Introduction open Ladd’s procedure, described by William E.

Introduction 

Malrotation is a rare congenital
intestinal abnormality with an incidence of 0.2-1% in the pediatric population1. It results from errors
in fetal intestinal rotation and fixation. Symptomatic patients with
malrotation undergo an open Ladd’s procedure, described by William E. Ladd in
19364, 5. However,
with the advancement of minimally invasive surgical techniques, laparoscopic Ladd’s
is increasingly utilized.

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The potential benefits of
laparoscopic surgery include better cosmesis secondary to smaller incisions,
increased visualization, decreased risk of infection, and reduced length of
stay. Potential disadvantages include difficulty with mobilization and
decreased adhesions that theoretically put the patient at a greater risk of
post-operative volvulus2, 3, 10{Kinlin,
2017, The surgical management of malrotation: A Canadian Association of
Pediatric Surgeons survey;Huntington, 2017, Comparing laparoscopic versus open
Ladd’s procedure in pediatric patients;Ferrero, 2017, Intestinal Malrotation
and Volvulus in Neonates: Laparoscopy Versus Open Laparotomy;Ferrero, 2017,
Intestinal Malrotation and Volvulus in Neonates: Laparoscopy Versus Open
Laparotomy}.

Pediatric surgeons are polarized regarding the laparoscopic versus open
surgical approach to fix malrotation. Although some surgeons are utilizing the
laparoscopic approach more frequently, evidence regarding the safety and
efficacy of this procedure is lacking3, 10-14.

We conducted a retrospective
review of patients at our freestanding children’s hospital to compare
post-operative outcomes in patients undergoing laparoscopic versus open Ladd’s
procedure. We hypothesized that patients undergoing laparoscopic Ladd’s
procedure for malrotation have longer operative times, time to diet, length of
stay, and post-operative recurrence of volvulus.

 

Methods

After approval by the Institutional
Review Board (#CHLA-15-00531), we
conducted a five-year retrospective chart review of patients (0-18 years) that
underwent Ladd’s procedure at Children’s Hospital Los Angeles, a freestanding
quaternary care institution. Our primary interest was to investigate the
differences in outcome between patients that undergo laparoscopic versus open
Ladd’s procedure. The primary outcomes we measured included operative time,
time to resume diet, length of hospital stay, clinic visits, ED visits, readmission
rates, and reoperation rates.

 

 

 

Patient
Selection and Definitions

We conducted a five-year
retrospective chart review of all patients 0-18 years who underwent Ladd’s
procedure (defined per CPT
code 44055 and ICD-9 and ICD-10 codes 751.4 and Q43.3) at our
institution from 2010-2015. Exclusion of patients included those with
concomitant conditions, such as cyanotic heart disease leading to poor gut
perfusion, patients with failure to thrive requiring g-tube at time of
operation, significant reflux, tracheoesophageal fistula, and biliary atresia. Patients were defined as either
undergoing laparoscopic Ladd’s procedure, open Ladd’s procedure, or laparoscopic
converted to open (lap-open) Ladd’s procedure.

 

Open versus laparoscopic techniques

Patients
undergoing open procedure underwent a traditional Ladd’s procedure involving
inspection and detorsion of the intestine, widening of the base of the
mesentery, adhesiolysis of Ladd’s peritoneal bands, and an appendectomy. Patients with malrotation who underwent
laparoscopic management per surgeon’s preference were included in this study.

One patient was removed from the study that also underwent laparoscopic
gastrostomy tube placement at the time of the Ladd’s procedure. Patients who were
converted from laparoscopic to open operation are included in this study.  

 

Statistical
Analysis

Descriptive statistics were
used to summarize and describe the distribution of continuous variables
(expressed as mean +/- standard deviation) and categorical variables (expressed
as percentages). Data
outliers were eliminated by ROUT method with a Q value of 1%.  Due to the non-normal distribution of data, Kruskal-Wallis
one-way ANOVA on ranks was used for determining differences in outcomes between
open, laparoscopic, and lap-open procedures. 
Follow-up pairwise Mann-Whitney tests were performed where appropriate
to determine the significance of between-groups differences.  Mann-Whitney tests were additionally
performed to determine differences between volvulus and no volvulus groups with
respect to the outcome variables.  All
statistical tests were performed with a p-value < 0.05 considered to be significant.

