Laparoscopic 'steering wheel' derotation technique for midgut volvulus in children with intestinal malrotation.

INTRODUCTION: Since the first description by William Ladd, the Ladd's procedure has been the surgery of choice for the correction of malrotation. The laparoscopic Ladd's procedure is becoming popular with the advent of minimal access surgery and is described in the literature. Various techniques of the Ladd's procedure have been described but none of them describes the stepwise technique for derotation of volvulus which is the most difficult and confusing part of the surgery. We describe 'steering wheel' technique for easy derotation of volvulus associated with malrotation.
METHOD: A total of 62 patients were diagnosed to have an intestinal malrotation between 2010 and 2017. All cases which had complete non-rotation with a midgut volvulus were reviewed. Out of these, 48 patients were operated with open technique and 14 patients were subjected to the laparoscopic correction. TECHNIQUE: Using three-port technique, stepwise derotation of volvulus is done which simulates the rotation of steering of car at an acute turn and has been described in four simple steps. This technique also stresses the importance of the release of Ladd's band before derotation.
RESULTS: Of 62 patients diagnosed with malrotation, 14 (22.6%) patients underwent the laparoscopic Ladd's procedure. The mean age was 26 + 8 months, mean weight was 10 + 2 kg and included eight males (57%) and six females (43%). There was only one (7.14%) conversion to open technique, due to a huge dilatation of duodenum causing difficulty in dissection in a patient with malrotation without volvulus. The laparoscopic Ladd's procedure took an average time of 70 ± 15 min.
CONCLUSION: The laparoscopic 'steering wheel' derotation technique is easy and provides a stepwise description of the laparoscopic derotation of volvulus associated with malrotation in children.

INTRODUCTION

Rotational anomalies of the midgut encompass a broad spectrum of incomplete rotational events with malfixation of the intestines during fetal development.[1] This malrotation and malfixation result in narrow mesenteric base leading to a midgut volvulus and the formation of Ladd's bands in neonates and young children.[2] Older children present with recurrent attacks of bilious emesis due to intermittent volvulus and intestinal obstruction, unlike neonates, who present with an acute volvulus and early gangrene.[3] Since the first description by William Ladd, the Ladd's procedure has been the surgery of choice for the correction of malrotation.[4] Recently, there has been a remarkable increase in the number of laparoscopic procedures in paediatric age group.[5] After the first evidence of successful laparoscopic management of an intestinal malrotation in a neonate, it's efficacy and safety have been confirmed by the number of case reports and smaller series.[6] Various techniques of the Ladd's procedure have been described in the literature which is similar to open technique but derotation of volvulus remains a challenge in laparoscopy which has to be done with two graspers and is poorly described.[789] We describe ‘steering wheel’ technique for easy derotation of volvulus associated with malrotation.

METHODS

A total of 62 patients were diagnosed to have an intestinal malrotation between 2010 and 2017. All cases which had complete non-rotation with a midgut volvulus were reviewed. Out of these, 48 patients were operated with open technique and 14 patients were subjected to the laparoscopic correction. Diagnosis was based on clinical signs and symptoms, ultrasound with Doppler and upper gastrointestinal (GI) contrast study. Patients preoperatively, diagnosed to have malrotation as associated anomaly along with gastroschisis, omphalocele and congenital diaphragmatic hernia, were excluded from the study. All the procedures were performed by attending paediatric surgeon team.

