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WJOLS

Laparoscopic Management of a Volvulus Secondary to Midgut Malrotation
Abdominal X­ray revealed dilated small bowel, and Adult manifestations of midgut malrotation differ from
although a suspicion of adhesions from the previous the pediatric group. More often, symptoms tend to be
surgery was a possibility, a contrasted CT scan of chronic rather than acute, characterized by cramp­like
the abdomen was performed given the history of a abdominal pain, bloating, and vomiting over a period
2
small intestinal anomaly. The findings confirmed the of months to years. Frequently, these symptoms are
small intestinal obstruction and a high location of the mistaken for another condition. The commonest cause
vermiform appendix and cecum below the right lobe of of an acute presentation of midgut malrotation in an
the liver. Free fluid was present in the abdomen without adult is a volvulus or an internal herniation due to
any signs of perforation or pneumoperitoneum. A Ladd’s bands. 3
diagnosis of a midgut malrotation and small intestinal Preoperative diagnosis of midgut malrotation is
obstruction was made. currently possible with the increasing use of preoperative
A diagnostic laparoscopy was then performed imaging. A plain abdominal X­ray may show a nonspecific
with the findings of grossly dilated small intestines bowel dilatation, but it may help lead to subsequent
until the distal ileum. The distal ileum was twisted investigations. The upper gastrointestinal contrast
along its mesenteric axis several times and the bowel study remains to be a gold standard for the diagnosis
3
appeared dusky and congested. The terminal ileum of midgut malrotation. Ultrasound abdomen has
was collapsed but remained viable. A Meckel’s diver­ also been described with a typical presentation of the
3,4
ticulum was discovered incidentally. The volvulus “whirlpool sign.” However, in the acute or emergency
was untwisted laparoscopically in a counterclockwise setting, especially with the presence of an intestinal
direction, and the mesenteric pedicles were widened obstruction, ultrasound or contrast studies are rarely
by releasing adhesions between the cecum and the being performed. Contrasted CT scans, on the contrary,
3
duodenum around the superior mesentery artery may be the preferred choice of imaging. The twisting
(SMA). Ladd’s bands were released. As the bowel of the intestines around its axis gives the appearance of
appeared ischemic, an enterectomy was performed the “whirlpool sign.”
extracorporeally through a small incision in the right Elective surgical correction of symptomatic midgut
hypochondrium. A stapled side­to­side primary anas­ malrotation is recommended to prevent acute pres­
tomosis was made. Caecopexy was performed using entations and complications like bowel ischemia and
3­5
nonabsorbable sutures, and appendicectomy was gangrene. Resolution of symptoms was seen in most
2­5
prophylactically performed. The postoperative period patients following elective surgical repair. In acute
was marked by a brief period of ileus, but the patient presentations of midgut malrotation or intestinal obstruc­
was ambulating on the first day following surgery and tion, surgical repair is performed by correction of the
had experienced tolerable pain. He was discharged a malrotation by freeing the adhesions around the SMA,
week after the surgery. a counterclockwise rotation of the small intestines, a
release of the Ladd’s bands, and fixation of the cecum
and right colon to the abdominal wall. The laparoscopic
DISCUSSION
approach has been described to be safe and feasible, and
Midgut malrotation is a congenital anomaly due to a equally as effective as the open procedure in the absence
failure in the normal counterclockwise rotation of the of a midgut volvulus. 3
embryonic gut. There are varying degrees of this anomaly In conclusion, midgut malrotation may be a rare but
and may be characterized by the right­sided location of important cause of volvulus in adults. Its presentation
the small intestines, displacement of the cecum toward may vary from a chronic to an acute setting. An index
the right hypochondrium and the ligament of Treitz of suspicion should be present in the adult patient hav­
inferiorly, the presence of Ladd’s bands, and a narrow ing nonspecific abdominal symptoms or intermittent
base of the small intestinal mesentery. The latter may intestinal obstruction. Symptomatic midgut malrota­
result in a volvulus of the small intestines which can tion should be electively repaired before potential
manifest acutely or chronically. Internal herniation and complications like bowel ischemia and volvulus occur
duodenal obstruction may also take place due to the as evident in this patient. Early diagnosis followed by
presence of the anomalies. 1,2 an immediate repair may prevent a fatality. The lapa­
However, most of the complications arising from roscopic approach is feasible and safe even in the acute
midgut malrotation manifest in the pediatric age setting and may result in less postoperative pain and
group. Some remained asymptomatic until adult life. early ambulation.

World Journal of Laparoscopic Surgery, May-August 2016;9(2):98-100 99