Laparoscopic Ladd Procedure for the Management of Malrotation and Volvulus

Abstract

Introduction:

While laparoscopic Ladd procedure is commonly performed in patients with asymptomatic malrotation, a paucity of data exists on children with volvulus or with low weight (≤3 kg). Our purpose was to evaluate the safety and efficacy of the laparoscopic Ladd procedure in these complex patient populations.

Methods:

A retrospective review of patients undergoing operation for malrotation from 2008 to 2018 was performed. Specific subgroup analysis was performed comparing outcomes after open and laparoscopic approaches in patients presenting with acute volvulus or in low-weight (<3 kg) patients.

Results:

Out of 110 patients, 38 (35%) presented with volvulus and 72 (65%) without volvulus. In patients with volvulus, 16 (42%) underwent laparoscopy and 22 (58%) had an open procedure. More patients in the open group had a preoperative diagnosis of volvulus (63.6% vs. 12.5%, P = .002). Operative time was longer in the laparoscopic group (87 vs. 61 minutes, P = .029), with 7 patients being converted to an open procedure (44%). Days to regular diet, hospital length of stay, and recurrent volvulus were similar between groups. In patients weighting <3 kg, 10 patients underwent laparoscopy and 10 patients had an open procedure. Demographics, operative time, postoperative outcomes, and complications were similar between groups. One person in the laparoscopic group was converted to open.

Conclusion:

Laparoscopic management of malrotation, even in the presence of volvulus and low patient weight, is safe and effective, with low rates of recurrent volvulus. If exposure is suboptimal, conversion to open in patients with volvulus should be considered.

Introduction

Since Ladd's first description of the eponymous procedure in 1936, intestinal malrotation, with or without volvulus, has historically been managed by laparotomy.¹ The first description of the laparoscopic Ladd procedure in children was in 1995 in a 3.6 kg, 7- day-old neonate who presented with malrotation and volvulus.² Further reports followed, demonstrating successful completion of the Ladd procedure laparoscopically with subsequent series validating the safety and efficacy of the technique.^3–6 Similar to other laparoscopic procedures, this approach to malrotation has been shown to expedite goal feeding and shorten hospital stay.^7,8 However, controversy still remains if this is the best approach for all patients with malrotation due to concern for recurrent volvulus from perceived lack of adhesions with laparoscopy, the viability of laparoscopy in neonates, and the ability to derotate friable bowel in the setting of volvulus.^9–12

The purpose of this study was to evaluate the safety and efficacy of the laparoscopic Ladd procedure for symptomatic malrotation, focusing specifically on those found to have volvulus and in the subpopulation of low-weight children (≤3 kg) with and without volvulus. We hypothesized that the laparoscopic approach would be noninferior to laparotomy, even for complex patients.

Methods

Data enrollment

This was a single-center retrospective analysis that included all patients <18 years of age, who underwent operation for symptomatic malrotation between January 1, 2008, and August 1, 2017, at an academic, freestanding pediatric hospital. This study was approved by the Institutional Review Board of Children's Mercy Hospital (no. 17080470); a waiver of consent was granted, given the retrospective nature of the work. Patients were identified from hospital records based on appropriate ICD-9 and ICD-10 diagnostic codes for malrotation and current procedure terminology codes for open and laparoscopic correction of malrotation. Demographics, diagnostic evaluation, surgical management, and outcomes were recorded.

Laparoscopic procedural technique

For the laparoscopic Ladd procedure, a 5 mm port is first placed directly through the umbilicus. Two to three additional stab incisions are placed, depending on surgeon preference, in the left mid-abdomen and left lower quadrant, and if needed in the right mid-abdomen. Some surgeons elect for instrument placement in the left and right mid-abdomen. If there is a question of bowel viability or if patient condition necessitates, the operation can be converted to an open approach by extending the umbilical incision vertically. If the patient is found to have a volvulus, careful detorsion was performed. The Ladd bands are divided with blunt dissection, scissors, or electrocautery. The cecum and right colon are completely mobilized to the left, and the base of the mesentery is widened by opening the anterior peritoneal leaf. The duodenum is fully mobilized to the right. The appendix is either removed or inverted.

