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Dr. Steve Rothenberg

Pediatric Surgery · View profile →

Malrotation Infant

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

Timestops (5)

Port Placement and Initial Dissection

Mobilizing Dilated Duodenum and Adhesions

Dividing Ladd's Bands Causing Obstruction

Complete Colon Mobilization to Left

Bowel Derotation and Appendectomy Completion

Topic Overview

This is a surgical demonstration of a laparoscopic Ladd's procedure performed on an infant presenting with repetitive bilious vomiting secondary to malrotation. The procedure involves systematic mobilization of a redundant, non-midline-crossing duodenum through division of Ladd's bands and peritoneal attachments using a 3-millimeter sealer device. The operation concludes with complete derotation of the bowel, positioning the colon on the left and small bowel on the right, and appendectomy to prevent future diagnostic confusion.

Key Takeaways

3mm sealer enables safe dissection of dense Ladd's bands with minimal energy spread, allowing immediate bowel grasping post-activation (1:33)
Proximal-to-distal dissection mobilizes dilated duodenum; posterior attachments require complete Ladd's band division first (2:23)
Complete colon mobilization is necessary due to posterior attachments; final anatomy positions colon left, small bowel right (4:08)
Ladd's bands crossing ileum can cause partial obstruction; enlarged mesenteric nodes indicate chronic mild obstruction (4:59)
In small infants, appendectomy via right trochar site prevents future diagnostic confusion after malrotation repair (9:06)

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
Speaker 2
Speaker 3

Chapters

0:00Case Presentation and Room Setup — Introduction of infant case with bilious vomiting and malrotation on upper GI series. Description of operating room configuration and trocar placement strategy.
0:47Initial Duodenal Mobilization — Dissection begins under the liver, mobilizing a markedly dilated proximal duodenum by dividing adhesions and omentum using the 3-millimeter sealer in a proximal-to-distal fashion.
2:56Mobilization of Colon and Ladd's Bands — Division of thick Ladd's bands between transverse colon and duodenum, followed by complete mobilization of ascending colon and cecum to expose posterior duodenal attachments.
5:19Posterior Duodenal Release and Straightening — Final division of retroperitoneal attachments allows complete duodenal mobilization and straightening, eliminating the kinking that caused obstruction.
7:31Bowel Derotation and Appendectomy — Systematic running of bowel from duodenum to terminal ileum achieves complete derotation with colon positioned left and small bowel right. Procedure concludes with appendectomy.

Key claims

0:00The infant presented with repetitive bilious vomiting — Speaker 1
0:09Upper GI series showed a redundant duodenum which did not cross the midline — Speaker 1
0:16The surgeon positions at the end of the table with the baby brought down to the foot to allow alignment with the foregut — Speaker 1
0:28A 4 or 5 millimeter port is placed in the umbilicus with right and left hand operating ports placed either side — Speaker 1
0:36In a small infant, the right hand port is placed above the umbilicus to prevent conflict between the right hand and the scope — Speaker 1
0:47A very dilated proximal duodenum was visualized under the liver — Speaker 1
1:00The 3 millimeter sealer can be used to safely grasp the bowel and act as an atraumatic forceps — Speaker 2
1:22The first portion of the duodenum is extremely dilated — Speaker 2
1:33Dense adhesions to the proximal duodenum can be safely taken down using the sealer by dissecting them off the bowel, then sealing and gently tearing them off the duodenal surface — Speaker 2
1:51The minimal energy spread of the sealer makes it very safe to dissect in this fashion — Speaker 2
1:58The bowel can be grasped immediately after the sealer is activated without any evidence of heat injury — Speaker 2
2:10The sealer is more useful than using a hook, which has significant energy spread and cannot be used to grasp the bowel — Speaker 2
2:23The dissection is continued in a proximal to distal fashion, exposing the second portion of the duodenum — Speaker 2
2:56There is minimal bleeding using this technique and no injury to the bowel — Speaker 2
3:13As is common in these cases, the duodenum goes towards the retroperitoneum, and this is the most difficult part to mobilize — Speaker 2
3:35Adhesions between the transverse colon and the second and third portions of the duodenum, some consistent with Ladd bands, can be extremely thick and dense — Speaker 2
4:08Complete mobilization of the transverse and proximal ascending colon is necessary due to posterior attachments — Speaker 2
4:19Lateral wall attachments between the cecum and retroperitoneum are extremely flimsy and easily taken down — Speaker 2
4:59Ladd's bands were seen crossing portions of the ileum, causing a partial obstruction — Speaker 2
5:19The minimal energy spread from the sealer allows use in close proximity to the small bowel without risk of injury — Speaker 2
5:52The duodenum was seen doubling back on itself — Speaker 2
7:01The posterior attachments of the duodenum could not be reached until the Ladd's bands had been completely divided — Speaker 2
7:24The area where the duodenum transitioned in the proximal portion was extremely dilated — Speaker 2
7:39The sealer can act as an atraumatic bowel grasper during bowel running, though the jaws are not quite as large as the 3 millimeter bowel grasper — Speaker 2
7:56The sealer is used during bowel running because other bands are often encountered, allowing immediate sealing and division — Speaker 2
8:29Enlarged lymph nodes in the mesentery and chylous appearance within the bowel show evidence of chronic mild obstruction — Speaker 2
8:56At completion of the Ladd's procedure, all of the colon is on the left and the small bowel is on the right — Speaker 2
9:06In a small infant with a small appendix, the appendix can be brought out through the right trochar site and amputated extracorporeally — Speaker 2

