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.

Intestinal malrotation of the midgut is well documented in infants and children but rare in adults. Most adults with intestinal malrotation are asymptomatic, and the anomaly is found incidentally at laparotomy. Classically, the Ladd procedure via a laparotomy is the treatment of choice for patients with symptomatic malrotation. Laparoscopic Ladd procedures have been described in the pediatric literature, but little is known of its efficacy and applicability in adults. We present the case of a symptomatic adult patient found to have malrotation of the midgut with a cocoon deformity, a rare anomaly, that was treated successfully by a laparoscopic Ladd procedure, and we discuss the role of laparoscopy in this entity.

A 33-year-old female developed an isolated stricture of the mid portion of her ileal pouch nine years after proctocolectomy and J-ileal pouch-anal anastomosis for ulcerative colitis. Repeated episodes of pouchitis and partial small-bowel obstruction led to pouchoscopy and pouchography, which demonstrated pouch inflammation and a long, tight, midpouch stricture. Her diagnosis was changed to Crohn's disease and she was treated with azathioprine, budesonide, and infliximab. Repeat pouchoscopy demonstrated mucosal healing but a persistent fibrotic stricture. Pouch reconstruction was performed with a midpouch strictureplasty alleviating her obstructive symptoms. One year after surgery, the patient has no clinical evidence of obstruction and repeat pouchography demonstrates a wider pouch lumen across the strictureplasty site. Strictureplasty is an alternative to pouch excision in the management of patients with Crohn's disease who have an isolated pouch stricture.