Outcome measures

The primary outcome measures examined were recurrent volvulus, acute postoperative complication (such as surgical site infection, intra-abdominal abscess, enterocutaneous fistula, high-grade ileus, bowel obstruction, anastomotic stricture, stoma complication, and/or cardiac arrest), long-term complications (defined as any complication occurring beyond 30 days postoperation), total parenteral nutrition (TPN) dependence for more than 30 days postoperatively, and reoperation. Cases converted from laparoscopic to open were considered laparoscopic in the analysis, as per an intention-to-treat analysis.

Statistical analysis

Descriptive analysis was performed, and all values were reported as means with standard deviations. Differences in means were analyzed with a Mann–Whitney U test. Continuous data were compared with a t-test, and proportions were analyzed with a Fisher's exact test or chi-squared test based on the normality of the data. Results with P < .05 were considered significant.

Results

Initial analysis of all patients with malrotation

From 2008 to 2017, 110 patients were identified. Thirty-eight patients (35%) were found to have a volvulus, while 72 patients (65%) had malrotation without volvulus. Patients with a volvulus were more likely to be male (73.7% vs. 48.6%, P = .015), to be present at a younger age (1.5 vs. 3.4 years, P = .036), and to weigh less at the time of surgery (7.74 vs. 17.20 kg, P = .019) than patients who did not have a volvulus (Table 1). Patients without a volvulus were more likely to undergo a procedure that was completely laparoscopic (47.2% vs. 23.7%, P = .017); yet, the rate of conversion from laparoscopic to an open procedure was similar between groups (Table 2). Patients who had a volvulus on the initial operation were more likely to develop a postoperative volvulus (8.11% vs. 0%, P = .015); however, days to a regular diet, hospital length of stay, need for re-operation, need for long-term TPN, and length of follow-up were similar between groups (Table 3).

Table 1.

Demographic Comparison Between Patients With and Without Volvulus

Demographics	Volvulus (n = 38)	No volvulus (n = 72)	P
Male gender, n (%)	28 (73.7)	35 (48.6)	.015
Age at surgery, years (mean ± SD)	1.50 ± 3.43	3.44 ± 5.04	.036
Weight at surgery, kg (mean ± SD)	7.74 ± 11.50	17.20 ± 23.05	.019
Cardiac comorbidity, n (%)	4 (10.5)	9 (12.5)	1.00

This table compared the demographic characteristics of patients with malrotation either with or without volvulus at the time of operation.

Bold numbers indicate statistical significance.

SD, standard deviation.

Table 2.

Intraoperative Comparison Between Patients With and Without Volvulus

	Volvulus (n = 38)	No volvulus (n = 72)	P
Type of approach, n (%)
Laparoscopic	9 (23.7)	34 (47.2)	.017
Laparoscopic to open	7 (18.4)	7 (9.7)	.195
Open	22 (57.9)	31 (43.1)	.141
Operative time, minutes (mean ± SD)	72.3 ± 60.2	66.7 ± 34.9	.435
Bowel resection, n (%)	3 (7.9)	2 (2.8)	.338

This table compared the intraoperative characteristics, including type of operation, bowel resection, and length of the procedure between patients who had malrotation with volvulus and those without volvulus.

Bold numbers indicate statistical significance.

SD, standard deviation.

Table 3.

Comparison of Postoperative Outcomes Between Patients With and Without Volvulus

	Volvulus (n = 38)	No volvulus (n = 72)	P
Days to regular diet	6.38 ± 4.03	11.51 ± 26.12	.239
Hospital length of stay, days (mean ± SD)	10.92 ± 17.37	34.67 ± 72.68	.053
Postoperative complications, n (%)	5 (13.2)	12 (16.7)	.631
Re-operation	3 (7.9)	7 (9.7)	1.00
Volvulus, n (%)	3 (8.11)	0 (0)	.015
Need for TPN >30 days, n (%)	2 (5.26)	4 (5.63)	1.00
Length of follow-up, days (mean ± SD)	784.61 ± 911.91	633.89 ± 765.72	.379

Comparison was performed either with percentages for binary outcomes or in mean ± SD for continuous outcomes.

Bold numbers indicate statistical significance.

SD, standard deviation; TPN, total parenteral nutrition.

