The Ladd's Procedure for Correction of Intestinal Malrotation ... - AORN

2.1 

The Ladd’s Procedure for 

Correction of Intestinal 

Malrotation With Volvulus in Children 

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Renee Ingoe, RN; 

Patricia Lange, MD 

Intestinal malrotation with volvulus 

is an emergent and possibly lifethreatening 

condition that can occur 

in infants and children and that requires 

immediate surgical intervention. The 

term malrotation is defined as an abnormality 

of the anatomic position of the 

bowel that occurs in utero during embryonic 

development. The term volvulus 

describes a situation in which a portion 

of the bowel becomes twisted upon itself. 

This can cause bowel necrosis from 

lack of a blood supply. 

Symptoms of intestinal malrotation 

with or without a volvulus can be varied, 

but when a volvulus is suspected or 

diagnosed, emergency surgery is performed 

during which the intestines are 

untwisted to allow restoration of blood 

flow, and the mesentery (ie, tissue containing 

blood and lymphatic vessels) is 

widened to prevent recurrence of the 

ABSTRACT 

• MALROTATION that occurs when the embryonic, 

two-part, intestinal rotation does not proceed normally 

results in an abnormal anatomical position of 

the intestines. 

• VOLVULUS OCCURS when the intestines are 

not fixated to the intestinal wall but are suspended 

on a narrow stalk of mesenteric tissue containing the 

supplying blood vessels. This formation allows the 

intestines to twist on themselves and cut off the 

blood supply to the bowel. 

• WHEN MALROTATION WITH VOLVULUS is 

diagnosed, emergency surgery must be performed to 

untwist the intestines, restore blood flow, and widen 

the mesentery. AORN J 85 (February 2007) 300-312. 

© AORN, Inc, 2007. 

300 • AORN JOURNAL • FEBRUARY 2007, VOL 85, NO 2 

volvulus. The Ladd’s procedure is the 

gold standard for treatment of intestinal 

malrotation. 1 

EPIDEMIOLOGY 

Intestinal malrotation occurs in approximately 

one in 500 births and occurs 

equally in males and females. 2 Approximately 

60% of intestinal malrotation 

cases present in the first month of life, 

about 20% present between one month 

and one year of age, and the remainder 

present after the first year. 3 Malrotation 

may occur as an isolated condition, but 

it usually is found in combination with 

other congenital anomalies. As many as 

70% of children with intestinal malrotation 

also have other congenital malformations 

(eg, any combination of digestive 

system, cardiac, or spleen and liver 

abnormalities). 3 When intestinal malrotation 

is associated with volvulus, 

however, the anomaly usually is the patient’s 

only disorder. 4 Intestinal malrotation 

is considered a life-threatening situation 

when it occurs in conjunction 

with a volvulus that is causing a bowel 

obstruction. 

All children diagnosed with or suspected 

of having intestinal malrotation 

should be referred to a pediatric surgeon 

who should look immediately for 

any signs of obstruction or sepsis related 

to the condition. It is not clear, however, 

whether intestinal malrotation 

should be treated when the condition is 

discovered inadvertently and no symptoms 

are present. Some surgeons advise 

that the abnormality be surgically 

corrected only in patients younger than 

two years of age. Others believe that 

treatment should be more aggressive 

and that it should be corrected whenever 

it is discovered to minimize the 

chance of an emergent situation later. 5 

© AORN, Inc, 2007

Ingoe — Lange FEBRUARY 2007, VOL 85, NO 2 

ANATOMY AND PHYSIOLOGY 

During embryonic development, the 

colon and small bowel grow very rapidly. 

The bowel starts out as a straight tube 

from the end of the stomach to the rectum. 

6 As the intestines develop further, 

they move into the umbilical cord for a 

short time where they receive nutrients. 

Between the seventh and 10th week of 

gestation, the bowel begins to gravitate 

back toward the abdominal cavity, during 

which time the intestines undergo a 

two-part rotation before assuming their 

normal position in the abdominal cavity. 

In the first phase of rotation, the 

duodenojejunal junction passes behind 

the superior mesenteric artery and becomes 

attached to the upper left retroperitoneum. 

