VM19 - Laparoscopic Ladd Procedure for Intestinal Malrotation with Cocoon Deformity

Purpose/Background: Cocoon deformity is a rare variant of intestinal malrotation in which a portion of the small intestine is encapsulated in a peritoneal sac. Few case reports in the literature exist describing the surgical management of such patients. We present a 37-year-old woman with a body mass index of 26.1 kg/m2 who underwent a laparoscopic Ladd procedure for intestinal malrotation with cocoon deformity. She presented with 2-3 years of chronic abdominal pain, bloating, early satiety, and chronic constipation. She had no previous abdominal surgeries. Intestinal malrotation was diagnosed on magnetic resonance imaging, which was confirmed on upper gastrointestinal double contrast follow-through.

Methods/Interventions: The patient proceeded to a laparoscopic Ladd procedure. The abdomen was entered through a supraumbilical incision with a 0° laparoscopic scope and a 5 mm optical trocar. Two additional 5 mm trocars were placed in the left upper and lower quadrants under direct vision. A third 5 mm trocar was placed in the right lower quadrant. On initial abdominal exploration, the small bowel was found to be completely encased in a peritoneal sac. Findings were consistent with a rare “cocoon” variant of intestinal malrotation. The peritoneal sac was opened and at least 75% was excised using electrocautery and the LigaSure device. Additional lateral attachments (Ladd bands) were also divided. The 4th portion of the duodenum and proximal jejunum were mobilized to broaden the base of the mesentery. An appendectomy was performed to complete the Ladd procedure. At the end of the case, the small bowel was placed on the right side of the abdomen and the colon on the left side. Prior to closure, bilateral transversus abdominis plane blocks were performed.

Results/Outcomes: No intraoperative complications occurred, and the patient was discharged home on postoperative day one.

Conclusion/Discussion: Intestinal malrotation with cocoon deformity is a rare variant that can be safely and effectively treated with a laparoscopic Ladd procedure.