Intestinal Malrotation: Management

by Kevin Pei, MD

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    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.

    About the Lecture

    The lecture Intestinal Malrotation: Management by Kevin Pei, MD is from the course Special Surgery.

    Included Quiz Questions

    1. Bilious emesis
    2. Nausea
    3. Non-bilious emesis
    4. Diffuse abdominal pain
    5. Distended abdomen
    1. Dopamine
    2. Phenylephrine
    3. Epinephrine
    4. Norepinephrine
    5. Fentanyl

    Author of lecture Intestinal Malrotation: Management

     Kevin Pei, MD

    Kevin Pei, MD

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