Laparoscopic versus open Ladd’s procedure for intestinal malrotation in adults

Abstract

Background Intestinal malrotation results from errors in fetal intestinal rotation and fixation. While most patients are diagnosed in childhood, some present as adults. Laparoscopic Ladd's procedure is an accepted alternative to laparotomy in children but has not been well-studied in adults. This study was designed to investigate outcomes for adults undergoing laparoscopic Ladd's repair for malrotation. Methods We performed a single-institution retrospective chart review over eleven years. Data collected included: patient age, details of pre-operative work-up and diagnosis, surgical management, complications, rates of re-operation, and symptom resolution. Patients were evaluated on an intent-to-treat basis based on their planned operative approach. Categorical data were analyzed using Fisher's exact test. Continuous data were analyzed using Student's T-test. Results Twenty-two patients were identified (age range 18-63). Fifteen were diagnosed pre-operatively; of the remaining seven patients, four received an intra-operative malrotation diagnosis during elective surgery for another problem. Most had some type of pre-operative imaging, with Computed Tomography being the most common (77.3%). Comparing patients on an intent-to-treat basis, the two groups were similar with respect to age, operative time, and estimated blood loss. Six patients underwent successful laparoscopic repair; three began laparoscopically but were converted to laparotomy. There was a statistically significant difference in length of stay (LOS) (5.0±2.5d vs 11.6±8.1d, p=0.0148) favoring the laparoscopic approach. Three patients required re-operation: 2 underwent side-to-side duodeno-duodenostomy and 1 underwent a re-do Ladd's procedure. Ultimately, 3 (2 laparoscopic, 1 open) had persistent symptoms of bloating (n=2), constipation (n=2), and/or pain (n=1). Conclusion Laparoscopic repair appears to be safe and effective in adults. While a small sample size limits the power of this study, we found a statistically significant decrease in LOS and a trend toward decreased postoperative nasogastric decompression. There were no significant differences in complication rates, re-operation, or persistence of symptoms between groups.

Má rotação intestinal em adultos: um relato de caso e revisão da literatura / Malrotation in adults: a case report and literature review

“…Entretanto, entendemos que indicado o tratamento operatório, sua realização de forma eletiva quando possível, é preferencial à realização na urgência. O preparo adequado para o procedimento eletivo quando possível, seguramente é acompanhada de menor morbidade, motivo pelo qual foi a nossa opção terapêutica no presente caso (8)(9) .…”

Intestinal malrotation in an adult patient with other congenital malformations: A case report

“…However, some children may escape this period if they were asymptomatic or only had vague abdominal symptoms which were misinterpreted for another cause [ 5 ]. Diagnosis is rare and unexpected in adults due to presentation with non-specific symptoms such as colicky abdominal pain, bloating, chronic vomiting, malabsorption/inability to gain weight and alternating diarrhoea and constipation [ [1] , [2] , [3] ].…”

“…Surgical management of intestinal malrotation at any age is by the Ladd’s procedure [ 3 ]. This procedure was first described by William Ladd in 1936 and consists of the following steps [ 2 , 12 , 18 , 19 ]: Division of Ladd’s bands (fibrous bands) lying over the duodenum to the caecum Widening of the narrowed root of the mesentery Counterclockwise detorsioning of the midgut volvulus if present and inspecting the bowel to observe if bowel resection is required Appendicectomy if required Placing the small bowel to the right and fixing the colon to the left …”

“…Ladd’s procedure can be performed through midline laparotomy or laparoscopically. Usually if an adult patient presents acutely, as in our case, it is reasonable to proceed to midline laparotomy [ 3 ]. Laparoscopy appears to be safe and effective when performed by experienced laparoscopic surgeons and usually in the absence of volvulus [ 12 ].…”

“…Cases of adult intestinal malrotation are rare but can have devastating consequences if not recognised early. Usually, adults with intestinal malrotation report chronic abdominal symptoms such as intermittent abdominal pain and vomiting, bloating, malabsorption and alternating constipation and diarrhoea [ [1] , [2] , [3] ]. Gold standard diagnosis in adults is usually with cross-sectional imaging with oral and intravenous contrast (computed tomography (CT)), although it is often encountered intra-operatively as well [ 4 ].…”