Laparoscopic Ladd procedure for adult-onset intestinal malrotation with midgut volvulus: a case report

Introduction

Intestinal malrotation is a rare congenital abnormality that occurs early in gestation (approximately from the 4–5^th to 12^th week) affecting the physiological 270-degree counterclockwise rotation of the midgut around the superior mesenteric artery (SMA). During the early weeks of gestation (roughly between weeks 4 and 12), the normal counterclockwise rotation of the midgut around the SMA can be disrupted. Depending on when this process is interrupted, delayed, or inverted, several anatomical variations can occur, such as non-rotation, incomplete rotation, reversed rotation, or abnormal mesenteric attachment (1). While these structural anomalies are present in about 0.2% to 1% of healthy individuals, the vast majority stay silent, leaving the true prevalence unknown; though neonatal estimates suggest roughly 1 case per 6,000 live birth. Classic intestinal malrotation (incomplete) results in a narrowed mesenteric base, predisposing to volvulus (2); for this reason, the vast majority of cases affect newborns during the first year of life: the most severe presentation is midgut volvulus where the mesentery and the intestinal loops are twisted, resulting in intestinal occlusion and bowel ischemia due to the interrupted blood supply.

Symptoms include abdominal distension, pain, vomiting, constipation and bloody stools. Generally, 30–60% of cases have multiple congenital abnormalities (i.e., cardiac, anorectal, other) which should be looked for carefully (2).

Later onset is infrequent, symptoms can be more insidious like intermittent/chronic abdominal pain (subocclusive episodes). Adult presentation is extremely rare, accounting for only 0.2–0.5% of cases, of which only 15% present with midgut volvulus (3).

Cross-sectional imaging via computed tomography (CT) typically illustrates an atypical layout of the large and small intestines alongside inverted superior mesenteric vessels. Nonetheless, upper gastrointestinal (GI) contrast examinations continue to represent the diagnostic reference standard whenever the duodenojejunal flexure does not successfully cross the midline (4,5).

Traditionally, intestinal malrotation has been approached through midline laparotomy. The surgical procedure was first described by W. E. Ladd in 1936 (6): it consisted in counterclockwise rotation of the intestine, release of adhesion with cecum, broadening of the small intestine mesentery, bowel repositioning (small intestine in the right quadrant and colon on the left, so called “non rotation position”) and prophylactic appendectomy.

Laparoscopic Ladd procedure was first performed on a 7-day-old term-born girl in 1995 (7); afterwards, the feasibility and safety of the laparoscopic Ladd procedure for the treatment of intestinal malrotation have been reported in several papers, mainly case series from single institutions, both in the pediatric setting and in adults (7-13). Despite the trend toward minimally invasive approaches, experiences with emergency laparoscopy for malrotation with volvulus are limited, and to date, there is no consensus on this topic.

Herein, we describe a case of emergency laparoscopy in an adult-onset intestinal malrotation with acute volvulus. The laparoscopic exploration, providing a comprehensive view of the abdominal cavity, allowed us to exclude intestinal ischemia and the twisted bowel loops were carefully derotated. We present this article in accordance with the CARE reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0044/rc).

Case presentation

A 29-year-old female patient [body mass index (BMI) 23.3 kg/m²] presented to the emergency department (ED) in March 2025 complaining of acute onset abdominal pain associated with nausea without vomiting and diarrhea.

Past medical history reports previous episodes of intermittent abdominal pain that resolved spontaneously after a few days of fasting.

The patient had previously undergone laparoscopic cholecystectomy.

Upon arrival, vital signs were normal with no fever, the abdomen was mildly distended with diffuse tenderness on deep palpation without guarding or signs of peritonism.

Blood tests [complete blood count and arterial blood gas (ABG) analysis] were not significant with a lactate level of 1.4 mmol/L.

A CT scan was then performed which revealed an extensive volvulus of the bowel on the mesenteric axis (true malrotation) along with distorsion of the pancreaticoduodenal complex, markedly congested superior mesenteric vein (SMV) with the so-called “whirlpool sign” (wrapping of the SMV around the SMA in a clockwise direction) and no signs of ischemia, free fluid or air into the abdominal cavity.

Given both the high-risk of visceral complications and failure of conservative treatment an exploratory laparoscopy was then performed.

Surgical steps (Video 1):

• Exploratory phase: malrotation on the mesenteric axis was confirmed, no gross other anatomical abnormalities were noticed. The bowel appeared non distended, well perfused with engorged and convoluted mesenteric vessels (especially the SMV).
• Intestinal derotation: the first step was to identify and cut the Ladd’s band and perform a complete adhesiolysis in order to release the small bowel from entero-enteral and entero-parietal adhesions. The next step was retrograde derotation of the intestine; however, due to tough adhesions at the root of the mesentery, the normal intestinal configuration was successfully restored by antegrade derotation.
• Appendectomy was performed to avoid reintervention and avoid confounding causes of acute abdominal pain in case of recurrence.
• Bowel repositioning (variant of classic Ladd’s procedure): ileocecal complex and right colon were then placed back from the left quadrant to the right one.
• A pelvic tubular drain was placed at the end.
• The postoperative period was uneventful with early flatus and start of oral liquid and food intake.

The patient was discharged 4 days after surgery.

Follow-up at 3 months did not reveal any recurrence of abdominal pain or discomfort apart from bowel habit characterized by 3–4 movements of liquid stools per day. A CT scan showed almost complete resolution of the volvulus.

