2 views 0 likes

Dr. Steve Rothenberg

Pediatric Surgery · View profile →

Malrotation and Volvulus with Trinity

Video Published 2026-05-05 Updated 2026-08-29

Timestops (4)

Port Placement and Initial Findings

Band Division and Vascular Exposure

Bowel Inspection and Hernia Reduction

Final Bowel Run and Extraction

Topic Overview

A laparoscopic reduction of midgut volvulus with Ladd's procedure in a 12-year-old female who presented with three months of intermittent pain and weight loss, then acute worsening. CT imaging confirmed midgut volvulus. The operation involved systematic division of Ladd's bands causing internal hernia and 360-degree bowel twist, widening of the mesentery to visualize the superior mesenteric vessels without obstruction, repositioning of the colon to the left abdomen, and appendectomy. The procedure was completed in approximately 90 minutes using 5mm ports and the CoolSeal Trinity device.

Key Takeaways

Complete bowel inspection from DJ junction to ileocecal valve is critical to ensure all Ladd's bands are released. (4:00)
Mesentery must be broadly widened so SMA/SMV run straight down midline without twist to prevent recurrent volvulus. (6:29)
Operating in front of the camera and running bowel anteriorly prevents disorientation in 360° twist anatomy. (2:38)
CoolSeal Trinity device allows safe tissue sealing/division and can rest on bowel wall without injury during dissection. (1:06)
5mm ports throughout procedure (including appendectomy with 5mm stapler) avoid upsizing and maintain minimal access. (0:29)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1

Chapters

0:00Case Presentation and Initial Findings — Introduction of a 12-year-old female with midgut volvulus confirmed on CT, taken emergently to OR. Initial laparoscopic entry revealed disorientation of bowel, internal hernia, and complete twist.
1:31Division of Ladd's Bands and Anatomy Clarification — Systematic division of obstructing Ladd's bands using the CoolSeal device. Gradual release of adhesive bands overlying small bowel and colon, with visualization of engorged superior mesenteric vessels due to twist.
4:29Bowel Running and Mesenteric Widening — Complete running of bowel from duodenojejunal junction to ileocecal valve to ensure all bands released. Widening of mesentery to visualize superior mesenteric artery and vein without twist or obstruction. Colon repositioned to left side of abdomen.
6:49Final Bowel Assessment and Appendectomy — Final proximal-to-distal bowel run to confirm no missed bands, with small bowel positioned on patient's right and colon on left. Appendectomy performed using CoolSeal for mesentery and 5mm stapler for appendix division.

Key claims

0:08A 12 year old female presented with a three month history of intermittent pain and weight loss with an acute worsening of her symptoms — Speaker 1
0:15A CT scan showed evidence of a mid gut volvulus — Speaker 1
0:18The patient was positioned in a Dorsal lithotomy position with the surgeon positioned between the patient's legs — Speaker 1
0:295 millimeter ports were used for the procedure — Speaker 1
0:51There was an internal hernia and a complete twist of the bowel — Speaker 1
1:06The ability to dissect grasp tissue and then seal and divide the tissue safely in close proximity to the bowel wall is key to the success of this operation — Speaker 1
2:13The ability to have the Trinity device activated while laying on the bowel wall without any injury is key to the success of this procedure — Speaker 1
2:38The anatomy in this case is quite confusing because of the 360 degree twist of the bowel as well as the internal hernia — Speaker 1
2:52The key to this operation is to operate in front of the camera and eventually run the bowel in front of the camera instead of chasing the bowel around the abdomen — Speaker 1
3:02Operating in front of the camera prevents disorientation and allows the surgeon to keep a clear view of the affected area — Speaker 1
3:13The superior mesenteric vessels were quite engorged because they had been twisted — Speaker 1
4:00It is critical that the bowel be completely run from the duodenojejunal junction all the way to the ileocecal valve to ensure that all of these bands have been released — Speaker 1
6:29The key to this operation is making sure that the mesentery has been broadly widened to prevent a twist in the future — Speaker 1
6:39One should be able to see the superior mesenteric artery and vein coming straight down into the middle of the abdomen with no twists or obstruction — Speaker 1
7:17The final positioning places all the small bowel on the patient's right and the colon on the patient's left — Speaker 1
7:37The appendix is divided with a single application of the 5 millimeter stapler, which allows keeping all ports at 5 millimeters and not upsizing to a 12 millimeter port for a larger stapler — Speaker 1
7:58The operation took approximately 90 minutes, and the patient did well — Speaker 1

