Anomalies of intestinal rotation

Abstract

Bilious vomiting in the newborn is a surgical emergency until proven otherwise, and requires immediate evaluation for malrotation with midgut volvulus. In a stable infant with suspicion of malrotation, an upper gastrointestinal series is the diagnostic study of choice; however, surgical exploration should not be delayed in the symptomatic or unstable patient. A delay in diagnosis and treatment of malrotation with midgut volvulus can lead to substantial bowel ischemia, necrosis, and short bowel syndrome. A Ladd procedure is recommended for all patients with symptomatic malrotation due to the risk of midgut volvulus associated with a narrow mesenteric pedicle. The goals of the Ladd procedure are to relieve partial duodenal obstruction by dividing Ladd’s bands, to widen the base of the mesentery to prevent volvulus, to place the bowel in a safer configuration with the small bowel on the right and the large bowel on the left, and to remove the appendix to avoid diagnostic difficulty created by an abnormally positioned cecum.