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.
The lecture Intestinal Malrotation: Management by Kevin Pei, MD is from the course Special Surgery.
Which finding should lead you to suspect intestinal malrotation unless proved otherwise?
An infant presents with intestinal malrotation. She progressively becomes more hypotensive and lethargic. What drug would you administer to treat this infant while preparing for surgery?
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