Cases discussed

0:0812-year-old female with midgut volvulus and internal hernia

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Keywords

midgut volvulus malrotation internal hernia bowel obstruction Ladd's procedure laparoscopic reduction appendectomy division of Ladd's bands mesenteric widening

Hashtags

#LaparoscopicSurgery #MidgutVolvulus #PediatricSurgery #SurgicalTechnique #BowelObstruction #CoolsealTrinity5 #InternalHernia #Appendectomy #SurgicalEducation #SurgicalAnatomy #MinimallyInvasive #SurgicalInstruments #MesentericVessels #AdhesiveBands #SurgicalExposure #PostoperativeCare #SurgicalComplications #AnatomicalLandmarks #SurgicalDissection #DorsalLithotomy #LaddsProcedure #LaddProcedure #LaparoscopicTechnique

Transcript

This video demonstrates a laparoscopic reduction of a midgut volvulus with lad's procedure using the Coolseal Trinity 5 device. A 12 year old female presented with a three month history of intermittent pain and weight loss with an acute worsening of her symptoms. A CT scan showed evidence of a mid gut volvulus. She was taken emergently to the OR and positioned in a, Dorsal lithotomy position. The surgeon was positioned between the patient's legs, and here you see the port placement. 35 millimeter ports were used for the procedure. Upon entering the abdomen. It could be seen that there was a clear disorientation of the bowel. Initial attempts to run the bowel to determine the extent of the volvulus. We're done with 25 millimeter bowel clamps. But in early on, it became evident that there was an internal hernia and a complete twist of the bowel. Using the cool seal device, these lads bands can easily be taken. While manipulating the bowel, the ability to dissect grasp tissue and then seal and divide the tissue safely in close proximity to the bowel wall is key to the success of this operation. Here you can see some of the initial bands being taken down as we try to determine the anatomy. And Figure out the cause of the complete obstruction. Again, because we were able to manipulate the tissues as well as grasp them and then seal and divide them, we are able to limit our instrument instrumentation changes and do not lose exposure. Here you can see an overlying band, which is partially obstructing the small bowel. The ability to have the Trinity device activated while laying on the bow wall without any injury is key to the success of this procedure. Here we can see one of the large obstructing bands as we try to release the colon and move it to the left side of the abdomen. The anatomy in this case is quite confusing because of the. 360 degree twist of the bowel as well as the internal hernia. The key to this operation is to. Operate in front of the camera and eventually run the bowel in front of the camera instead of chasing the bowel around the abdomen. This prevents disorientation and allows the surgeon to keep a clear view of the. Affected area Now we can start to see the superior mesenteric vessels as they're released, and they're quite engorged because they've been twisted. Here are some further bands overlying the terminal ileum and near the area of the right colon. Gradually, all of this tissue is released, which allows us to place the colon. In the left side of the abdomen. As we run the bowel, we find further adhesive bands which continue to be partially obstructing. It is critical that the bow be completely run from. The duodeno jujunal junction all the way to the ileocecal valve to ensure that all of these bands have been released. Again, you can see the engorged vessels of the mesentery because of the twist. With the majority of the bands taken down, we now run the bowel from proximal to distal, trying to ensure that there are no further obstructive bands. As we get more distal, we do find bands extending from the colon and overlying the proximal small bowel or duodenum. These are taken with the cool seal as well. Does it continue to be large, uh, Adhesive bands which obstruct different portions of the proximal small bowel and by releasing these we are eventually able to relocate the colon to the left side of the abdomen. This is the last of the bands causing the internal hernia around which the twist was formed. Here, you can see the superior mesenteric vessel as it becomes freed. And this is followed up towards the base of the mesentery. The key to this operation is making sure that the mesentery has been broadly widened to prevent a twist in the future. One should be able to see the superior mesenteric artery and vein coming straight down into the middle of the abdomen with no twists or obstruction. These are the final bands which were obstructing the duodenum proximally. With all of this complete, we now run the bowel again from proximal to distal. Here you can see the duodenum as it has been straightened out. Coming from the first portion of the duodenum down to the communication with the jejunum. The ballots then run from proximal to distal to make sure that no bands have been missed. Also, this places all the small bowel on the patient's right and the colon on the patient's left. Again, the key to this is running the bowel in front of the camera, not chasing it around the abdomen. The final portion of the procedure is to take out the appendix. Here the appendiceal mesentery is taken using the cool seal, and then the appendix is divided with a single application of the 5 millimeter stapler. This allows us to keep all our ports at 5 millimeters and not upsize to a 12 millimeter port for a larger stapler. This is then brought out through the umbilical trochar site. The operation took approximately 90 minutes, and the patient did well.

Comments

Loading comments…