Outcomes of Laparoscopic Versus Open Ladd’s Procedure for Intestinal Malrotation in Adults

Lane Frasier, MD, Glen E Leverson, PhD, Ankush Gosain, MD, PhD, Jacob A Greenberg, MD, EdM. University of Wisconsin Hospital and Clinics, Department of Surgery.

Introduction: The purpose of this study was to investigate outcomes for adult patients undergoing laparoscopic vs open surgical repair for intestinal malrotation. Intestinal malrotation results from errors in fetal intestinal rotation and fixation beginning in the first trimester of pregnancy. Most patients are diagnosed in childhood, typically before two years of age; however, some patients remain undiagnosed into adulthood. Laparoscopic repair is now an accepted alternative to laparotomy in children but has not been well-studied in adults.

Methods and Procedures: After IRB approval, a retrospective chart review was performed for all patients ≥ 18 years of age diagnosed with intestinal malrotation presenting to a single tertiary-care institution from 2002 – 2013. Data collected included: age at diagnosis; pre-operative diagnosis; details of pre-operative imaging, surgical management, and complications; rates of re-operation, and symptom resolution.

Patients were evaluated on an intent-to-treat basis. Categorical data were analyzed using Chi-squared or Fisher’s exact test. Continuous data were analyzed using Student’s T-test. A two-tailed p-value ≤ 0.05 was considered statistically significant.

Results: Twenty-two patients were identified (age range 18 – 63). Fifteen patients were diagnosed pre-operatively; 4 received an intra-operative diagnosis of malrotation during an elective procedure for an alternate diagnosis. Twenty patients had some type of pre-operative imaging (data not available for one patient), with CT being the most common imaging modality employed (77.3%). Four patients had volvulus.

Six patients underwent successful laparoscopic repair; an additional three began laparoscopically but converted to laparotomy. There were no significant differences in age, operative time, or estimated blood loss between the two groups. There was a trend toward reduced need for nasogastric (NG) tube in the laparoscopic group (1.86 ± 2.7d vs 5.67 ± 4.1 d, p = 0.07), and a statistically significant difference in length of stay (5.0 ± 2.5 d vs 11.6 ± 8.1 d, p = 0.0148).

Three patients required re-operation: 2 underwent side-to-side duodeno-duodenostomy; 1 underwent a re-do Ladd’s procedure after an initial open procedure. Ultimately, 4 patients (2 laparoscopic, 2 open) had persistent symptoms: bloating (n=2), constipation (n=2), and/or pain (n=2).

Table 1. Comparison of Adult Patients Undergoing Laparoscopic vs Open Repair for Intestinal Malrotation
  Laparoscopic Open P-Value
Number of patients 9 13
Pre-Operative Diagnosis of Malrotation n (%) 8 (88.9) 7 (53.8) 0.5630
Age (years) 34.9 ± 9.5 41.2 ± 14.4 0.2686
Operative Time (minutes) 174.6 ± 69.7 200.5 ± 89.6 0.4807
Estimated Blood Loss (cc) 102.8 ± 191.6 99.2 ± 125.5 0.9585
NG Tube Decompression (days) 1.9 ± 2.7 5.7 ± 4.1 0.0701
Length of Stay (days) 5.0 ± 2.5 11.6 ± 8.1 0.0148
Re-Operation n (%) 1 (11.1) 2 (15.4) 1.00

Conclusions: Laparoscopic Ladd’s repair appears to be safe and effective in adults. While small numbers limit our ability to identify important differences, there was a statistically significant decrease in LOS and a trend toward decreased need for postoperative nasogastric decompression. There were no significant differences in major or minor complication rates, need for re-operation, or persistence of symptoms between the two groups.

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