Unusual Case
Laparoscopic correction of intestinal malrotation in adult Nilanjan Panda, Nitin Kumar Bansal, Mohan Narasimhan, Ramesh Ardhanari Department of Surgery, Meenakshi Mission Hospital & Research Centre, Madurai, Tamil Nadu, India Address for Correspondence: Dr. Nilanjan Panda, P 318 b, CIT Road, Scheme 6 M, Kankurgachi, Kolkata - 700054, West Bengal, India. E-mail: [email protected]
Abstract Intestinal malrotation is rare in adults. Patients may present with acute obstruction or chronic abdominal pain. These symptoms are caused by Ladd’s bands and narrow mesentery resulting from incomplete gut rotation. Barium, computed tomography (CT) and magnetic resonance imaging (MRI), angiography and sometimes explorative laparotomy are used for diagnosis. Ladd’s procedure is the treatment of choice but data about laparoscopic approach in adult is scarce. We report three cases of laparoscopic correction of adult malrotation presenting with chronic abdominal pain. The diagnosis is made by CT/MRI. Laparoscopic Ladd’s procedure (release of bands, broadening of mesentery and appendicectomy) was performed via three ports. Procedure time 25-45 min. All patients were discharged on postoperative day 2. At 6 month follow-up, all are symptom free. Laparoscopic Ladd’s procedure is an acceptable alternative to the open technique in treating chronic symptoms of intestinal malrotation in adults. Key words: Intestinal malrotation, ladd’s procedure, laparoscopy
INTRODUCTION Intestinal malrotation is a failure of gut to rotate completely (270 degree anticlockwise) in utero. It can cause small intestinal obstruction and strangulation in infants due to midgut volvulus. Adult patients may present with symptoms range from acute obstruction to chronic abdominal pain. Laparoscopic Ladd’s procedure is established in pediatric population. Experience in adult is limited. Access this article online Quick Response Code:
Website: www.journalofmas.com
DOI: 10.4103/0972-9941.129961
We present three cases of adult intestinal malrotation. They presented with chronic symptoms and successfully treated with laparoscopic Ladd’s procedure.
CASE REPORT Case 1 A 20-year female presented with a history of mild mid abdominal pain for 2 days. Ultrasound was normal. CT abdomen showed alteration of SMA/SMV (superior mesenteric artery and vein) axis with large bowel on the left and small bowel on the right. On laparoscopy, clumping of small bowel on right and caecum to left iliac fossa noted. Operative techniques-One 10 mm umbilical port for camera and two 5 mm working ports in the flanks were used. Peritoneal bands were divided with a combination of Harmonic Scalpel (Ethicon Endosurgery) and fine scissor. Small bowel released from membranous adhesions, malpositioned DJ flexure released and Ladd bands excised. Appendicectomy was done. No suture fixation was used. Case 2 A 14-year female presented with right sided abdominal pain, mainly early postprandial (within 1 h), on and off for 6 months. MRI abdomen showed SMV anterior and to the left of SMA. Small bowel loops were to the right and caecum and appendix was up towards epigastrium and to the left. Laparoscopic findings and procedure was as described in case one. Case 3 A 25-year-old female with epigastric pain on and off for 3 months was admitted with sub acute intestinal obstruction. She improved on conservative treatment. CT showed malrotated gut. Laparoscopic Ladd’s procedure was done. Procedure time ranged from 25-40 min.
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Journal of Minimal Access Surgery | April-June 2014 | Volume 10 | Issue 2
Panda, et al.: Laparoscopic Ladd procedure in adults
All the patients, when asked, confirmed that symptoms were present since childhood and either ignored or treated with common household remedies. Oral liquids started after 6 h and all three patients were discharge on second postoperative day. These patient, now in more than 6 months follow up, are doing well.