Laparoscopic versus open comparison of patients with an acute volvulus

Thirty-eight patients were found to have a volvulus at presentation and make up the cohort of this subgroup analysis. Sixteen patients (42.1%) underwent a laparoscopic Ladd procedure, while 22 patients (57.9%) underwent an open repair. Demographic characteristics, including gender, age, weight, history of cardiac comorbidity, and type of preoperative imaging were similar between groups. More patients in the open group had a preoperative diagnosis of volvulus (63.6% vs. 12.5%, P = .002) (Table 4). The operative time was shorter in the open group (61.32 vs. 87.44 minutes, P = .029), which may be due to the fact that 7 patients (43.8%) in the laparoscopic group were converted to open during the initial operation (Table 5). Bowel resection was required in 3 patients in the open group (13.6%), while none was required in the laparoscopic group (P = .249).

Table 4.

Demographic Comparison of Laparoscopic Versus Open Ladd's Procedure in Patients with Volvulus

	Laparoscopic (n = 16)	Open (n = 22)	P
Male gender, n (%)	13 (81.3)	15 (68.2)	.469
Age at surgery, years (mean ± SD)	2.19 ± 4.18	1.00 ± 2.75	.298
Weight at surgery, kg (mean ± SD)	11.28 ± 16.58	5.16 ± 4.50	.107
Cardiac comorbidity, n (%)	3 (18.8)	1 (4.55)	.291
Preoperative imaging, n (%)
Contrast study^a	10 (62.5)	17 (77.3)	.327
Advanced imaging	5 (31.3)	3 (13.6)	.192
Invasive diagnosis	1 (6.3)	2 (9.1)	.756
Preoperative diagnosis of volvulus, n (%)	2 (12.5)	14 (63.6)	.002

Subgroup analysis was performed looking at patients with an intraoperative diagnosis of volvulus at the time of Ladd's procedure.

Contrast study indicates upper gastrointestinal series. Advanced imaging included abdominal radiograph, ultrasound, or computed tomography. Invasive diagnosis included surgery or colonoscopy.

Bold numbers indicate statistical significance.

SD, standard deviation.

Table 5.

Comparison of Intraoperative Characteristics Between Patients Who Underwent Laparoscopic Versus Open Ladd's Procedure in Patients with Volvulus

	Laparoscopic (n = 16)	Open (n = 22)	P
Operative time, minutes (mean ± SD)	87.44 ± 46.18	61.32 ± 24.03	.029
Appendectomy, n (%)	14 (87.5)	10 (45.5)	.016
Bowel resection, n (%)	0 (0)	3 (13.6)	.249
Need to convert to open, n (%)	7 (43.8)	N/A	—

Analysis of intraoperative characteristics was performed within the subgroup of all patients with a diagnosis of malrotation and volvulus.

Bold numbers indicate statistical significance.

N/A, not applicable; SD, standard deviation.

There was no difference in days to regular diet, hospital length of stay, need for re-operation, or recurrent volvulus between the two groups. While the average length of follow-up was over a year longer in the open group, this was not statistically significant (988 vs. 500 days, P = .114) (Table 6).

Table 6.

Comparison of Postoperative and Long-Term Outcomes Between Patients Who Underwent Laparoscopic Versus Open Ladd's Procedure in Patients with Volvulus

	Laparoscopic (n = 16)	Open (n = 22)	P
Days to regular diet	5.6 ± 4.37	6.90 ± 3.79	.339
Hospital length of stay, days (mean ± SD)	6.8 ± 5.42	13.73 ± 21.84	.239
Postoperative complications, n (%)	3 (18.8)	2 (9.1)	.389
Re-operation	2 (12.5)	1 (4.55)	.562
Recurrent volvulus, n (%)	2 (13.3)	1 (4.55)	.554
Need for TPN >30 days, n (%)	2 (12.5)	0 (0)	.171
Length of follow-up, days (mean ± SD)	499.87 ± 898.14	988 ± 886.76	.114

Analysis of postoperative and long-term outcomes was performed within the subgroup of patients diagnosed with malrotation and volvulus who underwent either a laparoscopic or open procedure.

TPN, total parenteral nutrition.

