Laparoscopic Ladd's Procedure Is a Safe and Effective Treatment for Intestinal Malrotation in Children With and Without Volvulus

Sunday, October 27, 2013: 10:56 AM
Windermere Ballroom W (Hyatt Regency Orlando, formerly the Peabody)
Erik G. Pearson, MD, Stephen J. Fenton, MD and Thane A. Blinman, Division of General, Fetal and Thoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA

Purpose: Surgical management is often required in children with midgut rotational abnormalities.   Little literature exists concerning the laparoscopic approach.  We analyzed our experience in treating patients with this condition comparing laparoscopic and open techniques.

Methods: An IRB-approved retrospective review of children who underwent surgical intervention for intestinal malrotation between January 2006 and December 2012 was performed.  Student T-test and Fisher exact test were used for statistical analysis.

Results: Overall 103 children were reviewed: 49 in the laparoscopic group and 54 patients in the open group.  Laparoscopic Ladd’s was successful in 98% of cases, including four emergent cases for suspected intestinal volvulus.  Of those children who underwent Laparoscopic Ladd's, the oral diet was restarted at a median of 3 days post operatively and patients stayed in hospital for a median of 4 days.  Three patients required reoperation after a median follow-up of 555 days from laparoscopic Ladd's; 2 for small bowel obstruction, and 1 with pyloric stenosis.  Children who underwent an elective operation (laparoscopic = 45, open = 31) were compared.  Children in the laparoscopic group were more likely to be older (173 vs. 63 days, p=0.005) but were equally likely to have a comorbid condition.  Children with intestinal malrotation from heterotaxy (n=18) were less likely to have a laparoscopic operation (RR 0.20, 95% CI 0.07-0.54, p = 0.0003).  The laparoscopic procedure required slightly more operative (82 vs. 70 min, p=0.001) and anesthesia time (136 vs. 119 min, p=0.03).  Postoperatively, patients treated by the laparoscopic approach were less likely to require nasogastric decompression (RR = 0.46, 95% CI = 0.33-0.64, p = <0.0001), less likely to be admitted to the intensive care unit (RR=0.34, 95% CI 0.18-0.66, p=0.006) and had a reduced median post-operative stay (4 vs. 6 days, p=0.03).  There were no differences in the incidence of hospital readmission, reoperation, post-operative morbidity or death between the two groups with a median institutional follow up of 555 (laparoscopic) and 807 days (open).  On review of hospital charges there was no significant difference between the two groups with respect to operative or supply charges.

Conclusion: A laparoscopic Ladd’s procedure appears to be a safe and effective technique in both patients treated electively for intestinal malrotation as well as those requiring urgent surgical intervention for midgut volvulus.  The laparoscopic approach shortens time to resumption of enteric feeds, shortens length of stay, and does not increase costs.