In the second phase, the 

cecum passes from the left side of the abdomen, 

anterior to the superior mesenteric 

artery, and assumes its normal position 

right of the midline. At completion of 

the rotation, the mesentery becomes attached 

to the retroperitoneum by a broad 

band from the upper left at the duodenojejunal 

junction (ie, the ligament of Trietz) 

to the lower right abdomen at the ileocecal 

junction, which prevents the intestines 

from twisting on themselves. 4 This 

process usually is complete by the 12th 

week of gestation. 

ABNORMAL BOWEL DEVELOPMENT 

Intestinal malrotation occurs when the 

two-part process does not proceed normally 

and the intestines do not make 

complete turns on re-entry into the abdominal 

cavity from the umbilicus. This 

abnormal rotation can have variable results. 

The cecum and the attached appendix 

may be positioned in the right upper 

quadrant, midline, or to the left of midline. 

With malrotation, the intestines are 

not secured to the abdominal cavity by 

the mesentery; instead, the intestines are 

suspended on a narrow stem of tissue (ie, 

mesenteric stalk) containing the supplying 

blood vessels (Figure 1). 

Lack of fixation and a narrow, mesenteric 

stalk allow the intestines to twist on 

themselves, a condition known as volvulus. 

A volvulus cuts off the intestinal 

blood supply (ie, from branches of the superior 

mesenteric artery) causing vascular 

compromise that ultimately leads to 

catastrophic bowel infarction (ie, a massive 

loss of bowel as a result of the lack of 

blood supply) that could result in death. 

When a volvulus involves the entire 

small bowel, it is referred 

to as a mid-gut volvulus 

(Figure 2). This can result 

in the loss of most of 

the intestine and, in 

some cases, may result 

in death. 4 

Additionally, bands 

that normally fix the cecum 

to the sidewall may 

be abnormally situated 

within the abdominal 

cavity in such a position 

that they compress underlying 

bowel, causing 

partial or complete obstruction. 

These abnormally 

positioned bands, 

referred to as Ladd’s 

bands, are named after 

William Ladd, MD, a pioneer 

in pediatric surgery. 

During a Ladd’s 

procedure, the mesentery 

is widened, the bands 

are ligated, and the appendix 

is removed to prevent future confusion 

because the cecum will be on the left 

side of the abdomen after the procedure. 

Obstructions caused by a volvulus or 

Ladd’s bands are life threatening and indicate 

the need for an emergency surgical 

procedure. 6 

SIGNS AND SYMPTOMS 

The presentation of intestinal malrotation 

can be extremely varied, from lifethreatening 

sepsis as a result of bowel 

The intestines 

gravitate from 

the umbilical cord 

back to the 

abdominal cavity 

and undergo a 

two-part rotation 

before assuming 

their normal 

position in the 

abdomen. 

AORN JOURNAL • 301

FEBRUARY 2007, VOL 85, NO 2 Ingoe — Lange 

Figure 2 • In 

a midgut 

volvulus, the 

colon is 

tightly coiled 

around the 

base of the 

mesentery of 

the small 

intestine. 

302 • AORN JOURNAL 

necrosis to no symptoms at all. Bilious 

vomiting is the most common sign of intestinal 

malrotation with volvulus and 

should be considered a volvulus in infants 

until proven otherwise. Abdominal 

pain and lethargy also are common. 

Other symptoms may include sudden 

bouts of crying and drawing up of 

the legs because of abdominal cramps; 

rapid heart rate; rapid breathing; and 

Figure 1 • Part of the small and large 

intestine are unattached so they can twist 

and cut off blood supply, which will kill 

that part of the intestines. 

failure to pass flatus or stool. The child 

may become very dehydrated, which 

may manifest as decreased urination; 

dry mouth, lethargy; and possibly a 

depressed fontanel. When the intestines 

are compromised because of lack 

of blood flow, the infant’s vomit can 

become bloody. 5 Rectal bleeding is an 

ominous sign of bowel compromise 

and may indicate that the infant has a 

gangrenous bowel. 

