Laparoscopic Ladd Procedure

Intestinal malrotation refers to abnormal rotation and/or fixation of the midgut. As the intestine re-enters the abdominal cavity during the 8th to 10th gestational week, it undergoes a 270-degree counterclockwise rotation that causes the duodenum to be fixed to the retroperitoneum, thereby creating the ligament of Treitz. When the intestine does not re-enter or become fixed, various degrees of malrotational anatomy occur, which predisposes the intestine to twist on the resultant narrow mesentery or become obstructed through the presence of congenital (Ladd) bands. The laparoscopic approach for malrotation without volvulus has been well reported, and laparoscopic treatment with volvulus is gaining popularity as well.

Indications for Workup and Opeartion

Bilious emesis is an indication for an emergent upper gastrointestinal (UGI) contrast study to evaluate for malrotation with or without volvulus. When volvulus is identified, emergent operative intervention is indicated. In experienced hands, laparoscopy can be utilized in this situation. However, when the anatomy or bowel viability is unclear, conversion to an open approach is reasonable.

Laparoscopy is an ideal approach when the UGI study is equivocal or shows a low-lying ligament of Treitz ( Fig. 7-1 ). The intestinal anatomy can be assessed ( Fig. 7-2 ), and the surgeon can proceed with a laparoscopic Ladd procedure if indicated.

While a UGI contrast study is the most common diagnostic modality, ultrasound is becoming more commonly used. When malrotation with volvulus is present, the superior mesenteric artery and vein are seen to be inverted on ultrasound. Cross-sectional imaging (computed tomography and magnetic resonance imaging) is also used ( Fig. 7-3 ) but less commonly in the pediatric population.

Operative Technique

General anesthesia is induced and adequate intravenous access is established. The child is positioned in the supine position on the operating table. When the patient is positioned in the normal supine position, the surgeon will usually stand on the patient’s right and the assistant on the patient’s left ( Fig. 7-4 ). For a neonate, some surgeons prefer to turn the baby sideways on the table as is usually done for a laparoscopic pyloromyotomy. The infant can also be positioned at the foot of the bed ( Fig. 7-5A ). When this positioning is used, the surgeon and assistant stand at the foot of the patient with the monitor over the patient’s head.