Technique

Patient was kept in supine position with head end up. Monitor is placed on the right side of the patient at the head end and anaesthesia work station on the left. Surgeon stands on the right side, cameraman on to the left of surgeon and assistant on the right side. Three ports were used including 5 mm optical port (30° telescope, at umbilicus inserted by open technique) and two 3 or 5 mm ports depending on the size of the patient at both paraumbilical regions. The gas is insufflated at 1 L/min at the pressure of 6–10 mm Hg. Abdomen is inspected for the presence of volvulus, viability of bowel and the type of rotational abnormality. The first step is division of the Ladd's bands which allows free movement of cecum for derotation and is followed by ‘steering wheel’ derotation technique [Figure 1a and b]. The steering wheel derotation technique can be understood by imagining the way a steering of car is rotated at an acute turn. The first step, after the Ladd's band division, involves anticlockwise first turn rotating the cecum toward the right hypochondrium with prominent use of the right bowel grasper and the left as assistant [Figure 2a]. This is followed by the second step which involves anticlockwise turn rotating the ileum to the left hypochondrium [Figure 2b]. The third step is again an anticlockwise turn rotating the cecum to the left hypochondrium [Figure 2c]. This is followed by fourth and last turn which involves anticlockwise rotation of the ileum to the right hypochondrium [Figure 2d]. Moves explained in steps of derotation are usually few if cecum is rotated (step 1 and 3) while many are needed to rotate the small bowel (step 2 and 4). This whole manoeuvre corrects a 360° volvulus with lot of ease. After derotation, the cecum reaches in the left hypochondrium and duodenojejunal junction on the right side confirmed by visible release of mesenteric twist. After derotation, duodenum is straightened and mesentery is widened out safeguarding the mesenteric vessels to complete the Ladd's procedure [Figure 2e and f]. Appendectomy is not routinely performed as our unit policy. Nasogastric tube was kept until the aspirate changes to gastric. Feeding was started a day after the surgery in all the cases and patients were discharged after regaining full feeds.

Figure 1

(a) Laparoscopic division of Ladd's band. (b) Laparoscopic view showing volvulus and directions of steering wheel rotation. Step 1–4 described in Figure 2a–d GB: Gall bladder, V: Volvulus, C: Cecum, A: Appendix, SB: Small bowel, SMV: Dilated superior mesenteric vein, D: Duodenum, LB: Ladd's bands

Figure 2

(a) Step 1-Division of Ladd's band followed by anticlockwise first turn rotating the cecum to the right iliac fossa. (b) Step 2-Anticlockwise second turn rotating the ileum to the left hypochondrium. (c) Step 3-Anticlockwise third turn rotating the cecum to the left hypochondrium. (d) Step 4-Anticlockwise fourth turn rotating the ileum to the right hypochondrium. (e) Straightening of duodenum and widening of mesentery. (f) Completed Ladd's procedure with Divided Ladd's band, corrected volvulus, straightened duodenum, widened mesentery, appendectomy (optional) LB: Ladd's band, D: Duodenum, C: Cecum, A: Appendix, J: Jejunum, I: Ileum, V: Volvulus

RESULTS

Of 62 patients diagnosed with malrotation, 14 (22.6%) patients underwent the laparoscopic Ladd's procedure and 48 (77.4%) patients were operated with open technique. Age of patients operated with the laparoscopic Ladd's procedure, ranged from 5 months to 12 years (26 ± 8 months). There were eight males (57%) and six females (43%). Average weight was 10 ± 2 kg. Presenting complaints include bilious vomiting, abdominal pain and postprandial discomfort. All the patients underwent ultrasound with Doppler and upper GI contrast study. Of 14 patients, 10 had a diagnosis of volvulus identified as clockwise whirlpool sign on Doppler ultrasound which was confirmed on laparoscopic intervention. There was only one (7.14%) conversion to open technique, due to huge dilatation of duodenum causing difficulty in dissection in a patient with malrotation without volvulus. None of the patient with volvulus required conversion to open and steering wheel derotation technique was successful in all patients. The laparoscopic Ladd's procedure took an average time of 70 ± 15 min. No intraoperative and early post-operative complications were encountered and patients were discharged after an overall average hospital stay of 3 ± 1 days. No recurrent volvulus or bowel obstruction was found during the follow-up period of 3 months to 7 years.