Cases discussed

0:00Infant with malrotation presenting with bilious vomiting, managed with laparoscopic Ladd's procedure

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.

Written for:

Laparoscopic Ladd's Procedure in an Infant with Malrotation and Dense Adhesions

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Case narrative · AI-written, human-reviewed

Presentation

An infant presented with repetitive bilious vomiting 0:00. Upper GI series demonstrated a redundant duodenum that failed to cross the midline 0:09. At laparoscopy, a markedly dilated proximal duodenum was visualized beneath the liver 0:47. The first portion of the duodenum was extremely dilated 1:22, and the anatomy was tortuous with multiple dense adhesions 1:33.

The Decision Point

The critical judgment in this case was how to safely mobilize a severely distorted duodenum in an infant without thermal or mechanical injury. The duodenum coursed toward the retroperitoneum — the most difficult portion to mobilize 3:13. Adhesions between the transverse colon and the second and third portions of the duodenum, some consistent with Ladd bands, were extremely thick and dense 3:35. The posterior attachments of the duodenum could not be reached until the Ladd's bands had been completely divided 7:01. The area where the duodenum transitioned proximally was extremely dilated 7:24, raising the stakes for any technical misstep.

The team chose to use a 3-millimeter sealer device as the primary dissecting instrument rather than electrocautery hook. The sealer could safely grasp the bowel and act as an atraumatic forceps 1:00. Dense adhesions to the proximal duodenum were taken down by dissecting them off the bowel, then sealing and gently tearing them off the duodenal surface 1:33. The minimal energy spread of the sealer made this approach safe 1:51, and the bowel could be grasped immediately after the sealer was activated without evidence of heat injury 1:58. One of the discussants stated this was "much more useful than using a hook, which had significant energy spread and also could not be used to grasp the bell" 2:10.

What Was Done

The surgeon positioned at the foot of the table with the infant brought down to align with the foregut 0:16. A 4- or 5-millimeter port was placed in the umbilicus with right and left hand operating ports placed on either side 0:28. In this small infant, the right hand port was placed above the umbilicus to prevent conflict between the right hand and the scope 0:36.

The dissection proceeded in a proximal-to-distal fashion, exposing the second portion of the duodenum 2:23. There was minimal bleeding and no injury to the bowel 2:56. Complete mobilization of the transverse and proximal ascending colon was necessary due to posterior attachments 4:08. Lateral wall attachments between the cecum and retroperitoneum were extremely flimsy and easily taken down 4:19. Ladd's bands were seen crossing portions of the ileum, causing a partial obstruction 4:59. The minimal energy spread from the sealer allowed its use in close proximity to the small bowel without risk of injury 5:19.

The duodenum was seen doubling back on itself 5:52. Once the Ladd's bands were completely divided, the freed duodenum could be grasped and pulled down to straighten it 7:01. The bowel was then run from proximal to distal to completely derotate it. The sealer acted as an atraumatic bowel grasper during bowel running, though the jaws were not quite as large as the 3-millimeter bowel grasper 7:39. The sealer was used during bowel running because other bands were often encountered, allowing immediate sealing and division 7:56.

Enlarged lymph nodes in the mesentery and chylous appearance within the bowel showed evidence of chronic mild obstruction 8:29. At completion of the Ladd's procedure, all of the colon was on the left and the small bowel was on the right 8:56. The appendix was brought out through the right trochar site and amputated extracorporeally 9:06.

