Malrotation and Midgut Volvulus

During normal development, the midgut undergoes a 270° counterclockwise rotation along the axis of the superior mesenteric artery. When this rotation is incomplete, problems can arise because of duodenal obstruction from Ladd bands or midgut volvulus. Their most common clinical presentation is that of bilious emesis in the newborn, but they occasionally may take up to one year to become apparent clinically. Diagnosis is confirmed by UGI study to assess if the duodenum crosses the vertebral column. Surgical therapy is pursued emergently and involves detorsion of the midgut in a counterclockwise direction, division of Ladd bands, passage of a rubber catheter to rule out duodenal obstruction, and replacement of the cecum in the LUQ and the duodenum in the RUQ, and appendectomy. If laparotomy reveals ischemic bowel, a second laparotomy is performed after 24 to 36 hrs to assess the viability of the bowel.

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