03 / Pediatric Surgery · open
Ladd's procedure for malrotation
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.
Read the imaging first
Practice before you scrub
The study that cannot wait
A three-day-old, previously feeding well, vomits bile twice. Urgent upper GI contrast study. (Fictional educational case.)
- Bilious vomiting in a neonate is malrotation with volvulus until proven otherwise, and this study is the urgent proof either way.
- The corkscrew or a misplaced DJ flexure sends the child to theatre now: Ladd's procedure, with centimetres of midgut as the currency of delay.
On the tray for this operation
Test yourself on the tray
Scalpel
Sharp division of tissue, most visibly the skin incision.
Richardson retractor
Retracting deeper wound edges, the abdominal wall's workhorse.
Metzenbaum scissors
Fine dissection of delicate tissue and planes.
DeBakey forceps
Atraumatic handling of vessels, bowel, and delicate tissue.
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Mosquito clamp
Clamping small bleeders and fine structures.
Kelly clamp
General-purpose clamping of vessels and tissue pedicles.
Needle driver
Holding the curved needle while suturing.
Stage
1 / 4
Entry 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.
Watch for: Delay costing the entire midgut
Why are we operating?
Ladd's procedure makes malrotation safe: the volvulus is untwisted, the peritoneal bands crossing the duodenum are divided, and the mesentery is broadened from a twistable stalk into a stable fan, with the appendix removed because it will live forever in the wrong quadrant. It does not create normal anatomy, it creates safe anatomy, and in the volvulised neonate it is a race for the entire midgut.
Pulls toward surgery
Gives the team pause
Shared foundations
What the surgeon is thinking
Entry and assessment
What is the first look actually grading?
The midgut's colour and the twist's tightness: dark congested bowel that may recover, or frank necrosis from duodenum to transverse colon, the anatomy of the superior mesenteric artery strangled at its root. The assessment sets the operation's register: routine Ladd's, or a fight for intestinal survival.
Detorsion
Why counterclockwise, and why then wait?
The volvulus almost always twists clockwise, so the gut is rotated counterclockwise ('turning back the clock') until the mesentery lies flat. Then warm packs and patience: reperfusing bowel declares itself over minutes, pinking and recovering peristalsis, and the waiting is diagnostic, deciding what if anything must be resected.
Dividing Ladd's bands and widening the mesentery
How does dividing bands and broadening the mesentery prevent recurrence?
The bands from caecum across the duodenum are divided to relieve obstruction, and the mesentery's leaves are opened so the duodenum descends on the right and the caecum settles on the left: the pedicle becomes a broad fan whose geometry cannot twist. The operation's protection is that width, not any fixation stitch.
Appendicectomy and final placement
Why does the appendix leave, and why is nothing sewn into place?
The caecum will live in the left abdomen, so future appendicitis would present as a diagnostic riddle: the appendix is removed now. Nothing is fixed because fixation does not prevent recurrence and adds adhesion planes; the broad mesentery is the security, and the final positions are simply where safe anatomy now rests.
Decision points
After detorsion, a long central segment stays dusky: resect now or close and relook?
Resect only certain necrosis, relook at 24-48h
The bowel-banking answer: marginal gut is given a day of perfusion to declare, and the second look resects the truth rather than the fear.
Resect to confident margins now
For the child who cannot return to theatre, or necrosis with clear demarcation: certainty bought with future absorption.
This is short-bowel arithmetic at its starkest: the midgut is the child's entire absorptive future, and centimetres resected in pessimism are decades of intestinal failure. The relook laparotomy exists to let time, not fear, draw the lines.
Malrotation found incidentally on imaging in an asymptomatic eight-year-old.
Elective Ladd's procedure
The volvulus risk never reaches zero and its cost is catastrophic: many centres offer prophylactic surgery, especially in younger children.
Informed surveillance
In older asymptomatic patients the risk declines: a counselled watch with an explicit 'bilious vomiting means now' plan is defensible.
The incidental malrotation is a genuine equipoise conversation: age, anatomy (how narrow the pedicle), and family understanding all weigh in, and the one wrong answer is a discharge without the volvulus warning taught by name.
Leaving the OR
The handoff
- Procedure
- Ladd's procedure for malrotation with volvulus, detorted 720 degrees
- Bowel
- Fully recovered with warm packs; no resection needed
- Steps
- Bands divided, mesentery broadened, appendicectomy done
- Watch for
- NG losses and abdominal girth, feed readiness, and any sign of re-twist: bilious aspirates escalate immediately
A fictional educational patient, handed over the way real ones are.
The postoperative course
- Day 0-2NG decompression while the insulted gut rests; the reperfused bowel's ileus is expected and watched rather than feared.
- Days 2-5Feeds introduced and advanced as aspirates clear: the pace is the baby's, and bilious aspirates reset the clock and the differential.
- First weeksHome feeding established; parents leave knowing that bilious vomiting, ever again, is an emergency word, because recurrence, though rare, exists.
- Long termAdhesive obstruction is the operation's lifelong footnote: any future obstructed presentation in this child starts with this history in its first sentence.
Watch it done
Laparoscopic Ladd's procedure
Dividing the bands, widening the mesentery, the appendix, and the bowel laid in non-rotation.
Source: SAGES · Watch on YouTube