A person can live with intestinal malrotation 

for life, however, and never experience 

any symptoms or present with 

signs of malrotation. In fact, malrotation 

in an adult usually is an incidental sign 

on a computed tomography (CT) scan 

diagnosed by the anatomic location of a 

right-sided small bowel, left-sided 

colon, and an abnormal relationship of 

the superior mesenteric artery. 7 This 

malrotation would have occurred in 

utero but not have been found until 

much later in life. Intestinal malrotation 

in an adult also may be discovered during 

abdominal surgery that is being performed 

for another reason (eg, cholecystectomy, 

trauma). 

DIAGNOSIS AND FINDINGS 

The most common and accurate way 

to diagnose intestinal malrotation with or 

without volvulus is an upper gastrointestinal 

(UGI) series. A barium enema 

(BE) also may be performed but yields 

less information. Both diagnostic procedures 

are quick and relatively safe, and 

they identify malrotation by demonstrating 

an abnormally positioned intestine. 

A UGI series is valuable in demonstrating 

the position of the ligament of 

Treitz, a band of tissue that anchors the 

last part of the duodenum to the retroperitoneum. 

This portion of bowel 

should be positioned to the left of midline 

and approximately at the level of the 

gastroduodenal junction. Any abnormal 

positioning of this portion of intestine 

should be considered diagnostic or at


least suspicious for intestinal malrotation. 

A volvulus may be seen as a thin 

line of contrast in a portion of intestine 

that is abnormally positioned. Either 

finding should generate an immediate 

referral to a pediatric surgeon. 

Plain x-rays, ultrasounds, and CT 

scans are not as reliable as a UGI series 

because the UGI uses contrast media 

that lights up on the scan. The contrast 

either stops flowing or only moves 

through a thin opening. A contrast BE 

may be performed for evaluation of 

cecal position if the cause of the obstruction 

still cannot be determined 

after a UGI series is performed. 4 A BE is 

more reliable than x-rays, ultrasounds, 

and CT scans but is not as reliable as a 

UGI series because the barium only 

flows up a certain distance, whereas the 

contrast in a UGI follows the intestines 

all the way down. The area above the 

obstruction would not be visualized 

during a BE. 

PREOPERATIVE PREPARATION 

When the OR is being prepared for a 

pediatric procedure, the circulating nurse 

turns up the room temperature to between 

75° F and 85º F (23.9º C and 46º C) 

depending on the surgeon’s preference. 

The circulating nurse places a pediatric, 

underbody, forced-air, temperatureregulating 

blanket on the bed 8 and obtains 

an IV-solution warmer and irrigation 

fluid warmer. The circulating nurse 

ensures that the pediatric emergency 

anesthesia cart is in the room. 

PREOPERATIVE CARE OF THE PATIENT. After the 

infant has been admitted to the preoperative 

holding unit, the circulating nurse 

greets the patient and his or her parents 

and confirms the patient’s identity using 

at least two identifiers (eg, the identification 

band, medical record, parent’s confirmation). 

After reviewing the patient’s 

medical record, the nurse ensures that 

the patient’s laboratory, radiology, and 

gastrointestinal test results are on the 

chart and verifies that the surgical consent 

is accurate according to the patient’s 

records, OR schedule, and parents. The 

nurse verifies the patient’s allergies and 

NPO status with the parents and medical 

record. The nurse then performs an 

assessment that includes the patient’s 

vital signs, nutritional status, skin turgor, 

and skin pallor. The nurse then develops 

a care plan specific for this patient undergoing 

the Ladd’s procedure 

(Table 1). 

CARING FOR THE PARENTS BE- 

FORE SURGERY. This surgery 

usually is performed on an 

emergency basis, so the infant’s 

parents may be emotionally 

distraught. The 

circulating nurse can take 

numerous actions to help 

alleviate some of the parents’ 

fear. If possible, the 

circulating nurse should 

sit down with the parents 

and introduce himself or 

herself. The nurse should 

explain exactly what the 

role of the circulating 

nurse is in taking care of 

their child and explain the 

role of each perioperative 

team member, including 

ancillary personnel. 

The nurse should speak 

in a soft, calm, and reassuring 

tone and should not 

speak rapidly. He or she 

should give the parents 

time to ask questions and 

to contemplate what he or 

she is telling them. To instill trust, the 

nurse should make eye contact with 

each parent and use touch when appropriate. 

