Ladd’s procedure for malrotation and volvulus

Malrotation is a difference in the way the bowel is positioned in the abdomen.

When a baby is growing during pregnancy, the bowel begins as a tube attaching the stomach to the anus. As the baby grows, the tube moves into the umbilical cord, where there is more space. It then coils back into its final position, attaching itself to the wall of the baby’s abdomen. 

A malrotation happens when the coil ends up in the wrong position. It is unknown what causes this to happen.

Malrotation happens in about 1 in 200 babies but only causes problems in about 1 in 6000 babies.

Volvulus is a type of bowel blockage that happens when the bowel twists and cuts off its own blood supply. When this happens, the bowel can start to die. This can make your baby very sick.

Children with malrotation can develop a volvulus because their bowels are in the wrong position, making it easier to twist. Babies born with malrotation may develop a volvulus in their first month of life.

Malrotation doesn’t always cause problems. Often, a baby with malrotation will not show any signs until they have a volvulus.

Signs of a volvulus in your baby include:

• passing blood in their poo
• pooing less
• fast breathing
• fast heart rate,
• irritability
• lethargy or sluggishness
• fever
• tummy pain which will make them cry and draw up their legs
• bilious vomiting - vomiting green liquid.

If your baby starts to vomit green liquid, this may mean they have a blocked bowel. Call triple zero (000) for an ambulance or attend your nearest emergency department immediately.

Tummy pain can happen as the bowel tries to push food past the twist. The pain may come and go, but your baby will be difficult to settle.

A baby can look very well and still have a volvulus. If your baby has any of the above symptoms, it is important that you see a doctor urgently as their bowel may already be in trouble.

A contrast study can be done to diagnose malrotation and volvulus.

In a contrast study, your baby is given some radioactive dye through a tube that goes from their nose to their stomach. This is called a nasogastric or NG tube. The dye travels through their digestive system, allowing the organs to show up on an x-ray.

Your child’s doctor will be able to make a diagnosis based on their signs and symptoms and the results of their test.

If malrotation is diagnosed, your baby will need to have an intravenous (IV) cannula inserted to give them fluids and antibiotics. They will also need urgent surgery to correct the malrotation and volvulus.

The only way to repair malrotation and volvulus is with an operation called a Ladd’s procedure. This operation needs to be done immediately because the twisted bowel may already be dying.

In malrotation, the risks of not operating on the malrotation and volvulus are far greater than the risks of the operation.

Risks can include:

• a blood transfusion if too much blood is lost during surgery
• damage to other organs, including the liver
• infection of the wound post-surgery
• blockages due to scar-tissue forming
• issues with absorbing nutrients after large parts of the bowel are removed.

Speak to your child’s doctor if you have any concerns about the risks of the Ladd’s procedure.

This surgery is done under a general anaesthetic, which means your baby will be asleep.

Your baby may be taken from the emergency department straight into surgery. Your baby's treatment team will be there to talk to you and answer any questions.

In the Ladd’s procedure:

1. a cut is made above the belly button
2. the surgeon will check the bowel and cut any abnormal bands or tissues that are holding it in the wrong position
3. if the bowel is healthy, the surgeon will put the bowel back in a safe position
4. if parts of the bowel are dead, the surgeon will remove the dead tissue while trying to keep as much of the healthy bowel as possible
5. if the remaining bowel parts are healthy, they can be joined back together
6. if the remaining bowel parts are not healthy, the surgeon may need to create a stoma to help the bowel rest and heal
7. at the end of the procedure, the cut will be closed with stitches, or the abdomen will be left open with a dressing if there is more surgery needed in the next few days.

Sometimes, your child will have their appendix removed if it is found to be sitting on the wrong side of the body. This is done to prevent any issues in the future. The appendix has no function, so it is safe to remove.

After the procedure, your baby may spend time in the paediatric intensive care unit (PICU) to recover. They may need a breathing tube and will get pain relief and nutrition through their IV cannula.

The treating team will support you in slowly transitioning your baby back to milk feeds, whether this is from breastfeeding or a bottle.

The stitches that are put in during your baby’s operation will dissolve on their own. A simple dressing will be applied over the top and can and taken off after a week or so.

If your baby has a stoma, you will get further support and education on cleaning and caring for the stoma.