Laparoscopic versus open comparison of patients with weight ≤3 kg

We predetermined low weight to signify patients weighing ≤3 kg, as this would signify patients found not only in the neonatal population but would also likely represent the most challenging population in which to perform a laparoscopic procedure, due to the small abdominal cavity.

Twenty patients in our cohort weighed 3 kg or less at the time of operation, with 10 patients undergoing a laparoscopic Ladd's procedure and 10 patients undergoing an open procedure. Weight was the only demographic variable nearing significance, with a mean weight of 2.44 kg for the laparoscopic group and 2.79 kg for the open group (P = .05) (Table 7). Intraoperative characteristics were also similar between laparoscopic and open groups, respectively, in terms of operative time (72.8 vs. 63.8 minutes, P = .635), performance of an appendectomy (90% vs. 70%, P = .582), or need for bowel resection (0% vs. 20%, P = .474). Only 1 patient in the laparoscopic group required a conversion to an open procedure (Table 8).

Table 7.

Demographic Comparison of Laparoscopic Versus Open Ladd's Procedure in Patients with Weight ≤3 kg

	Laparoscopic (n = 10)	Open (n = 10)	P
Male gender, n (%)	8 (80)	5 (50)	.350
Age at surgery, days (mean ± SD)	11.25 ± 11.74	15.82 ± 17.07	.495
Weight at surgery, kg (mean ± SD)	2.44 ± 0.50	2.79 ± 0.19	.050
Cardiac comorbidity, n (%)	2 (20)	1 (10)	1.000
Preoperative imaging, n (%)
Contrast study^a	7 (70)	9 (90)	.276
Advanced imaging	3 (30)	0 (0)	.067
Invasive diagnosis	0 (0)	1 (10)	.317
Preoperative diagnosis of volvulus, n (%)	1 (10)	3 (30)	.582

Subgroup analysis was performed looking at patients with a low weight of ≤3 kg at the time of Ladd's procedure.

Contrast study indicates upper gastrointestinal series. Advanced imaging included abdominal radiograph, ultrasound, or computed tomography. Invasive diagnosis included surgery or colonoscopy.

SD, standard deviation.

Table 8.

Comparison of Intraoperative Characteristics Between Patients Who Underwent Laparoscopic Versus Open Ladd's Procedure in Patients with Weight ≤3 kg

	Laparoscopic (n = 10)	Open (n = 10)	P
Operative time, minutes (mean ± SD)	72.8 ± 53.50	63.8 ± 24.56	.635
Appendectomy, n (%)	9 (90)	7 (70)	.582
Bowel resection, n (%)	0 (0)	2 (20)	.474
Need to convert to open, n (%)	1 (10)	N/A	—

Analysis comparing intraoperative characteristics was performed between patients <3 kg who underwent either a laparoscopic or open procedure.

N/A, not applicable; SD, standard deviation.

There was no difference in days to regular diet, hospital length of stay, need for re-operation, or recurrent volvulus between the two groups (Table 9). Length of follow-up was significantly longer in the open group (1025 vs. 180 days, P = .028), most likely owing to the more recent adoption of laparoscopy in the management of these low-weight patients.

Table 9.

Comparison of Postoperative and Long-Term Outcomes Between Patients Who Underwent Laparoscopic Versus Open Ladd's Procedure in Patients with Weight ≤3 kg

	Laparoscopic (n = 10)	Open (n = 10)	P
Days to regular diet	10.38 ± 4.57	8.3 ± 1.42	.348
Hospital length of stay, days (mean ± SD)	13.88 ± 5.94	35.4 ± 38.77	.142
Postoperative complications, n (%)	3 (30)	1 (10)	.276
Re-operation	3 (30)	0 (0)	.211
Recurrent volvulus, n (%)	2 (20)	0 (0)	.211
Need for TPN >30 days, n (%)	2 (20)	0 (0)	.211
Length of follow-up, days (mean ± SD)	180 ± 406.75	1025 ± 980.73	.028

The only significant difference between groups was that patients in the open group had a longer median follow-up time compared to the laparoscopic group.

Bold numbers indicate statistical significance.

TPN, total parenteral nutrition.

