A case of isolated malrotation without midgut volvulus diagnosed prenatally and treated by laparoscopic surgery

Abstract

Background: Malrotation is a congenital condition that predisposes individuals to midgut volvulus, which can result in significant bowel resection. While most cases of malrotation are diagnosed by the age of 1 year, typically presenting with symptoms related to volvulus or bowel obstruction, some cases remain asymptomatic. In children with visceral malposition, gastroschisis, omphalocele, or diaphragmatic hernia, malrotation may be suspected before symptoms manifest. However, isolated malrotation without midgut volvulus diagnosed prenatally is rare. We herein present a case of isolated malrotation without midgut volvulus that was prenatally diagnosed and successfully treated with laparoscopic surgery.

Case presentation: A 30-year-old woman (gravida 3, para 1) underwent routine obstetric ultrasound, which revealed increased blood flow in the lower uterine segment and abnormal placental attachment. To rule out placenta percreta, magnetic resonance imaging was performed at 34 weeks of gestation. Incidentally, abnormal fetal intestinal arrangement was noted, with the colon localized in the left hemi-abdomen and the small intestine distributed in the right hemi-abdomen, raising suspicion of malrotation. Postnatal contrast studies confirmed the diagnosis of malrotation without midgut volvulus. Given the risk of midgut volvulus, a laparoscopic Ladd's procedure was performed on day 6 of life. The postoperative course was uneventful, and the patient was still symptom-free 1 year postoperatively.

Conclusions: This case illustrates that malrotation can be prenatally diagnosed using fetal magnetic resonance imaging. Considering the risk of midgut volvulus, prophylactic Ladd's procedure should be performed in neonatal period. In cases where malrotation is not complicated by midgut volvulus, a laparoscopic Ladd procedure can be safely performed in neonates.

Keywords: Laparoscopy; Malrotation; Midgut volvulus; Pediatric; Prenatal diagnosis.

Fig. 1

Fetal magnetic resonance imaging. The colon, visualized as hyperintense in the T1-weighted image, was distributed in the left hemi-abdomen (arrow). The small intestine, visualized as hyperintense in the T2-weighted image, was distributed in the right hemi-abdomen (arrowhead)

Fig. 2

Postnatal contrast study. a Upper gastrointestinal study revealed that the Treitz ligament was not properly formed, and the first jejunal loop was located in the right-upper quadrant of the abdomen (arrow). b A contrast enema showed that the cecum was positioned in the right-upper abdomen (arrow)

Fig. 3

Laparoscopic findings. a Ladd’s band was dissected. b, c Accordingly, the abnormal membrane between the small intestine and cecum was dissected and widened the mesenteric root. Appendix was isolated in the right-upper quadrant of the abdomen. d Treitz ligament was not formed and the first jejunal loop was in the right-upper abdomen. e The mesentery was widened as much as possible. Ileocolic A/V: ileocolic artery and vein, SMA/V: superior mesenteric artery and vein