What the Case Changes

This case demonstrates that dense adhesions in infant malrotation can be safely mobilized using a low-energy-spread sealing device that doubles as an atraumatic grasper. The ability to dissect, seal, and immediately grasp tissue without thermal injury changes the risk calculus when working around a dilated, friable duodenum. The technique of dissecting adhesions off the bowel before sealing them — rather than sealing them in situ — may reduce the risk of full-thickness injury when bands are densely adherent. When posterior duodenal attachments cannot be reached until anterior bands are divided, the sequence of mobilization matters as much as the tool selection.

Takeaways from this story

A 3mm sealer with minimal energy spread can safely dissect dense Ladd's bands off dilated duodenum and immediately grasp tissue without thermal injury
Posterior duodenal attachments in malrotation may be unreachable until anterior Ladd's bands crossing the colon are completely divided
Enlarged mesenteric lymph nodes and chylous bowel appearance indicate chronic mild obstruction from malrotation even before acute volvulus
Complete colon mobilization including cecal lateral attachments may be necessary to access posterior duodenal attachments in complex malrotation

Laparoscopic Ladd's Procedure Using 3-Millimeter Sealer in an Infant

The essential version of this episode — what it covers, the points that matter most, and what it changes for you. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Core brief · AI-written, human-reviewed

Case Presentation

An infant presented with repetitive bilious vomiting 0:00. Upper GI series demonstrated a redundant duodenum that did not cross the midline 0:09. The case illustrates laparoscopic correction of malrotation using a 3-millimeter sealer as the primary dissecting instrument.

Technical Approach

Port placement uses a 4-5 millimeter umbilical camera port with bilateral operating ports 0:28. In small infants, the right-hand port is positioned above the umbilicus to prevent instrument conflict with the laparoscope 0:36. The surgeon stands at the foot of the table with the infant positioned distally to align with the foregut 0:16.

The 3-millimeter sealer functions both as an atraumatic bowel grasper and as a dissecting instrument 1:00. Its minimal energy spread allows safe use immediately adjacent to bowel — the bowel can be grasped directly after activation without heat injury 1:58. One discussant considers this more useful than electrocautery hook, which has significant energy spread and cannot grasp tissue 2:10.

Operative Sequence

Dissection proceeds proximal to distal, beginning under the liver where the extremely dilated first portion of duodenum is visualized 1:22. Dense adhesions to the proximal duodenum are taken down by dissecting them off the bowel, then sealing and gently tearing them from the duodenal surface 1:33. This technique produces minimal bleeding and no bowel injury 2:56.

The retroperitoneal portion of the duodenum represents the most difficult mobilization 3:13. Adhesions between transverse colon and the second and third portions of duodenum — some consistent with Ladd bands — can be extremely thick and dense 3:35. Complete mobilization of the transverse and proximal ascending colon is necessary due to posterior attachments 4:08. Lateral cecal attachments are flimsy and easily divided 4:19.

Ladd bands crossing portions of ileum caused partial obstruction 4:59. The posterior duodenal attachments could not be reached until Ladd bands were completely divided 7:01. Enlarged mesenteric lymph nodes and chylous bowel appearance indicated chronic mild obstruction 8:29.

Anatomic Result

At completion, all colon lies on the left and all small bowel on the right 8:56. In small infants with small appendices, the appendix can be exteriorized through the right trocar site and amputated extracorporeally 9:06.

Takeaways from this story

The 3mm sealer serves dual roles: atraumatic bowel grasping and safe dissection with minimal energy spread
Retroperitoneal duodenal attachments cannot be accessed until Ladd bands and colonic attachments are divided
Complete mobilization proceeds proximal-to-distal, ending with all colon left and all small bowel right
Dense Ladd bands between colon and duodenum are safely divided by dissecting off bowel then sealing and tearing

Keywords

malrotation bilious vomiting chronic mild obstruction laparoscopic Ladd's procedure upper GI series appendectomy

Hashtags

#LaparoscopicSurgery #Malrotation #PediatricSurgery #InfantHealth #SurgicalTechniques #BowelDissection #Duodenum #LaddsBands #SurgicalEducation #PediatricGastroenterology #SurgicalAnatomy #BiliaryObstruction #MinimallyInvasive #SurgicalProcedure #InfantSurgery #Healthcare #Surgery #MedicalEducation #SurgicalInstruments #GastrointestinalSurgery #LaddProcedure

