Page 62 - World Journal of Laparoscopic Surgery

Congenital Midgut Malrotation Presenting as Acute Duodenal Obstruction in an Adult—Laparoscopic Management

Fig. 3: Stringer classification of malrotation: type 1: nonrotation, type 2: incomplete rotation, and type 3: reverse rotation

embryogenesis. Franklin Mall was the first to describe the 1. Entry into the abdominal cavity and evisceration
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development and position of the human intestine in 1897. Stages of 2. Counterclockwise detorsion of the bowel (acute cases)
normal rotation include herniation, rotation, retraction, and fixation. 3. Division of Ladd’s bands
During normal embryonic development, the bowel protrudes 4. Broadening of the small intestine mesentery
into the base of the umbilical cord and promptly elongates. As it 5. Incidental appendectomy
returns to the abdominal cavity, it undergoes 270° counterclockwise 6. Placement of the small intestine along the right flank and colon
rotation around the axis of the SMA, and as a result, the DJ is along the left flank of the abdomen
commonly located to the left of the first lumbar vertebra (L1),
and the terminal ileum in the right iliac fossa. This results in a There are controversies regarding the management of incidental
broad mesentery, running obliquely down from the DJ flexure to intestinal malrotation. The following can be considered a relative
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the cecum, avoiding rotation around SMA. Any deviation from contraindication for performing the Ladd’s procedure:
normal rotation results in malrotation with the shorter root of the • Patient with asymptomatic or incidentally found rotational
mesentery, making it more vulnerable to volvulus. anomaly
Stringer classified malrotation based on the embryological state • Complex cardiac disease (i.e., heterotaxy) with asymptomatic
of development into three main types as (Fig. 3): type I (nonrotation) malrotation
here DJ lies on the right and the colon on the left, type II (duodenal • Older patients with chronic symptoms without volvulus
malrotation) with the cecum in the epigastric region overlying the
third part of the duodenum, and type III (combined duodenal and However, each of these may still warrant elective Ladd’s
cecal malrotation) here DJ loop anterior to SMA and transverse colon procedure, with the risk of future volvulus as high as 20%. Magnified
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posterior to SMA. Our patient had type II malrotation. vision, faster recovery, less hospital stay, and early mobilization are
Patients with malrotation can present with acute or chronic the main advantages of laparoscopic surgery over open technique.
symptoms or incidental findings on imaging/surgery. Acute Hence, it was preferred in our case. The patient was mobilized on
manifestations (sudden-onset abdominal pain, bilious vomiting, or the same evening and discharged on day three.
obstipation) may suggest midgut volvulus. However, dull aching/
crampy abdominal pain, altered bowel habits, and malabsorption conclusIon
are vague chronic symptoms. 8 An important feature noted in our case is our patient’s previous
CECT scan of the abdomen is the gold standard imaging history of dull aching, vague abdominal pain which was
modality for adult malrotation; however, an upper gastrointestinal misdiagnosed as “chronic gastritis.” This suggests that intestinal
contrast study is reserved for the pediatric population. Computed malrotation and volvulus may be worth considering, with a high
tomography (CT) can demonstrate inversion of SMA and SMV, bowel index of suspicion in an adult patient presenting with chronic vague
position and viability, and volvulus (whirlpool sign) (Fig. 1). Other symptoms of the abdomen. The early and prompt diagnosis will
less common modalities include ultrasonography and magnetic prevent fatal complications associated with this disease. Malrotation
resonance imaging of the abdomen. 9 can be managed laparoscopically by Ladd’s procedure.
Patients with malrotation can be treated by Ladd’s procedure.
The basic principle of the surgery remains the same, irrespective
of the technique (open/laparoscopy). pAtIent consent
There are six key elements in the operative correction of Written informed consent was obtained from the patient for
malrotation via Ladd’s procedure (Fig. 2). 10 publication of this case and any accompanying images.

World Journal of Laparoscopic Surgery, Volume 14 Issue 1 (January–April 2021) 63