Discussion

We found that, while there was a conversion rate of 43.8% from the laparoscopic to the open approach for patients with a volvulus, there was no difference in acute postoperative or long-term outcomes with close to 2 years of follow-up. Similarly, looking at another potentially complex subgroup of patients, there was no difference in operative length and acute postoperative or long-term outcomes in patients weighing 3 kg or less when comparing laparoscopic to open Ladd procedure. Notably, only 1 patient in the laparoscopic group required conversion to an open procedure, indicating the feasibility of performing a laparoscopic Ladd procedure in these 2 complex patient populations.

Retrospective analysis has previously shown open surgery for malrotation to be associated with higher overall complication rates, which may be due, in part, to selection bias for open management of complex cases.^7,13,14 We decided to analyze these complex subgroups specifically, to identify the safety of performing a laparoscopic procedure in patients with volvulus or weighing <3 kg. Our series found that there was no difference between the approaches in terms of postoperative complications, complications requiring re-operation, long-term complications, or recurrent volvulus. This was found both in the subgroup with volvulus and those who underwent an operation weighing ≤3 kg. A recently published 10-year retrospective review also analyzed the outcomes of the laparoscopic Ladd procedure in the subgroup of patients who had malrotation with a volvulus. Postoperative outcomes were similar to our study with time to a regular diet of 5–6 days and length of hospital stay of 6–10 days.¹⁵ Our complication rate was also similar in this study at 14%–16%.¹⁵ From this, we can conclude that performing a laparoscopic Ladd procedure appears safe and can be considered in both of these patient populations.

In a large meta-analysis, a conversion rate of 25% from laparoscopic to an open procedure was reported.⁷ Others have reported the conversion rate to be between 8.3% and 45.5%, with the most recent report citing a 38% conversion rate in the group who had malrotation with volvulus.^8,11,13–16 Our study focused on high-risk patient subgroups, and we found that our conversion rates were within this range of previous studies (43.8% in the volvulus group and 10% in the low-weight group). Conversion from laparoscopic to open is likely associated with increased complexity, which lends itself to a higher risk for complications; therefore, converted cases were analyzed in the laparoscopic group, as per an intention-to-treat analysis, to demonstrate conservative estimates on the safety of this procedure in both patients with volvulus and with a weight ≤3 kg.

Looking at our entire patient population of 110 patients, those selected for laparoscopy were older and larger than those managed entirely open, a selection bias that has been seen previously in retrospective studies.^7,16 However, separate subgroup analysis in our population did not show any difference in age or weight between patients undergoing either a laparoscopic or open procedure.

Other case reports and retrospective series have supported the use of a laparoscopic Ladd procedure in younger children.^2,13,17 We report 10 cases of volvulus managed entirely laparoscopically with a mean weight of 2.44 kg, no increase in the rate of recurrent volvulus or complications compared to open repair, and only one conversion to an open approach. This demonstrates feasibility of performing this procedure in some of the smallest patients, an addition to the literature that has not yet been fully described. Our conversion rate remains within range of previous reports (25.3%–45.5%); while one must keep in mind that many previous reports did not look at patients with volvulus, our conversion rate remains in line with Arnaud et al.'s reported conversion rate in their patients who had a volvulus.^{7,8,11,13–16}

The biggest limitation of this study includes its single-center retrospective design, which inherently leads itself to selection bias. In this study, the majority of cases with volvulus were preferentially approached with an open technique, and all bowel resections occurred in cases managed entirely open. These data suggest that there is still some discretional bias to not even attempt laparoscopy in the more difficult cases. However, we have shown that laparoscopy is safe in patients with volvulus, although a high threshold for conversion may still be needed. Small case numbers also limit statistical power, while the setting of a tertiary care center with laparoscopic expertise limits generalizability to centers that are comfortable performing laparoscopy in small infants and neonates. Further long-term follow-up data are needed to better assess long-term complications, such as recurrent volvulus, as our follow-up is as short as an average of 180 days in some patients.

Conclusions

Laparoscopic management of malrotation, even in the presence of volvulus and in low-weight children, is safe and effective, with low rates of recurrent volvulus. If exposure is suboptimal, conversion to open in patients with volvulus should be considered.

Footnotes

Acknowledgments

Yara Duran and Pete Meunks, Clinical Research Coordinators at Children's Mercy Kansas City.

Disclosure Statement

No competing financial interests exist.

Funding Information

The authors received no specific funding for this work.

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