Ladd's Procedure (Malrotation)
Intestinal malrotation [with midgut volvulus / without volvulus]
Same
Ladd's procedure ([emergent for volvulus / elective]): division of Ladd's bands, duodenal mobilization, appendectomy, and intestinal repositioning
[***, MD/DO]
[Resident name]
General endotracheal. Orogastric tube placed.
Patient is a [age]-old [male / female] presenting with [bilious emesis / abdominal distension / acute abdomen] and [upper GI series / ultrasound / CT] demonstrating [malrotation with midgut volvulus / malrotation without volvulus]. [Whirlpool sign on Doppler ultrasound.] [Bowel ischemia suspected given bloody stools / bilious emesis duration X hours.] Emergent [/ elective] surgical correction indicated. Risks including ischemic bowel loss, short gut syndrome, anastomotic leak, and prolonged ileus discussed with parents. Consent obtained.
Clockwise midgut volvulus [X] turns. [Ischemic bowel, [viable after detorsion / frankly necrotic, requiring resection].] Ladd's bands crossing duodenum from cecum to right upper quadrant. Duodenojejunal junction to right of midline, confirming malrotation. After Ladd's procedure: duodenum positioned on right side, cecum in left lower quadrant. [Bowel pink and peristaltic at end of case.]
The patient was taken urgently to the operating room and positioned supine. A supraumbilical transverse incision was made and the abdomen entered.
The midgut was delivered from the abdomen. [A clockwise volvulus of [X] turns was present and reduced by counterclockwise detorsion.] The bowel was assessed for viability (color, peristalsis, Doppler) after detorsion.
Ladd's bands (peritoneal attachments from the cecum and right colon crossing the duodenum) were divided with sharp dissection, completely freeing the duodenum. The mesenteric base was widened by separating the superior mesenteric artery from the superior mesenteric vein and dividing peritoneal attachments at the mesenteric root, broadening the mesenteric base. The duodenum and proximal small bowel were straightened and positioned along the right side of the abdomen. The cecum and right colon were positioned in the left side. The bowel was returned to the abdomen in this non-rotation position.
An incidental appendectomy was performed by ligating and dividing the appendiceal base and mesoappendix with [electrocautery / 3-0 Vicryl / Endo GIA stapler].
[Ischemic bowel resected with primary anastomosis / ostomy creation. See concurrent note.]
Fascia closed with [running 0-PDS / figure-of-eight 0-Vicryl]. Skin closed. Patient tolerated the procedure well.
None
[Appendix to pathology / Ischemic bowel to pathology / None]
[X] mL
[None / OGT decompression only]
Patient taken to pediatric ICU / NICU in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Intestinal malrotation [with midgut volvulus / without volvulus]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Ladd's procedure ([emergent / elective]): division of Ladd's bands, duodenal mobilization, appendectomy, intestinal repositioning
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal, OGT placed
INDICATIONS: The patient is a .PTAGE-old .PTSEX presenting with [bilious emesis / acute abdomen] and [UGI series / Doppler ultrasound / CT] demonstrating malrotation [with midgut volvulus]. [Bowel ischemia suspected.] Emergent [/ elective] correction indicated. Risks including bowel loss, short gut, and anastomotic complications discussed with parents. Informed consent obtained.
FINDINGS: Clockwise midgut volvulus *** turns. [Ischemic bowel: viable after detorsion / necrotic — resected.] Ladd's bands crossing duodenum; duodenojejunal junction to right of midline. After procedure: duodenum on right, cecum in left lower quadrant. Bowel [pink and viable / ischemic segment resected].
DESCRIPTION OF PROCEDURE:
Patient supine. Supraumbilical transverse incision. Abdomen entered. Midgut delivered. [Clockwise volvulus *** turns; reduced by counterclockwise detorsion.] Bowel viability assessed (color, peristalsis, Doppler). Ladd's bands divided sharply; duodenum freed completely. SMA/SMV separated; peritoneal attachments at mesenteric root divided; mesenteric base widened. Duodenum and proximal jejunum straightened and positioned on right. Cecum positioned in left lower quadrant. Appendectomy performed [with ligation and division of appendiceal base and mesoappendix]. [Ischemic bowel resected — see concurrent note.] Bowel returned to abdomen in non-rotation position. Fascia closed with 0-PDS. Skin closed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: [Appendix to pathology / Resected bowel to pathology / None]
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient to [peds ICU / NICU] in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Volvulus with ischemic bowel
Plan second-look laparotomy at 24-48 hours for borderline viability — use staged-or-related-procedure reporting (planned staged). Document extent of ischemia and residual bowel length; short gut risk if residual small bowel <75 cm (term infant normal range 150-250 cm).
Laparoscopic Ladd's procedure
Laparoscopic approach was historically reserved for elective cases; recent evidence (2019-2025) supports laparoscopic technique even for volvulus in hemodynamically stable patients at experienced centers. Convert to open for hemodynamic instability, extensive ischemia, or inadequate visualization.
Charting Tips
- Document direction and number of volvulus turns (midgut volvulus is essentially always clockwise; documented turns number guides detorsion)
- Note bowel viability assessment after detorsion: color, peristalsis, capillary refill, and Doppler if used
- Document division of Ladd's bands completely and SMA/SMV separation with mesenteric root widening
- Document appendectomy and rationale: (1) prevents future diagnostic confusion if appendicitis develops in an atypical left-sided position; (2) Ladd's band division may compromise appendiceal blood supply, making appendectomy appropriate
- If bowel resected, document residual small bowel length — critical for short gut syndrome risk assessment
- Include ultrasound whirlpool sign if present preoperatively; document time from symptom onset to OR for ischemia timeline
Documentation & Reimbursement Considerations
- Report Ladd's Procedure (Malrotation) as the primary service when it is the definitive operation performed.
- Incidental appendectomy during Ladd's procedure is bundled into the primary service and is NOT separately billable.
- Document extent of ischemia, residual bowel length, and anastomosis vs. ostomy decision.
- Second-look laparotomy: if planned at the first operation for borderline bowel viability, use staged-or-related-procedure reporting (planned staged procedure in postoperative period). Related unplanned return-to-the-operating-room reporting is for unplanned return to the OR for a complication of the primary procedure — do not use related unplanned return-to-the-operating-room reporting for a preemptively planned second-look.
- Laparoscopic Ladd's procedure: there is no specific reporting options for laparoscopic Ladd's. Document port placement and full extent of band division and mesenteric widening.