DISCUSSION The incidence of intestinal malrotation in adults is approximately 0.2%. [1] Many a time, it is an incidental discovery at imaging or laparotomy. When symptomatic, patients present with acute obstruction or chronic abdominal pain or nonspecific complaints. In patients with chronic symptoms, workup includes a barium or CT /MRI abdomen. Imaging shows small bowel in the right and colon up and to the left (Figure 1a). Angiography shows SMA /SMV axis alteration (whirl sign-SMA going around SMV)
with possibility of intestinal ischemia. As in pediatric patients, physical examination and abdominal imaging, followed by diagnostic laparoscopy/laparotomy and Ladd’s procedure is the treatment of choice in adults.[2] Often the anomaly is discovered incidentally at laparotomy.[3] If identified, Ladd’s procedure is recommended to avoid the risk of midgut volvulus. The surgical steps consist of division of Ladd’s band (Figure 1b and 1c) and other congenital fibers and adhesions constricting the base of mesentery, appendectomy and functional positioning of the intestine (Figure 1d) with or without fixation. At the end, widening of the mesentery base (Figure 2a and 2b) and straightening duodenum occurs. Duodenum descends along the right gutter, small intestine lie on the right and the caecum and ascending colon in the midline or left side of the abdomen. The SMA and its branches lie exposed. Appendicectomy (Figure 2c) helps avoiding future diagnostic confusion and also help fixation of caecum. It is reported in some series that pathophysiology of pain and other chronic symptoms may not correlate with the extent of radiological anomaly seen, especially the obstructive
Figure 1a: Small intestine to right and cecum up and to left
Figure 1b: Ladd’s bands
Figure 1c: Ladd’s bands being dissected
Figure 1d: Bowel being released
Journal of Minimal Access Surgery | April-June 2014 | Volume 10 | Issue 2
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Panda, et al.: Laparoscopic Ladd procedure in adults
Figure 2b: Brodedned mesentry untwisted the SMA/SMV axis
Figure 2a: Twisted Mesentery getting released
Figure 2d: Abnormal positioned ligament of traitz in malrotated duodenum Figure 2c: Appendicectomy
component.[4] All our cases had twist of the narrowed mesenteric pedicle that was easily reversed after peritoneal band lyses. Peritoneal bands may have a restrictive effect on normal duodenal motility and duodenal malrotation (Figure 2d) often coexists with other parts of intestinal malrotation. Complex neurohumoral or neuromuscular changes that occur as the result of release of entrapped bowel also contribute to symptom resolution.
rather than try to bring caecum to right and small bowel to left, the procedure becomes straightforward and can be accomplished laparoscopically much easily.
REFERENCES 1. 2.
3.
There is evidence that laparoscopic Ladd’s procedure in pediatric age group is safe and gives similar results as in open procedure. Our result agrees with other studies showing laparoscopic Ladd procedure as safe and effective with the advantage of minimally invasive approach in adult patients with intestinal malrotation without midgut volvulus.[5] If the embryological origin of the malrotation is kept in mind and the systematic steps are followed to divide the bands and release the bowel
92
4. 5.
Kantor JL. Anomalies of the colon. Radiology 1934;23:651-62. Von Flue M, Herzog U, Ackermann C, Tondelli P, Harder F. Acute and chronic presentation of intestinal nonrotation in adults. Dis Colon Rectum 1994;37:192-8. Fu T, Tong WD, He YJ, Wen YY, Luo DL, Liu BH. Surgical management of intestinal malrotation in adults. World J Surg 2007;31:1797-805. Seymour NE, Andersen DK. Laparoscopic treatment of intestinal malrotation in adults. JSLS 2005;9:298-301. Mazziotti MV, Strasberg SM, Langer JC. Intestinal rotation abnormalities without volvulus: The role of laparoscopy. J Am Coll Surg 1997;185:172-6.
Cite this article as: Panda N, Bansal NK, Narasimhan M, Ardhanari R. Laparoscopic correction of intestinal malrotation in adult. J Min Access Surg 2014;10:90-2. Date of submission: 06/09/2013, Date of acceptance: 25/10/2013 Source of Support: Nil, Conflict of Interest: None declared.