DISCUSSION

It is mandatory to correct the malrotation, whenever the diagnosis is made, due to known devastating consequences of volvulus. Conventionally, the Ladd's procedure is performed with open technique to treat the intestinal malrotation, and has been the gold standard and involves the division of Ladd's bands, derotation of volvulus, straightening of duodenum, widening of mesentery and appendectomy (debated).[4] Doppler imaging and upper GI contrast study are mainstay in the diagnosis of volvulus in children.[10] It is now proven that the laparoscopic surgery is efficacious and safely applicable in paediatric population with malrotation.[5] It is advantageous in relation to reduced morbidity and decreased hospital stay.[11] The overall outcome of the laparoscopic Ladd's procedure is mainly dependent on the ability to completely assess and identify the intestinal and mesenteric anatomy and skilfully perform all steps of the Ladd's procedure for malrotation correction.[12]

Conventionally, the open Ladd's procedure has been applied but has been found to have higher postoperative adhesions and patient discomfort due to open surgery.[13] Various studies now support the safety of laparoscopic approach to correct malrotation in children and is associated with more patient comfort, less adhesions formation and complications of incisions; hence, is increasingly being used.[11112] In the presence of volvulus, laparoscopy poses a challenge for its correction and its efficacy has been debated.[1415] Although, the laparoscopic Ladd's procedure essentially emulates open technique but there is no clear description of technique of derotation for laparoscopic treatment of an intestinal malrotation which has to be done with two instruments and is found difficult by laparoscopic surgeons.[789] The sequence of steps involved in laparoscopic correction include straightening of duodenum, release of Ladd's bands, brushing the bowel aside and autocorrection of volvulus and widening of mesentery. The correction of volvulus sounds simple but laparoscopic surgeons always discuss about an ideal technique of derotation of volvulus due to difficulties encountered.[15161718192021] Palanivelu et al., described the reduction of volvulus after division of bands but exact manoeuvre is not elucidated.[9] The ‘orbit’ technique has been described where the bowel was devolvulated counterclockwise with the grasper used as a pivot which compels the use of one grasper fixing the mesentery at the level of superior mesenteric artery. Although this technique has tried to address the concern of derotating volvulus, it has stressed more on use of one grasper as a pivot or fixation point rather than describing the manoeuvre for derotation. Moreover, the grasper held by the assistant which is placed near the superior mesenteric vessels (including a dilated vein of volvulus) as a pivot is at risk of slipping during derotation and can injure the vein.[22] Zamfir and Allal described devolvulation which requires a panned-out view to keep rotation in perspective at all times, leads to out of frequent sight phenomenon of instruments, does not define an end point and stress on the need of repeated identification of duodenojejunal junction and ileocecal junction. As a result, surgeon has to search for his bearings and landmarks repeatedly.[23]

In ‘steering wheel’ derotation technique described by us, surgeon does not have to rely on panned out view, gets advantage of using both instruments to their maximum, uses cecum and jejunum as holding points which are easy to hold, do not have to keep any instrument as a fixed instrument hindering the field of vision and allows to steer the whole midgut as many times as needed depending on the degree of rotation as done in open surgery. In all our cases, one full 360° rotation was enough to correct the volvulus. We also stress on the importance of release of Ladd's bands before the derotation which allows easy manoeuvrability of the cecum for derotation. We had only one conversion (out of 14 patients) to open surgery due to inability to handle severely dilated duodenum. The conversion rate for the laparoscopic Ladd's procedure ranges from 8.3% to 25% as described in the literature otherwise.[1101116] Operative time for the laparoscopic Ladd's procedure in the study was 70 ± 15 min which correlates well with the literature.[121718]

An ideal technique for laparoscopic derotation of volvulus in children should have following qualities:

Broad visual field so graspers holding intestines do not go out of ‘field’

Ease of derotation

Avoid putting graspers in ‘susceptible to inadvertent trauma’ positions

Avoid holding of grasper by assistant who may not fully appreciate the above point

Both graspers should be held by operating surgeon so he/she remains in full control

Delineation of ‘steps’ which are needed ‘in sequence’ to complete the process of derotation.

The laparoscopic ‘steering wheel’ derotation technique fulfils these criteria and is easy to adopt as most of us can learn the manoeuvre which simulates the rotation of steering wheel of a car at an acute turn. This adds an important and useful manoeuvre in the laparoscopic management of malrotation and volvulus in children to simplify the surgical procedure.

CONCLUSION

The laparoscopic ‘steering wheel’ derotation technique is easy, simplified, safe and effective way to correct volvulus associated with malrotation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.