After 1 year the patient returned to normal bowel habit with a CT scan showing no evidence of recurrence.

All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the Declaration of Helsinki and its subsequent amendments. Publication of this case report and the video was waived from patient consent according to the institutional review board of the IRCCS Humanitas Research Hospital’s policy: routine authorization for the research use of clinical data is integrated into the standard admission agreement.

Discussion

Completeness of minimally invasive derotation is still a matter of debate as high-level evidence is lacking on this topic; however, surgical steps should follow the same principles as open procedure (14).

The largest case series available from a single institution comes from the Mayo Clinic (9) collecting 44 cases of adult patients who underwent a laparoscopic Ladd procedure in almost 30 years: female gender and white race were prevalent, with a median age of 36.6 years and chronic symptoms in 83% of patients. After a median follow-up of 8 years, 77.3% of patients had complete resolution of symptoms after surgery conversion was 13.6%, with 9% of hospital readmission rate and no surgical reinterventions, confirming the safety and effectiveness of the laparoscopic approach in this setting (9).

Controversy remains about performing or not prophylactic appendectomy. A recent systematic review of the literature about appendectomy during Ladd’s procedure over the past 30 years (15) showed 90% agreement among surgeons in favor of appendectomy because the appendix, if not removed, being in an abnormal position, could make the diagnosis of appendicitis very difficult in the future. However, long term follow-up data about the risk of appendicitis are not available for these patients.

Herein, we reported a case of symptomatic intestinal malrotation with non-complicated small bowel volvulus in a young adult female patient, which was successfully approached by laparoscopy with uneventful recovery. A careful initial exploration of the abdominal cavity confirmed the absence of intestinal ischemia, thus allowing us to proceed to the next steps of the Ladd procedure, taking care to handle cautiously the intestinal loops and complete the derotation of the volvulus.

Conclusions

Provided that patients are carefully selected, we believe that laparoscopy, at least as an initial approach, may be a reasonable choice for the treatment of midgut volvulus associated with intestinal malrotation, although to date, given the rarity of this condition, there is a lack of available evidence from prospective studies.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0044/rc

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0044/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0044/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the Declaration of Helsinki and its subsequent amendments. Publication of this case report and the video was waived from patient consent according to the institutional review board of IRCCS Humanitas Research Hospital’s policy: routine authorization for the research use of clinical data at IRCCS Humanitas Research Hospital is integrated into the standard admission agreement.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Alani M, Rentea RM. Midgut Malrotation. 2026 Jan 31. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan.
2. Ludwig K, De Bartolo D, Salerno A, et al. Congenital anomalies of the tubular gastrointestinal tract. Pathologica 2022;114:40-54. [Crossref] [PubMed]
3. Butterworth WA, Butterworth JW. An adult presentation of midgut volvulus secondary to intestinal malrotation: A case report and literature review. Int J Surg Case Rep 2018;50:46-9. [Crossref] [PubMed]
4. Pickhardt PJ, Bhalla S. Intestinal malrotation in adolescents and adults: spectrum of clinical and imaging features. AJR Am J Roentgenol 2002;179:1429-35. [Crossref] [PubMed]
5. Zissin R, Rathaus V, Oscadchy A, et al. Intestinal malrotation as an incidental finding on CT in adults. Abdom Imaging 1999;24:550-5. [Crossref] [PubMed]
6. Ladd WE. Surgical diseases of the alimentary tract in infants. N Engl J Med 1936;215:705-8.
7. van der Zee DC, Bax NM. Laparoscopic repair of acute volvulus in a neonate with malrotation. Surg Endosc 1995;9:1123-4. [Crossref] [PubMed]
8. Mizuta N, Kikuchi T, Fukuda Y. Adult Intestinal Malrotation Treated with Laparoscopic Ladd Procedure. Case Rep Surg 2022;2022:6874885. [Crossref] [PubMed]
9. Gomaa IA, Mirande MD, Armenia SJ, et al. Intestinal malrotation in the adult population: Diagnosis, management, and outcomes after laparoscopic Ladd procedure. J Gastrointest Surg 2024;28:1339-43. [Crossref] [PubMed]
10. Fu T, Tong WD, He YJ, et al. Surgical management of intestinal malrotation in adults. World J Surg 2007;31:1797-803. [Crossref] [PubMed]
11. Frasier LL, Leverson G, Gosain A, et al. Laparoscopic versus open Ladd's procedure for intestinal malrotation in adults. Surg Endosc 2015;29:1598-604. [Crossref] [PubMed]
12. Matzke GM, Dozois EJ, Larson DW, et al. Surgical management of intestinal malrotation in adults: comparative results for open and laparoscopic Ladd procedures. Surg Endosc 2005;19:1416-9. [Crossref] [PubMed]
13. Seymour NE, Andersen DK. Laparoscopic treatment of intestinal malrotation in adults. JSLS 2005;9:298-301. [PubMed]
14. Svetanoff WJ, Srivatsa S, Diefenbach K, et al. Diagnosis and management of intestinal rotational abnormalities with or without volvulus in the pediatric population. Semin Pediatr Surg 2022;31:151141. [Crossref] [PubMed]
15. Al Smady MN, Hendi SB, AlJeboury S, et al. Appendectomy as part of Ladd's procedure: a systematic review and survey analysis. Pediatr Surg Int 2023;39:164. [Crossref] [PubMed]