Ladd's procedure for malrotation

Why are we operating?

The bilious-vomiting emergency: untwist the volvulus the wrong-rotated gut allowed, divide the bands, and widen the mesenteric stalk so it cannot twist again.

Indication: Malrotation with midgut volvulus is the emergency; malrotation found otherwise is discussed case by case.

The operation in 4 steps

1. 01Entry and assessment

   Rapid laparotomy; the gut is delivered and its rotation and colour assessed, the volvulus usually obvious as a twisted bundle on a narrow stalk.

   Why: Bilious vomiting in a neonate is midgut volvulus until proven otherwise because the whole small bowel hangs on the twisted stalk; the clock is measured in bowel viability, and diagnosis-to-knife time is the outcome.

2. 02Detorsion

   The volvulus is untwisted counterclockwise, and the bowel wrapped warm while perfusion declares itself.

   Why: The twist is conventionally clockwise, so the cure is counterclockwise turns until the mesentery lies flat. Then patience: bowel that looked doomed often pinks over minutes, and the difference is metres of child's intestine.

3. 03Dividing Ladd's bands and widening the mesentery

   The peritoneal bands crossing the duodenum are divided, the duodenum straightened, and the mesenteric base broadened by separating its leaves.

   Why: The bands obstruct the duodenum from outside; the narrow stalk is the recurrence risk. Both are corrected here, which is the actual operation named after Ladd.

4. 04Appendicectomy and final placement

   The appendix is usually removed, and the bowel returned deliberately: small bowel to the right, colon to the left.

   Why: The gut will now live in non-rotated anatomy, where a future appendicitis would present in the wrong quadrant and be missed; taking the appendix deletes that trap. The final layout is chosen, not tidied.

Danger zones

• Iliohypogastric nerve

  Runs between the oblique layers; injury causes groin numbness and weakens the inguinal canal mechanism.

• Cecum

  Immediately deep to the peritoneum; the reason the peritoneum is tented before opening.

• Appendiceal artery

  An end artery in the mesoappendix, secure ligation is the operation's key vascular step.

Anatomy you need

The bowel and its mesentery: malrotation narrows the mesenteric root, and widening it is the whole operation.

What can go wrong

• Postoperative ileus

  Distension, absent flatus, intolerance of diet, and quiet bowel sounds in the days after abdominal surgery.

• Surgical-site infection

  Wound erythema, warmth, discharge, and pain out of proportion, typically from postoperative day 4–7.

• Postoperative bleeding

  Tachycardia first, hypotension late; falling urine output; a distending abdomen or rising drain output.