 

 

Results

From 2010-2015, 130 patients
underwent Ladd’s procedure for malrotation at our institution. Of these,

53 patients were excluded for cyanotic heart disease resulting in poor gut
perfusion, nonrotation,

significant
reflux, esophageal atresia with tracheoesophageal fistula, biliary atresia, and
patients requiring additional procedures at time of operation (eg. central line
placement, gastrostomy placement).  The
remaining 77 patients were divided into Open (n=62), laparoscopic (n=8), and
laparoscopic to open (n=7) categories. Forty-four percent of patients
undergoing open surgery presented with volvulus (Figure 1).

The
laparoscopic Ladd’s group was slightly older than the patients undergoing open
operation. No difference was found in presenting heart rate amongst the groups.

However, we found that patients undergoing open surgery presenting with
volvulus had greater presenting heart rates than those patients that presented
without volvulus. We found no difference in the WBC, presenting systolic blood
pressure, or temperature amongst the groups (Table 1).

As
expected, we found that patients undergoing initial laparoscopic surgery
(laparoscopic and lap-open) had longer operative times compared to patients
undergoing initial open operation. Patients presenting with volvulus had longer
operative times compared to patients that did not present with volvulus. Patients
presenting with volvulus took a longer time to return to diet compared to
patients that did not present with volvulus. Interestingly, in patients that
did not present with volvulus, patients with open surgery returned to diet
faster than those who underwent initial laparoscopic surgery that was converted
to open. No difference was noted in the length of stay related to Ladd’s
procedure between the open and laparoscopic group. However, patients who were
converted to open operation from laparoscopy had greater average LOS compared
to the open group. Interestingly, patients undergoing laparoscopic surgery had
a greater amount of post-operative clinic visits compared to patients
undergoing open surgery. No difference was seen in the number of ED visits
amongst the groups (Figures 2 &3).

Patients presenting with
volvulus were more ill: two patients required second-look laparotomies, one
patient required reoperation secondary to anastomotic leak, two patients
experienced post-operative respiratory failure, and one patient required reoperation
for wound infection.  Two open surgery
patients that did not present with volvulus required reoperation for adhesive
bowel obstruction. In patients undergoing laparoscopic surgery, only one
patient required reoperation secondary to adhesive bowel obstruction. One
patient requiring laparoscopic to open Ladd’s required reoperation secondary to
duodenal obstruction.

 

Discussion

Normal intestinal rotation is
established as a result of herniation of intestinal contents and a 90-degree counter-clockwise
rotation from the abdomen during the 4th gestational week. Between
weeks 8-10, the midgut returns to the peritoneal cavity and in the process
rotates another 180 degrees and results in the duodenal-jejunal junction
placement to the left of the midline and cecum in the right iliac fossa2, 3.   In patients with malrotation, the
duodenal-jejunal fixture lies to the right of the midline and close to the
ileocecal valve resulting in a narrow mesenteric root that is at risk for
volvulus. 1 out of 2500 children present with symptoms of midgut volvulus1.   The Ladd operation involves inspection and
detorsion of the intestine, widening of the base of the mesentery, adhesiolysis
of Ladd’s peritoneal bands, and an appendectomy. Traditionally, this procedure
is performed via an open technique 2, 6-9.

However, with the advent of laparoscopic surgery, laparoscopic Ladd’s is
increasingly used. The first laparoscopic Ladd’s procedure was performed in
1995 by Van Der Zee8.

Controversy exists in the
operative management of malrotation amongst pediatric surgeons3, 4, 10-15. Our institutional
data suggests that patients undergoing laparoscopic Ladd’s procedure are older,
have longer operative times and more clinic visits compared to patients
undergoing the open technique.  Besides
age, patients undergoing laparoscopic Ladd’s present in a clinically similar
manner to patients undergoing open Ladd’s, and no difference exists in
post-operative complications in patients undergoing open versus laparoscopic
Ladd’s.  Interestingly, patients who
undergo lap-open surgery take longer time to return to diet, have more clinic
visits, and longer hospitalizations. 
Increased period of bowel manipulation in these patients may contribute
to inferior outcomes. Limitations of our study include its retrospective nature
and a dataset derived from a single institution.

Patients that present with
volvulus generally undergo open operation. These patients are clinically ill
compared to those that do not have volvulus (greater presenting heart rates, more
complications). The majority of patients that were converted from laparoscopic
to open surgery presented with volvulus, suggesting that open Ladd’s should
continue to be the standard of care for patients presenting with volvulus. In
conclusion, we find that open Ladd’s procedure should continue to be the
standard of care for patients that present with volvulus and that laparoscopic
Ladd’s results in longer operative times and more clinic visits. Further
studies are needed to determine the utility of performing laparoscopic Ladd’s
in older patients.