Transcript

This video represents a laparoscopic lad's procedure for malrotation in an infant who presented with repetitive bilious vomiting. An upper sheet GI showed a redundant duodenum which did not cross the midline. The room set up as it shows. The surgeon is at the end of the table with the baby brought down to the foot of the table in order to allow the surgeon to be in line with the foregu. Trochar placement is as seen. A 4 or 5 millimeter port is placed in the umbilicus, and right and left hand operating ports are placed either side of the umbilicus. In a small infant, the right hand port is placed above the umbilicus so that the right hand does not conflict with the scope. The initial dissection takes place under the liver. A very dilated proximal duodenum can be seen. Adhesions and omentum were taken down off of this using the 3 millimeter sealer. You can see that the 3 millimeter sealer can be used to safely grasp the bow and act as a forceps. Which is atraumatic to the bowel. The duodenum is followed distally, taking down all attachments. To fully mobilize it. The first portion of the duodenum is extremely dilated. In the left hand, there is a 3 millimeter bowel grasper, which is also atraumatic. The multiple dense adhesions to the proximal duodenum, and it can be seen to be quite torturous. These can be safely taken down using the sealer, dissecting them off the bow, and then sealing and gently tearing them off the surface of the duodenum. Because of the minimal energy spread of the sealer, it is very safe to dissect in this fashion. You also see that the bow can be grasped immediately after the sealer is activated without any evidence of any heat injury to the bow. You find this much more useful than using a hook, which had significant energy spread and also could not be used to grasp the bell. You can see that there are many dense adhesions around the dude. But the dissection is continued in a proximal to distal fashion, exposing now the second portion of the duodenum. Continued upward pressure is placed on the freed portion of the duodenum, exposing other adhesions. Trying to completely free up the torturous. To demon. Pas minimal bleeding using this technique and no injury to the bowel. Now see the cut a lobe of the liver. As we continue to free up the redeemer. As is common in these cases, the duodenum. Goes towards the retroperitum, and this is the most difficult part to mobilize. You can see the transverse colon attachments up to the 2 and 3 portion of the duodenum. These adhesions Some of which are consistent with loud bands can be extremely thick and dense and difficult to take down. But again, by dissecting them off. Of the duodenum using the. Section and grasping properties of the sealer, this can be done atraumatically. Because of the posterior attachments, it was felt at this point that complete mobilization of the transverse. And proximal or ascending colon is necessary. Here you can see some stretched lateral wall attachments. Between the cecum And the retroperitoneum. These are extremely flimsy and are easily taken down using the ceiling. By doing this, we will get exposure to the. Complete aspect of the duodenum, which is quite torturous. With these lads' bands mobilized. The colon easily flips over. Into the. That's portion of the abdomen. Where you can see some of the lads bands crossing it. Over portions of the. Uh, Ilium. Also causing a partial obstruction. Again, the minimal energy spread from the sealer allows this device to be used in close proximity to the small bowel without any risk of injury to it. Now see the last of the lad's bands as it traverses across the duodenum which was causing the proximal obstruction. There we can see the de demon doubling back on itself. These last Attachments allow us to mobilize the colon completely into the left. Portion of the abdomen and now the kinking retroperineal attachment of the duodenum can be mobilized. And taken. You're now able to see the. Posterior aspect of the duodenum and completely mobilize it. This will allow us to run the bow. And completely de-rotate the bowel. To eliminate the risk of loulus in the future. Again, these last posterior attachments could neither be Reached until the lad's bands had been completely divided. Now we're able to grasp the Frieda Dudenum. And pull it down to ensure that we are able to straighten the duodenum as you see here. Now the duodenum is completely freed, and you can see the area where it was transitioned in the proximal portion was extremely dilated. The bow is now run from proximal to distal to completely de-rotate the bow. And this again can be done safely with the sealer asking, acting as a. A traumatic bowel grasper. The jaws are not quite as large as the 3 millimeter valve grasper, but they work quite effectively. We use it during this portion of the procedure because often other bands are. Encountered, and this allows us to immediately seal them and divide them. The bowers run all the way until the. Terminal ileum and cecum are. Reached. Here you can see the valve almost completely derotated. The enlarged lymph nodes in the mesentery and the chyous appearance within the bowel show the evidence of chronic mild obstruction. Finally, the terminal ileum and the cecum are reached. And at this point, We mobilize. The mesentery of the appendix so that it can be removed. At this point of the operation, all of the colon is on the left and the small bowel is on the right. And we've completed the lab's procedure. With the appendiceal mesentery taken down with the sealing, the appendix can either be taken intracorporeally or in a small infant, with a small appendix can be brought out through the right through know of the trochar site. And then amputated exporially as seen here.

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