Journal of Minimal Access Surgery | April-June 2014 | Volume 10 | Issue 2
Copyright of Journal of Minimal Access Surgery is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Laparoscopic correction of intestinal malrotation in adult Nilanjan Panda, Nitin Kumar Bansal, Mohan Narasimhan, Ramesh Ardhanari Department of Surgery, Meenakshi Mission Hospital & Research Centre, Madurai, Tamil Nadu, India Address for Correspondence: Dr. Nilanjan Panda, P 318 b, CIT Road, Scheme 6 M, Kankurgachi, Kolkata - 700054, West Bengal, India. E-mail: [email protected]
Abstract Intestinal malrotation is rare in adults. Patients may present with acute obstruction or chronic abdominal pain. These symptoms are caused by Ladd’s bands and narrow mesentery resulting from incomplete gut rotation. Barium, computed tomography (CT) and magnetic resonance imaging (MRI), angiography and sometimes explorative laparotomy are used for diagnosis. Ladd’s procedure is the treatment of choice but data about laparoscopic approach in adult is scarce. We report three cases of laparoscopic correction of adult malrotation presenting with chronic abdominal pain. The diagnosis is made by CT/MRI. Laparoscopic Ladd’s procedure (release of bands, broadening of mesentery and appendicectomy) was performed via three ports. Procedure time 25-45 min. All patients were discharged on postoperative day 2. At 6 month follow-up, all are symptom free. Laparoscopic Ladd’s procedure is an acceptable alternative to the open technique in treating chronic symptoms of intestinal malrotation in adults. Key words: Intestinal malrotation, ladd’s procedure, laparoscopy
INTRODUCTION Intestinal malrotation is a failure of gut to rotate completely (270 degree anticlockwise) in utero. It can cause small intestinal obstruction and strangulation in infants due to midgut volvulus. Adult patients may present with symptoms range from acute obstruction to chronic abdominal pain. Laparoscopic Ladd’s procedure is established in pediatric population. Experience in adult is limited. Access this article online Quick Response Code:
Website: www.journalofmas.com
DOI: 10.4103/0972-9941.129961
We present three cases of adult intestinal malrotation. They presented with chronic symptoms and successfully treated with laparoscopic Ladd’s procedure.
CASE REPORT Case 1 A 20-year female presented with a history of mild mid abdominal pain for 2 days. Ultrasound was normal. CT abdomen showed alteration of SMA/SMV (superior mesenteric artery and vein) axis with large bowel on the left and small bowel on the right. On laparoscopy, clumping of small bowel on right and caecum to left iliac fossa noted. Operative techniques-One 10 mm umbilical port for camera and two 5 mm working ports in the flanks were used. Peritoneal bands were divided with a combination of Harmonic Scalpel (Ethicon Endosurgery) and fine scissor. Small bowel released from membranous adhesions, malpositioned DJ flexure released and Ladd bands excised. Appendicectomy was done. No suture fixation was used. Case 2 A 14-year female presented with right sided abdominal pain, mainly early postprandial (within 1 h), on and off for 6 months. MRI abdomen showed SMV anterior and to the left of SMA. Small bowel loops were to the right and caecum and appendix was up towards epigastrium and to the left. Laparoscopic findings and procedure was as described in case one. Case 3 A 25-year-old female with epigastric pain on and off for 3 months was admitted with sub acute intestinal obstruction. She improved on conservative treatment. CT showed malrotated gut. Laparoscopic Ladd’s procedure was done. Procedure time ranged from 25-40 min.
90
Journal of Minimal Access Surgery | April-June 2014 | Volume 10 | Issue 2
Panda, et al.: Laparoscopic Ladd procedure in adults
All the patients, when asked, confirmed that symptoms were present since childhood and either ignored or treated with common household remedies. Oral liquids started after 6 h and all three patients were discharge on second postoperative day. These patient, now in more than 6 months follow up, are doing well.
