What is Ladd's Band?
Ladd's bands are congenital fibrous peritoneal adhesions that extend from the abnormally positioned cecum in the right upper quadrant across the duodenum to the retroperitoneum, causing extrinsic compression and obstruction of the duodenum in patients with intestinal malrotation. 1, 2
Anatomical Context
Ladd's bands form as part of the malrotation complex, where incomplete rotation of the midgut during fetal development results in the cecum remaining high in the right upper quadrant rather than descending to its normal position in the right lower quadrant 1, 3
These bands bind the malpositioned cecum to the retroperitoneum and cross over the duodenum, creating a mechanical obstruction that can be partial or complete 2, 4
The bands are named after William Ladd (1880-1967), considered "the father of pediatric surgery," who in 1932 presented a coherent surgical approach to managing malrotation that included division of these obstructing adhesions 1
Clinical Significance
Presentation in Infants
Bilious vomiting within the first 2 days of life is the critical presenting sign, indicating intestinal obstruction that requires immediate evaluation 5, 6
Midgut volvulus is a medical emergency that can occur when the narrow mesenteric base associated with malrotation allows the bowel to twist around the superior mesenteric artery 5
Normal abdominal radiographs do not exclude malrotation, as malrotation with incomplete obstruction may have a normal bowel gas pattern 5
Presentation in Adults
Adult presentation is exceptionally rare and often asymptomatic, with many cases discovered incidentally on imaging performed for other reasons 2, 3
When symptomatic in adults, patients present with vague cramping abdominal pain, recurrent vomiting, or acute small bowel obstruction 3, 7
Delayed diagnosis risks bowel ischemia and perforation, making prompt recognition critical even in older patients 2, 3
Diagnostic Approach
Upper GI series is the reference standard for diagnosing malrotation with 96% sensitivity, identifying the abnormal position of the duodenojejunal junction (ligament of Treitz) 5
The key finding is the duodenum failing to cross the midline to reach its normal left-sided position, with the duodenojejunal junction positioned abnormally to the right 5, 8
Ultrasound may identify the "whirlpool sign" (clockwise wrapping of the superior mesenteric vein and mesentery around the superior mesenteric artery), which is specific for midgut volvulus 5
CT imaging can demonstrate the malpositioned cecum, abnormal mesenteric vessel relationship, and in some cases dilated superior mesenteric vein trapped within Ladd's bands 4
Surgical Management: The Ladd Procedure
The Ladd procedure is the definitive surgical treatment and consists of a series of steps 1, 7:
Division of Ladd's bands to relieve duodenal obstruction 1, 2, 3
Untwisting of any volvulus in a counterclockwise direction 1
Widening of the mesenteric base to prevent future volvulus 3, 7
Placement of the small bowel on the right side of the abdomen and the colon on the left (opposite of normal anatomy) to prevent retwisting 3
Appendectomy is typically performed since the cecum will be in an abnormal left-sided position, making future diagnosis of appendicitis difficult 3, 7
Critical Clinical Pearls
Laparoscopic Ladd procedure is feasible and safe in both pediatric and adult patients, appearing as effective as the open approach 7
Urgent surgical consultation is mandatory when malrotation with potential volvulus is suspected, as this is a surgical emergency 6
The superior mesenteric vein can become dilated and trapped within Ladd's bands, forming a venous collar that contributes to duodenal obstruction 4