 by Dr. W.E. Ladd, begins with counterclockwise detorsion of the bowel, division of Ladd bands, widening of the small intestine mesentery, and reorientation of the small bowel on the right and the cecum and colon on the left.[2],[3] A Ladd procedure does not result in a normal anatomical position of the bowel because the duodenojejunal flexure will always be malpositioned in these patients. Volvulus can recur if the mesentery is not widened sufficiently, and therefore, a previous procedure does not exclude volvulus as the cause of recurrent pain.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Katheresan V, Ramamurthy C, Kumar Dinesh K, Kesavan B, Ponchidambaram M, Sivasankar A. Case series of acute abdomen with midgut malrotation presenting in adulthood. GHEP 2022;2:20-2.  |
| 2. | Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston textbook of surgery: The biological basis of modern surgical practice. 21 st ed. St. Louis, Missouri: Elsevier Inc.; 2022. |
| 3. | Sutton JM, Beckwith MA, Johnson BL, Knod JL, Walther A, Watson CL, et al. editors. The University of Cincinnati Residents. The Mont Reid Surgical Handbook. 7 th ed. Philadelphia, PA: Elsevier, Inc.; 2018. |
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