DISCUSSION The incidence of intestinal malrotation in adults is approximately 0.2%. [1] Many a time, it is an incidental discovery at imaging or laparotomy. When symptomatic, patients present with acute obstruction or chronic abdominal pain or nonspecific complaints. In patients with chronic symptoms, workup includes a barium or CT /MRI abdomen. Imaging shows small bowel in the right and colon up and to the left (Figure 1a). Angiography shows SMA /SMV axis alteration (whirl sign-SMA going around SMV)
with possibility of intestinal ischemia. As in pediatric patients, physical examination and abdominal imaging, followed by diagnostic laparoscopy/laparotomy and Ladd’s procedure is the treatment of choice in adults.[2] Often the anomaly is discovered incidentally at laparotomy.[3] If identified, Ladd’s procedure is recommended to avoid the risk of midgut volvulus. The surgical steps consist of division of Ladd’s band (Figure 1b and 1c) and other congenital fibers and adhesions constricting the base of mesentery, appendectomy and functional positioning of the intestine (Figure 1d) with or without fixation. At the end, widening of the mesentery base (Figure 2a and 2b) and straightening duodenum occurs. Duodenum descends along the right gutter, small intestine lie on the right and the caecum and ascending colon in the midline or left side of the abdomen. The SMA and its branches lie exposed. Appendicectomy (Figure 2c) helps avoiding future diagnostic confusion and also help fixation of caecum. It is reported in some series that pathophysiology of pain and other chronic symptoms may not correlate with the extent of radiological anomaly seen, especially the obstructive
Figure 1a: Small intestine to right and cecum up and to left
Figure 1b: Ladd’s bands
Figure 1c: Ladd’s bands being dissected
Figure 1d: Bowel being released
Journal of Minimal Access Surgery | April-June 2014 | Volume 10 | Issue 2
91
Panda, et al.: Laparoscopic Ladd procedure in adults
Figure 2b: Brodedned mesentry untwisted the SMA/SMV axis
Figure 2a: Twisted Mesentery getting released
Figure 2d: Abnormal positioned ligament of traitz in malrotated duodenum Figure 2c: Appendicectomy
component.[4] All our cases had twist of the narrowed mesenteric pedicle that was easily reversed after peritoneal band lyses. Peritoneal bands may have a restrictive effect on normal duodenal motility and duodenal malrotation (Figure 2d) often coexists with other parts of intestinal malrotation. Complex neurohumoral or neuromuscular changes that occur as the result of release of entrapped bowel also contribute to symptom resolution.
rather than try to bring caecum to right and small bowel to left, the procedure becomes straightforward and can be accomplished laparoscopically much easily.
REFERENCES 1. 2.
3.
There is evidence that laparoscopic Ladd’s procedure in pediatric age group is safe and gives similar results as in open procedure. Our result agrees with other studies showing laparoscopic Ladd procedure as safe and effective with the advantage of minimally invasive approach in adult patients with intestinal malrotation without midgut volvulus.[5] If the embryological origin of the malrotation is kept in mind and the systematic steps are followed to divide the bands and release the bowel
92
4. 5.
Kantor JL. Anomalies of the colon. Radiology 1934;23:651-62. Von Flue M, Herzog U, Ackermann C, Tondelli P, Harder F. Acute and chronic presentation of intestinal nonrotation in adults. Dis Colon Rectum 1994;37:192-8. Fu T, Tong WD, He YJ, Wen YY, Luo DL, Liu BH. Surgical management of intestinal malrotation in adults. World J Surg 2007;31:1797-805. Seymour NE, Andersen DK. Laparoscopic treatment of intestinal malrotation in adults. JSLS 2005;9:298-301. Mazziotti MV, Strasberg SM, Langer JC. Intestinal rotation abnormalities without volvulus: The role of laparoscopy. J Am Coll Surg 1997;185:172-6.
Cite this article as: Panda N, Bansal NK, Narasimhan M, Ardhanari R. Laparoscopic correction of intestinal malrotation in adult. J Min Access Surg 2014;10:90-2. Date of submission: 06/09/2013, Date of acceptance: 25/10/2013 Source of Support: Nil, Conflict of Interest: None declared.
Journal of Minimal Access Surgery | April-June 2014 | Volume 10 | Issue 2
Copyright of Journal of Minimal Access Surgery is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