The nurse should ensure that all 

of the parents’ questions have been answered 

and that they understand the procedure 

completely. The nurse should reassure 

the parents that he or she will call 

the waiting room periodically to give 

The circulating 

nurse can take 

numerous actions 

to help alleviate 

the parents’ fear, 

such as speaking 

in a reassuring 

voice and 

explaining the 

role of the 

circulating nurse 

in taking care of 

their child. 



TABLE 1 

Nursing Care Plan for Pediatric Patients Undergoing the Ladd’s Procedure 

Diagnosis 

Risk for 

compromised 

family coping 

related to the 

stress of 

surgery 

Risk of 

hypothermia 

related to 

perioperative 

environment, 

patient age, 

and exposed 

body surfaces 

Risk for 

infection 

related to 

immature 

immune 

system 

and poor 

nutritional 

status 


Nursing interventions 

• Identifies communication barriers and 

knowledge level. 

• Assesses readiness to learn. 

• Elicits family members’ perception of 

anesthesia and surgery. 

• Uses appropriate communication skills to 

ease fears and improve comprehension of 

patient and family members, such as 

• sitting with family member when performing 

patient education, 

• making eye contact with each parent, 

• speaking slowly and clearly and observing 

for indications of confusion versus 

comprehension, and 

• allowing time for questions and answers. 

• Ensures parental presence during anesthesia 

induction, if desired and permitted by facility 

policy. 

• Evaluates family members’ response to 

instruction. 

• Monitors body temperature throughout the 

perioperative period. 

• Implements thermoregulation measures, 

including 

• heating the OR to between 75° F and 

85º F (23.9º C and 46º C); 

• placing a pediatric, underbody, forcedair, 

temperature-regulating blanket 

on the OR bed under the patient; 

• placing a stocking cap on the infant’s 

head; 

• using IV and irrigation solution warmers 

according to manufacturer instructions; 

and 

• wrapping the infant’s extremities with 

cotton cast padding to help minimize 

skin exposure as much as possible. 

• Evaluates response to thermoregulation 

measures. 

• Assesses skin integrity, sensory impairments, 

and gastrointestinal status. 

• Observes sterile field and perioperative 

team members to ensure that asepsis is 

maintained. 

• Validates that preoperative antibiotic was 

administered according to facility policy. 

• Allows sufficient time for surgical prep 

solution to dry before the patient is 

draped. 

Interim outcome 

criteria 

Patient’s family 

members 

• verbalize understanding 

of 

the procedure, 

sequence of 

events, and expectedoutcomes 

and 

• demonstrate 

the ability to 

cope throughout 

the perioperative 

period. 

Parents and 

patient demonstrate 

appropriate 

bonding. 

Patient’s core 

body temperature 

remains in expected 

range throughout 

the perioperative 

experience. 

Patient’s wound 

is dry, nonreddened, 

and 

non-tender. 

Patient does not 

demonstrate 

symptoms of infection 

(eg, wound 

induration, foul 

odor, purulent 

drainage, fever) 

Outcome 

statement 

Patient’s 

family 

members 

demonstrate 

knowledge 

of the 

physiological 

and 

psychological 

responses 

to the 

procedure. 

Patient is at 

or returning 

to normothermia 

at the 

conclusion of 

the immediatepostoperative 

period. 

Patient is 

free of 

signs and 

symptoms of 

infection 

through the 

30 days 

after the 

perioperative 

procedure.


them updates on how the procedure is 

progressing. 

INTRAOPERATIVE NURSING CARE 

The circulating nurse and anesthesia 

care provider transport the patient to the 

OR. The circulating nurse ensures that all 

surgical team members are present and 

then initiates the surgical time out. 

INTRAOPERATIVE PATIENT WARMING. Infants 

and children—particularly those who 

are younger than one month old as is 

the case for many patients with intestinal 

malrotation—can lose body heat 

very rapidly and will lose even more 

body heat when the abdomen is 

opened. Infants 

• have a large body surface area in comparison 

to their size, 

• have only a thin layer of subcutaneous 

fat, and 

• are unable to shiver. 

