Ladd's Procedure (Malrotation)
What the Examiner Expects
The definitive operation for intestinal malrotation, performed emergently for midgut volvulus or electively for diagnosed malrotation. The examiner expects you to recognize the presentation of midgut volvulus (bilious vomiting in a neonate — this is midgut volvulus until proven otherwise), diagnose with upper GI series (duodenojejunal junction does not cross the midline, corkscrew appearance), and describe the Ladd's procedure: (1) detorse the volvulus (counterclockwise — return the bowel to its pre-rotation state), (2) divide Ladd's bands (peritoneal bands crossing the duodenum from the cecum to the RUQ, causing duodenal obstruction), (3) widen the mesenteric root by separating the SMA from the SMV, (4) place the cecum and colon in the LLQ and the duodenum/small bowel in the RLQ, (5) appendectomy (the cecum will be in an abnormal position).
Key Examiner Focus Points
- Midgut volvulus is a life-threatening emergency — bilious vomiting in a neonate = volvulus until proven otherwise
- Upper GI series: corkscrew appearance of duodenum, DJ junction not crossing midline
- Ladd's procedure: detorse the volvulus (counterclockwise), lyse Ladd's bands, widen the mesenteric root, appendectomy
- The bowel is NOT fixed in normal position — the cecum is placed in the LLQ, duodenum stays on the right
- Appendectomy is performed because the cecum is left in an abnormal position
Common Curveballs
After detorsion, the entire midgut appears ischemic — dusky and non-peristaltic
Wrap the bowel in warm laparotomy pads and wait 15–20 minutes for reperfusion. If the bowel recovers with pink color and peristalsis, complete the Ladd's procedure. If it remains non-viable, resect only clearly necrotic bowel and plan a second-look laparotomy in 24–48 hours. Extensive small bowel resection in a neonate leads to short bowel syndrome — preserve every possible centimeter.
A 15-year-old is incidentally found to have malrotation on a CT scan — should you operate?
Controversial. Elective Ladd's procedure is generally recommended for incidentally discovered malrotation in children due to lifelong volvulus risk. In asymptomatic adults, the decision is more nuanced — some surgeons recommend observation given the lower volvulus risk, while others still recommend prophylactic Ladd's procedure. Laparoscopic approach is preferred for elective cases.