00:01
Before offering surgery to the
patient for intestinal malrotation,
we need to do some preoperative planning.
00:08
We have to offer the
patient supportive care
very importantly
to correct the electrolyte abnormalities
and restore the patient's
intravascular volume.
00:17
They are very likely
to be dehydrated
from the volume of emesis.
00:25
Let's talk about a classic procedure
called the Ladd’s procedure.
00:29
This is the procedure that is
known to fix malrotation patients.
00:34
At the time of an exploratory laparotomy,
you want to assess
whether or not
the intestines are actually viable.
00:40
Remember,
during a clinical scenario presented to you,
if there's any signs that
the bowel is ischemic,
that ischemic segment
needs to be resected.
00:50
During a Ladd’s procedure,
we first eviscerate all the intestines.
00:55
Then we detorse the intestines
usually in a counterclockwise direction.
01:02
Next, we divide the duodenal bands
called the Ladd’s bands.
01:06
Remember, the duodenojejunal junction
is now attached to the right
upper quadrant of the abdomen
and that is abnormal.
01:13
And we always do an appendectomy.
01:15
Remember,
because the cecum is not in
the right lower quadrant of the abdomen
in malrotation patients,
appendicitis later on as
a diagnosis can be difficult.
01:26
I’d like to pose a question to you.
01:27
What if the child has
progressive hypotension
or is progressively lethargic?
I’ll give you a second
to think about this.
01:39
That's right.
01:39
Take the patient to
the operating room.
01:42
This patient is demonstrating failure to thrive
and potentially ischemic intestines.
01:47
Particularly with hypotension,
it may be indication of septic shock.
01:51
In babies, we use dopamine.
01:54
Again, a clinical scenario that presents
the patients as deteriorating,
who initially was not peritoneal,
take the patient to the operating room.
02:04
Let's visit some important clinical pearls
and high-yield information
for intestinal malrotation.
02:10
Malrotation is considered a surgical emergency.
02:12
Don't sit on these patients.
02:14
Remember,
resuscitate,
replace the electrolytes
and take the patient
to the operating room.
02:20
Hopefully,
by the time you’ve taken
the patient to the operating room
that the intestines are still alive
and require no resection.
02:27
But a Ladd’s procedure
is still performed.
02:32
High-yield information.
02:33
Remember bilious emesis in
a child is intestinal malrotation
until proven otherwise.
02:40
This is particularly important
because malrotation can
lead to ischemic bowel.
02:45
Have a high index of suspicion.
02:48
Thank you very much for joining me
on this discussion of intestinal malrotation.