Laparoscopic correction of intestinal malrotation in adult.

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.

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.

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 mal-rotated gut. Laparoscopic Ladd's procedure was done.

Procedure time ranged from 25-40 min.

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.

Figure 1a

Small intestine to right and cecum up and to left

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.

Figure 1b

Ladd's bands

Figure 1c

Ladd's bands being dissected

Figure 1d

Bowel being released

Figure 2a

Twisted Mesentery getting released

Figure 2b

Brodedned mesentry untwisted the SMA/SMV axis

Figure 2c

Appendicectomy

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 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.

Figure 2d

Abnormal positioned ligament of traitz in malrotated duodenum

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 rather than try to bring caecum to right and small bowel to left, the procedure becomes straightforward and can be accomplished laparoscopically much easily.