Laparoscopic diagnostic findings in atypical intestinal malrotation in children with equivocal imaging studies

Abstract

Background Atypical presentations of intestinal malrotation are more common in older children with a diagnostic and therapeutic challenge. Upper gastrointestinal (UGI) contrast study is essential for the diagnosis of the majority of cases. Recently, laparoscopy has been used in the management of malrotation. We present our experience with laparoscopic management of atypical presentations of intestinal malrotation in children, describing laparoscopic findings in these cases.

Patients and methods A total of 40 patients with atypical presentations of malrotation were included in this study. The main presentations were recurrent abdominal pain, intermittent intestinal obstruction, recurrent bilious vomiting, and failure to thrive. They all were subjected to thorough history taking, clinical  examination, routine laboratory investigations, and UGI contrast study. No preoperative definitive diagnosis of malrotation was performed and all patients underwent laparoscopic evaluation.

Results Forty patients (25 males and 15 females) with a mean age of 7± 2.8 years were subjected to laparoscopy. Thirty-six patients (90%) were found to have definite laparoscopic findings in the form of markedly dilated stomach and first part of duodenum, ectopic site of cecum, medial and low position of duodenojejunal  junction, congested mesenteric veins with lymphatic ectasia, generalized mesenteric lymphadenopathy, reversed relation of superior mesenteric artery and vein, and rightsided small bowel and narrow mesenteric base. Four patients had differed laparoscopic diagnosis. All the procedures were completed laparoscopically. All the patients achieved full recovery without intraoperative or postoperative complications.

Conclusion Laparoscopy permits direct evaluation and treatment of undocumented malrotation in children, with equivocal UGI contrast study. These newly described laparoscopic findings are the key for the diagnosis of malrotation with atypical presentation.

Keywords: Ladd’s procedure, laparoscopy, mesenteric lymphadenopathy, undocumented malrotation