Laparoscopic Ladd’s procedure for intestinal malrotation in the adult patient without volvulus: Surgical technique

Intestinal malrotation occurs when there is arrest or disruption of the normal rotation of the embryonic gut during the fourth to twelfth week of embryonic development. Normally, the midgut undergoes a 270° counterclockwise rotation around the superior mesenteric artery, leading to retroperitoneal fixation of the duodenum at the ligament of Treitz and fixation of the cecum by peritoneal bands to the lateral abdominal wall. This leads to elongation and fixation of the takeoff of the superior mesenteric artery branches along an axis extending from the ligament of Treitz in the left upper quadrant to the ileocecal valve in the right lower quadrant [1]. Disruption or arrest of this rotation leads to the cecum remaining in the epigastrium. The fibrous bands that fix the duodenum and cecum continue to form, resulting in Ladd’s bands that extend from the cecum and cross over the duodenum to the lateral abdominal wall. Because the takeoff of the branches of the superior mesenteric artery remain confined to the epigastrium, the resulting narrow mesenteric base leads to an increased lifetime risk of bowel obstruction, volvulus, or strangulation.