All of these factors contribute to the 

possibility of rapid hypothermia for infants 

during surgery. 

Before transporting the patient from 

the preoperative area, the circulating 

nurse ensures that the patient is wearing 

a hospital stocking cap to prevent heat 

loss from the head. As soon as the patient 

is placed on the OR bed, the circulating 

nurse and anesthesia care provider institute 

active warming techniques. The 

anesthesia care provider implements 

temperature monitoring that he or she 

will maintain throughout the surgical 

procedure; a nasopharyngeal temperature 

probe is a reliable method to approximate 

the infant’s core temperature. The 

circulating nurse ensures that the pediatric, 

underbody, forced-air, temperatureregulating 

blanket is turned on. 8 

The circulating nurse remains with 

the patient throughout induction of 

anesthesia and offers assistance to the 

anesthesia care provider as necessary. 

The anesthesia care provider inserts peripheral 

IV lines and uses a solution 

warmer according to the manufactur- 

er’s instructions to warm the IV solutions. 

When the peripheral IV lines have 

been inserted, the circulating nurse 

wraps the patient’s extremities with cotton 

cast padding, making sure it is not 

too tight. The scrub person uses irrigation 

fluids warmed by an irrigation 

warmer to approximately 98.6º F (37º C). 

The irrigation warmer keeps the fluids 

warm throughout the procedure and 

prevents the fluids from getting too 

hot, which can occur if irrigation 

fluids are taken 

directly out of a fluidwarming 

unit. 

Infants are 

ESSENTIALS OF POSITIONING. 

The circulating nurse, vulnerable to 

anesthesia care provider, 

and surgeon place the pa- hypothermia 

tient in the supine position. 

The circulating nurse during surgery 

places rolled-up sheets 

lengthwise alongside the because they have 

patient according to surgeon 

preference to keep a large body 

the patient from shifting to 

the side. The surgeon may surface area in 

place a rolled towel under 

the patient’s buttocks to comparison to 

gently lift the pelvis into 

a modified Trendelenburg their size, have 

position to displace abdominal 

contents upward. only a thin layer 

The circulating nurse or 

of subcutaneous 

surgeon may place plastic 

adhesive drapes around fat, and are 

the abdomen before the 

surgical skin prep is per- unable to shiver. 

formed to keep the patient 

warm and dry and to prevent 

pooling of fluids during 

the prep and the procedure. 

THE SURGICAL SKIN PREP. Patients of this 

age have immature immune responses. 

Furthermore, they may have poor nutritional 

status as a result of their condition, 

so they are less capable of 

fighting infection. It is of great importance, 

therefore, to ensure that all team 




members strictly adhere to aseptic 

technique. 

The circulating nurse performs a 

surgical skin prep of the patient’s entire 

abdomen from nipple line to pubis 

with a solution of the surgeon’s preference. 

The nurse ensures that the prep 

solution has enough time to dry sufficiently 

and that no solution pools 

under the patient. 

THE PROCEDURE 

After the surgeon makes a midline laparotomy 

incision to ensure adequate visualization 

of the intestines and related 

structures, he or she takes the intestines 

out of the abdominal cavity and untwists 

them if a twist is present. The surgeon 

then removes any Ladd’s bands overlying 

the cecum or duodenum (Figure 3) 

with a goal of spreading out the mesentery, 

separating the small and large intestines 

as much as possible. Eventually, the 

surgeon positions the small bowel primarily 

to the right of the patient’s midline 

and positions the large intestine on 

the left. Although these bowel positions 

are the opposite of where they normally 

would lie if the complete turn had oc- 

Figure 3 • The surgeon excises Ladd’s bands so 

that the mesentery can be released, allowing the 

intestines to relax unrestrained. 

curred during fetal development, the 

bowel will remain in this backwards position 

for the rest of the patient’s life. The 

cecum and appendix, therefore, are positioned 

on the left, and appendicitis could 

very easily be misdiagnosed later in life. 

To prevent this kind of misdiagnosis 

from occurring, the surgeon also will 

perform an appendectomy. 4 

When a volvulus is present, the surgeon’s 

first step is to immediately untwist 

the intestine by rotating the bowel 

counterclockwise. After the surgeon has 

reduced the volvulus, the intestines 

usually are edematous and congested, 

and some areas may even appear necrotic. 

