In the Ladd's procedure for intestinal malrotation with midgut volvulus, what is the correct sequence of operative steps?

• A Untwist volvulus (counter-clockwise); divide Ladd's bands; widen the mesentery; appendicectomy; place caecum in left iliac fossa ✓
• B Divide Ladd's bands first; then untwist volvulus; appendicectomy
• C Resect non-viable bowel first; then untwist; divide Ladd's bands
• D Perform appendicectomy first to gain access; divide bands; replace caecum in right side

Explanation

In Ladd's procedure the essential steps in order are: (1) Untwist the volvulus counter-clockwise ('turning back the clock') to restore blood flow and assess bowel viability; (2) Divide Ladd's peritoneal bands crossing from the caecum/right colon to the posterior abdominal wall that obstruct the duodenum; (3) Widen the base of the mesentery by dividing peritoneal attachments to prevent re-volvulus; (4) Appendicectomy (to prevent misdiagnosis of appendicitis as appendix is in an abnormal position); (5) Place the small bowel on the right and large bowel on the left (non-rotation position). Non-viable bowel is resected at the end after volvulus decompression.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.