Laparoscopic Ladd’s procedure for triple obstruction in an adult: Ladd’s band duodenal obstruction, chronic midgut volvulus through an internal hernia and a novel intestinal malrotation variant with concomitant post-superior mesenteric artery reverse rotation

ABSTRACT: Intestinal malrotation is a rare congenital anomaly that typically presents during infancy; adult presentations are uncommon and often manifest with vague, chronic gastrointestinal (GI) symptoms. We report a unique case of a woman in her 30s who presented with acute bilious vomiting, severe malnutrition and a 2-year history of post-prandial vomiting and weight loss. Imaging revealed high-grade distal duodenal obstruction, mesenteric swirling and an absent right colon. Laparoscopic exploration demonstrated Ladd's band duodenal obstruction, pre-superior mesenteric artery (SMA) malrotation or non-rotation with concomitant post-SMA reverse rotation and a separate bowel segment involved in a chronic midgut volvulus through an internal hernia defect - a combination not previously described. A laparoscopic Ladd's procedure with internal hernia reduction was carried out. Laparoscopic management of complex cases of intestinal malrotation is feasible. Clinicians should maintain a high index of suspicion for congenital anomalies in adults who present with duodenal obstruction or recurrent, unexplained GI symptoms.