What is the Ladd (LADDS) procedure for intestinal malrotation, including its indications, operative steps, surgical approaches, outcomes, and postoperative care?

Ladd Procedure for Intestinal Malrotation

Overview

The Ladd procedure is the definitive surgical treatment for intestinal malrotation, consisting of four key steps: counterclockwise detorsion of midgut volvulus (if present), division of Ladd's bands, widening of the mesenteric base, appendectomy, and placement of bowel in non-rotated position with cecum in left lower quadrant. 1, 2

Indications for Surgery

All patients diagnosed with intestinal malrotation should undergo Ladd procedure, regardless of whether midgut volvulus is present, because there is no way to predict which patients will develop catastrophic volvulus. 3

Emergency Indications

• Midgut volvulus with or without bowel ischemia 1, 2
• Bilious vomiting in neonates or infants (40% occur in neonatal period, 73% within first year) 4
• Radiographic evidence of bowel obstruction or "whirlpool sign" on ultrasound 4, 1

Elective Indications

• Asymptomatic malrotation discovered incidentally 3
• Chronic recurrent abdominal pain with confirmed malrotation 5, 3
• Malrotation discovered during appendectomy or other abdominal surgery 6

Diagnostic Workup

Imaging Sequence

1. Plain abdominal radiographs first - may show proximal bowel obstruction, "double bubble" sign, or paucity of distal gas, though normal films do not exclude malrotation 4, 1

2. Upper GI series is the reference standard - demonstrates abnormal position of duodenojejunal junction (ligament of Treitz) with 96% sensitivity, though false-positives occur in 10-15% due to redundant duodenum or bowel distension 7, 1, 2

3. Ultrasound with color Doppler - highly specific "whirlpool sign" (clockwise wrapping of superior mesenteric vein around superior mesenteric artery) confirms midgut volvulus 7, 4, 1

Critical Diagnostic Pitfall

Do not delay surgery for contrast enema, as it has no role in diagnosing or managing midgut volvulus and has 20% false-negative rate for malrotation. 7, 1

Operative Steps of Ladd Procedure

The Four Essential Components 2, 3

1. Evisceration and inspection of mesenteric root - complete visualization of anatomy 2

2. Counterclockwise derotation of midgut volvulus (if present) - untwist the bowel and assess viability 1, 2

3. Division of Ladd's bands - lyse all peritoneal bands crossing the duodenum, straighten duodenum along right abdominal gutter, and widen the mesenteric base 5, 2, 3

4. Appendectomy and bowel positioning - perform inversion-ligation appendectomy and place cecum in left lower quadrant with small bowel on right side 2, 3

Assessment of Bowel Viability

• If intestinal ischemia is present, surgical resection is required 2
• Five of 15 patients (33%) with volvulus in one series required bowel resection for ischemia 2
• Consider indocyanine green (ICG) fluorescence angiography when available to assess extent of resection needed 7

Surgical Approach

Laparoscopic vs. Open

Laparoscopic Ladd procedure is safe and effective for both pediatric and adult patients with malrotation, offering shorter hospital stays (3-5 days average) and faster recovery. 5, 3

Laparoscopic Technique 5, 3

• Four-port approach is standard 5
• Successfully completed in 89% of cases (8/9 patients in one series) 3
• Average operative time 111 minutes (range 77-176 minutes) 3
• Conversion to open required if enterotomy occurs or anatomy unclear 6, 3

Open Approach 6, 2

• Required for emergency volvulus with hemodynamic instability 2
• Necessary when laparoscopic approach complicated by bowel injury 6
• Preferred when extensive bowel ischemia suspected 2

Outcomes and Prognosis

Mortality and Morbidity

• Overall mortality is low when treated promptly 2
• One death reported in series of 22 patients (4.5%) from overwhelming sepsis after bowel resection 2
• Catastrophic outcomes occur when diagnosis delayed and bowel infarction develops 2

Symptom Resolution

• 71% of adult patients (5/7) reported substantial improvement in chronic abdominal discomfort after laparoscopic Ladd procedure 5
• Complete resolution of symptoms in 8/8 successfully treated patients in another series 3
• Immediate relief of symptoms reported at 2-week and 2-month follow-up 6

Postoperative Care

Hospital Course 5, 3

• Discharge typically on postoperative days 1-3 for laparoscopic approach 5
• Hospital stay 3-5 days average (3.6 days mean) 3
• All patients discharged on regular diet 3

Follow-up

• Monitor for recurrence of symptoms, though rare after complete Ladd procedure 5, 3
• Long-term outcomes are favorable with appropriate surgical technique 2, 3

Special Considerations in Adults

Intestinal malrotation in adults accounts for only 0.2-0.5% of all cases but presents with chronic recurrent abdominal pain rather than acute volvulus. 8

Adult Presentation Patterns 5, 6, 8

• History of abdominal discomfort dating from childhood or early adolescence 5
• Recurrent postprandial abdominal pain with bloating 5
• May be discovered incidentally during appendectomy when cecum found in abnormal position 6
• Years of vague abdominal symptoms often precede diagnosis 6

Critical Pitfall in Adults

When performing appendectomy and finding the appendix outside normal right lower quadrant position, always evaluate for malrotation with upper GI series postoperatively, as surgical correction is imperative. 6