Overview
Definition:
Ladd's procedure is a surgical intervention primarily used to correct intestinal malrotation, a congenital anomaly where the intestines fail to complete their normal 270-degree counterclockwise rotation during fetal development, leading to abnormal positioning and potential complications like midgut volvulus.
Epidemiology:
Intestinal malrotation occurs in approximately 1 in 500 live births
Of these, 50-75% become symptomatic, most commonly within the first year of life
It is more prevalent in neonates presenting with intestinal obstruction
Asymptomatic cases are often discovered incidentally.
Clinical Significance:
Malrotation is a critical surgical emergency due to the high risk of midgut volvulus, which can lead to bowel ischemia, necrosis, perforation, sepsis, and potentially death
Early diagnosis and surgical correction significantly improve outcomes and prevent life-threatening complications.
Clinical Presentation
Symptoms:
Presents acutely with bilious vomiting, often the hallmark of obstruction
Abdominal pain and distension may be present
In neonates, failure to thrive, poor feeding, and irritability are common
Chronic intermittent symptoms like abdominal pain, constipation, or intermittent vomiting can also occur.
Signs:
Physical examination may reveal abdominal distension, tenderness, and absent bowel sounds in cases of acute obstruction
A palpable mass or "cabbage-like" mass in the epigastrium can be noted in some cases
Signs of dehydration and shock may be evident in severe cases of volvulus.
Diagnostic Criteria:
Diagnosis is typically suspected based on clinical presentation and confirmed with imaging
There are no formal "diagnostic criteria" in the sense of a scoring system
rather, it is a clinical-radiological diagnosis.
Diagnostic Approach
History Taking:
Detailed history focusing on onset, character, and frequency of vomiting (bilious nature is key)
Inquiry about stool passage (meconium, blood), abdominal pain, feeding intolerance, and prior episodes is crucial
Family history of gastrointestinal anomalies should also be considered.
Physical Examination:
Thorough abdominal examination, assessing for distension, tenderness (location and severity), bowel sounds (present, hyperactive, or absent), and any palpable masses
Assess hydration status and vital signs
Rectal examination may reveal bloody stools.
Investigations:
Upper gastrointestinal (UGI) series with small bowel follow-through is the gold standard for diagnosing malrotation, demonstrating a classically abnormal duodenal-jejunal junction and a misplaced ligament of Treitz
Abdominal ultrasound can show a reversed position of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV)
CT scan can also be diagnostic but is less preferred in neonates due to radiation
Plain abdominal X-rays may show signs of obstruction (dilated loops, air-fluid levels) but are often non-specific for malrotation itself
Laboratory tests include CBC for infection/anemia, electrolytes for dehydration, and coagulation profile.
Differential Diagnosis:
Conditions to consider in neonates with bilious vomiting include other causes of intestinal obstruction such as atresia, stenosis, intussusception, Meckel's diverticulum, Hirschsprung's disease, and hernias
In older children, appendicitis, gastroenteritis, and functional constipation might be considered.
Management
Initial Management:
Immediate resuscitation with intravenous fluids for dehydration and electrolyte correction
Nasogastric tube insertion for gastric decompression
Broad-spectrum antibiotics are indicated if there is suspicion of bowel compromise or sepsis
Surgical consultation is paramount.
Surgical Management:
Ladd's procedure is indicated for symptomatic malrotation, especially in cases of midgut volvulus
The procedure involves: 1
Wide exploratory laparotomy
2
Division of peritoneal adhesions (Ladd's bands) that may be tethering the cecum and colon to the abdominal wall, thus freeing the mesentery
3
Mobilization of the entire small bowel and repositioning of the colon to create a broad-based mesentery
4
Appendectomy is typically performed to prevent future diagnostic confusion and potential appendicitis in an abnormal location
In cases of non-viable bowel, resection and primary anastomosis or staged management might be necessary.
Supportive Care:
Postoperatively, patients require ongoing fluid management, pain control, and monitoring for signs of infection, bowel leak, or recurrence of volvulus
Nasogastric decompression is continued until bowel function returns
Gradual introduction of enteral feeds is initiated once bowel sounds return and abdominal distension subsides.
Complications
Early Complications:
Bowel ischemia or necrosis requiring resection, bowel perforation, intra-abdominal abscess, wound infection, ileus, and re-operation for bleeding or leakage.
Late Complications:
Adhesions leading to recurrent bowel obstruction, chronic abdominal pain, malabsorption, and rarely, recurrence of volvulus
Nutritional deficiencies can occur if significant bowel resection was necessary.
Prevention Strategies:
Meticulous surgical technique during Ladd's procedure, ensuring complete division of obstructing bands and adequate mobilization of the bowel, is crucial
Careful postoperative monitoring for early signs of complications is also vital.
Prognosis
Factors Affecting Prognosis:
The most significant factor is the presence and extent of bowel ischemia at the time of surgery
Prompt diagnosis and surgical intervention before extensive necrosis lead to a much better prognosis
The extent of bowel resection also impacts long-term outcomes.
Outcomes:
With timely surgical intervention and minimal or no bowel compromise, the prognosis is excellent
Patients typically have a normal quality of life
If extensive bowel resection is required, long-term complications related to short bowel syndrome may arise.
Follow Up:
Follow-up care typically involves outpatient visits to monitor growth and development, assess for any signs of recurrent obstruction, and manage any nutritional deficiencies
Regular abdominal examinations and review of any new gastrointestinal symptoms are important.
Key Points
Exam Focus:
Ladd's procedure is the surgical management for intestinal malrotation with complications
Midgut volvulus is the most feared complication, presenting with bilious vomiting
UGI series is the investigation of choice
The key steps involve dividing adhesions, repositioning bowel, and appendectomy.
Clinical Pearls:
Always suspect malrotation in a neonate with bilious vomiting
The appearance of the mesentery on imaging (short, broad-based) and the position of the duodenojejunal junction are critical
Remember that appendectomy prevents diagnostic confusion later in life.
Common Mistakes:
Inadequate division of Ladd's bands leading to persistent obstruction
Failure to mobilize the entire bowel adequately
Not considering malrotation in the differential diagnosis of neonatal intestinal obstruction
Delaying surgical intervention in the face of volvulus.