4 The surgeon observes the bowel 

closely for several minutes to verify viability 

of the bowel. If the bowel does not 

regain some normality before the end of 

the procedure (ie, color change to indicate 

improved blood flow), the surgeon 

will resect the necrotic portions. If the 

surgeon has doubts as to the viability of 

some areas, the patient will be brought 

back to surgery within 24 to 36 hours for 

reevaluation. 

When the surgery is underway, the 

circulating nurse calls the waiting 

room to tell the parents that the procedure 

has started. The circulating nurse 

then calls periodically during the procedure 

to update the parents on the 

progress of surgery. 

POSTOPERATIVE NURSING CARE 

Where the patient is cared for and recovers 

after surgery depends on the 

surgical findings. Patients with uncomplicated 

malrotation with or without 

volvulus are managed on the pediatric 

surgical unit. Patients with severe volvulus 

or those needing extensive bowel resection 

often are acutely ill with shock or 

sepsis after the procedure, and require 

monitoring in the pediatric intensive care 

unit (PICU). The circulating nurse communicates 

closely with the anesthesia 

care provider and surgeon to plan for the


postoperative needs of the patient. The 

circulating nurse calls the pediatric 

surgical unit nurse or PICU nurse during 

wound closure to communicate 

these needs. This gives the receiving 

nurse time to prepare the room for the 

patient. The circulating nurse’s report 

includes 

• the type and length of procedure that 

was performed, 

• the amount and type of narcotics administered 

during the procedure, 

• the antibiotics received before and 

during the procedure, 

• the total amount of IV fluids administered 

intraoperatively, 

• the blood or blood products administered 

during surgery, 

• whether the patient will be extubated, 

and 

• the patient’s temperature during 

the procedure and a current end-ofprocedure 

temperature. 

More information may be provided depending 

on specific unit policies and patient 

circumstances. The nurse also ensures 

that extra support staff members 

are available to assist with transporting 

the patient. 

ENSURING POSTOPERATIVE NORMOTHERMIA. A 

child’s body temperature can drop 

very quickly, particularly during extubation 

or transport to the postoperative 

unit. The nurse ensures that the 

patient is kept warm during this time. 

If the child will be transported in a 

crib, the circulating nurse lines the bed 

of the crib with warm blankets immediately 

before placing the patient in the 

crib and keeps the patient securely 

wrapped in a warm blanket, papoosestyle, 

as much as possible. The circulating 

nurse also places a rolled blanket 

behind the patient’s back to keep 

the patient on his or her side to prevent 

aspiration if vomiting occurs. 

AVOIDING POSTOPERATIVE HYPOXIA. The circulating 

nurse ensures that a full oxygen 

tank is on the transport vehicle (ie, crib, 

bed) and easily accessible. After moving 

the patient from the OR bed to the transport 

vehicle, the circulating nurse attaches 

one end of the oxygen tubing to 

the tank and holds or tapes the other 

end close to the patient’s mouth and 

nose so that the oxygen is blowing by 

the patient. This is much like using a 

nasal cannula for an older patient. This 

method of administering supplemental 

oxygen is continued 

until the patient’s oxy- 

gen saturation level consistently 

remains within 

normal limits. 

If the anesthesia care 

provider does not extubate 

the patient, the circulating 

nurse ensures 

the availability of a selfinflating, 

bag-valve-mask 

resuscitator for transport. 

The circulating nurse obtains 

a portable cardiac 

monitor to monitor the 

patient’s condition during 

transport to the postoperative 

recovery unit. 

PROVIDING POSTOPERATIVE 

NUTRITION. Infants who undergo 

extensive intestinal 

resections often are not 

able to tolerate enteral nutrition for 

quite some time. If that is the situation, 

total parenteral nutrition (TPN) will be 

started and continued long term. Children 

on long-term TPN will be monitored 

for chronic liver damage, a risk of 

long-term TPN. 2 

PROGNOSIS 

If intestinal malrotation with volvulus 

is recognized and treated quickly, 

the patient should recover well and 

not have any long-lasting effects, providing 

there is enough bowel left 

to sustain life. Children who have undergone 

this procedure most often 

progress through life with little or no 

Supplemental 

oxygen is 

administered 

until the 

patient’s oxygen 

saturation level 

consistently 

remains within 

normal limits. 




additional consequences. Very rarely, 

volvulus can recur after surgical correction. 

Small bowel transplantation 

sometimes is indicated in children 

who have lost a significant amount of 

intestine. 

Individuals with intestinal malrotation 

but without associated volvulus 

may remain asymptomatic, and the 

condition may go undetected throughout 

life. Although some surgeons believe 

it should not be treated when discovered 

after infancy if the patient is 

asymptomatic, other surgeons believe 

it always should be treated surgically 

even if asymptomatic because of the 

lifetime risk of volvulus. 5 Some surgeons 

now are performing the Ladd’s 

procedure laparoscopically if there is 

no evidence of volvulus. This approach 

is especially useful if a diagnosis of intestinal 

malrotation is in question. 

Identifying structures appropriately 

and obtaining adequate separation of 

the mesentery, however, can be technically 

difficult during a laparoscopic approach. 

In this case, the surgeon may 

need to abandon the laparoscopic approach 

midprocedure and convert to 

an open procedure. This is especially 

true for younger, smaller patients. ❖ 

Renee Ingoe, RN, CNOR, is a perioperative 

staff nurse at Wake Med Health 

and Hospitals, Raleigh, NC. 

By supporting the AORN Foundation, you also 

support the advancement of perioperative nursing. 

There are many ways to extend your personal 

legacy to the AORN Foundation, including 

• naming the AORN Foundation in your last will 

and testament; 

• allocating gift annuities; 

• committing charitable remainder/annuity trusts; or 

• naming the AORN Foundation as a beneficiary 

Patricia Lange, MD, is an assistant professor 

of pediatric surgery at the University 

of North Carolina at Chapel Hill, 

Chapel Hill, NC. 

REFERENCES 

1. Parish A, Hatley R. Intestinal malrotation. 

Available at: http://www.emedicine.com/ped 

/topic1200.htm. Accessed December 7, 2006. 

2. Kamal, IM. Defusing the intra-abdominal 

ticking bomb: intestinal malrotation in children. 

CMAJ [online serial]. 2000;162. Available 

at: http://www.cmaj.ca/cgi/content 

/full/162/9/1315. Accessed December 

7, 2006. 

3. Cincinnati Children’s Hospital Medical 

Center. Intestinal malrotation. February 

2004. Available at: http://www.cincinnati 

childrens.org/health/info/abdomen/diag 

nose/intestinal-malrotation.htm. Accessed 

December 19, 2006. 

4. Ford EG, Senac MO Jr, Srikanth MS, Weitzman, 

JJ. Malrotation of the intestine in children. 

Annuals of Surgery. 1992;215:172-178. 

5. The American Pediatric Surgical Association. 

Malrotation and volvulus. Available 

at: http://www.eapsa.org/parents/rota 

tional.htm. Accessed December 7, 2006. 

6. KidsHealth. Intestinal malrotation. Available 

at: http://kidshealth.org/parent/med 

ical/digestive/malrotation.html. Accessed 

December 7, 2006. 

7. MedPix. Incidental malrotation and acute 

appendicitis. Available at: http://rad.usuhs 

.mil/medpix/medpix.html?mode=+search2. 

Accessed December 7, 2006. 

8. Bair Hugger® temperature management: 

model 555—pediatric underbody blanket. 

Arizant Healthcare. Available at: http:// 

www.bairhugger.com/arizanthealthcare 

/faw_b_pediatric_555.shtml. Accessed January 

3, 2006. 

Foundation Offers Ways to Support Perioperative Nursing 

in a life insurance policy. 

You can double or triple your donation to the Foundation 

if your employer matches your donation. To 

find out if your employer will match your gift to the 

AORN Foundation, please check with your human resources 

department. For more information on Foundation 

activities, call Nancy Harbin in the AORN 

Foundation office at (800) 755-2676 x 366, or visit 

http://www.aorn.org/foundation.

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