Caecal volvulus around a Ladd's band in undiagnosed adult malrotation.

A 45-year-old woman presented to the emergency department with a 1-week history of subocclusive bowel syndrome characterized by cessation of bowel movements with continued flatus passage and vomiting. She remained afebrile with no constitutional symptoms. Her medical history included two prior laparotomies for uterine fibroid (most recent three years prior), with histopathology revealing adenomyoma and endometriosis without malignancy. Physical examination revealed a hemodynamically stable patient, a WHO-Performance-Status of 0, with a Pfannenstiel scar, mild abdominal distension, and left iliac fossa tenderness. Digital rectal examination showed fecal impaction with no peritoneal signs. Laboratory investigations demonstrated leukocytosis (14 900/μL), elevated C-reactive protein (106 mg/L), suggesting an inflammatory process, and albumin 40 g/L, hemoglobin (15.2 g/dL), electrolytes, renal function, and lipase were within normal limits. Contrast-enhanced computed tomography (CT) revealed cecal volvulus causing colonic obstruction, with signs of bowel ischemia and small intraperitoneal fluid. Given the compromised bowel viability, emergency surgical exploration was performed ( Figs 1 – 3 ). Whirlpool sign on multiplanar CT reconstruction. (a) Axial and (b) coronal CT demonstrating the whirlpool sign (arrowheads)—the pathognomonic imaging feature of midgut volvulus characterized by spiral twisting of mesenteric vessels and bowel around a central axis. Preoperative axial CT demonstrating features of bowel ischemia. Axial contrast-enhanced CT images showing signs of ischemic compromise, cecal pneumatosis (red arrow), and intraperitoneal fluid (blue arrow). Preoperative CT revealing features of intestinal malrotation with reversed bowel positioning. (a) Coronal and (b) axial contrast-enhanced CT views showing characteristic features of malrotation. Red arrows indicate cecum displaced to atypical epigastric position. Yellow arrows show abnormal positioning of the third portion of duodenum (D3). Green arrows highlight small bowel loops completely occupying the right side of abdomen. Blue arrows mark ileocecal junction in abnormal location. Complete reversal of normal intestinal anatomy confirms incomplete common mesentery. Intraoperative findings revealed unexpected and complex anatomical anomalies ( Supplementary Video 1 ). The patient was found to have an incomplete common mesentery with associated intestinal malrotation, characterized by positioning of the entire small bowel on the right side of the abdomen and the ascending colon on the left side. A Ladd’s band extended from the colon to the anterior abdominal wall, and remarkably, the cecum had undergone volvulus around this abnormal peritoneal band, coming to rest in an epigastric position. The right colon was markedly distended with significant wall thinning and a pre-perforative appearance, most pronounced at the cecal level. The remainder of the colon appeared macroscopically normal without evidence of additional pathology ( Fig. 4 ). Intraoperative photographs demonstrating intestinal malrotation. Surgical field showing key anatomical findings. ① Ladd’s band extending from right colon to anterior abdominal wall, serving as the pathological torsion axis. ② Small bowel loops positioned on right side of abdomen. ③ Cecum in abnormal epigastric position with right colon on the left side of abdomen. Note the reversed intestinal positioning characteristic of incomplete common mesentery. Right hemicolectomy was performed, resecting ischemic bowel from terminal ileum to mid-transverse colon. Hand-sewn ileocolic anastomosis was created, and an abdominal drain placed. The specimen included the right colon, cecum, terminal ileum segment, and Ladd’s band ( Fig. 5 ). Resected specimen. Right hemicolectomy specimen demonstrating ① Ladd’s band, ② appendix, ③ terminal ileal loop, ④ cecum showing ischemic changes and wall thinning, ⑤ right colon. The specimen confirms the pathological anatomy with Ladd’s band serving as the torsion axis and ischemic compromise of the cecum and right colon necessitating resection.

In conclusion, this rare case of adult malrotation with cecal volvulus around a Ladd’s band highlights diagnostic pitfalls, atypical volvulus mechanisms, and surgical management controversies. Most importantly, it challenges conservative approaches to incidental malrotation, demonstrating that prolonged asymptomatic periods do not preclude catastrophic complications and underscoring the critical need for systematic intraoperative bowel assessment.

Intestinal malrotation is an extremely rare congenital anomaly, with a prevalence of 0.17% [ 1 ], resulting from incomplete rotation and fixation of the midgut during embryologic development. While typically diagnosed in neonates and infants, adult presentation remains exceedingly rare and often incidental, as the estimated presentation in adulthood is <5%, with most cases remaining asymptomatic throughout life [ 1 , 2 ]. Our case is therefore remarkable not only because of the late presentation at 45 years of age, but also due to the acute and life-threatening complication of cecal volvulus with impending ischemia. One of the key questions raised by this case is how such a significant anatomical anomaly remained undetected despite two prior laparotomies. Several hypotheses can be proposed. First, incomplete common mesentery may present with subtle anatomical variations that can be overlooked, particularly if the surgical field is limited to the pelvis, as in gynecological procedures (Pfannenstiel). Second, in the absence of obstructive symptoms or intraoperative suspicion, systematic exploration of bowel positioning is not routinely performed. This case is not the first case to highlight a patient with a common mesentery that escaped detection despite previous interventions [ 3 , 4 ]. This highlights a potential blind spot in abdominal surgery, where congenital anomalies may remain unnoticed unless specifically sought. Another important issue concerns the mechanism of volvulus in this patient. In classical malrotation, midgut volvulus typically occurs around a narrow mesenteric pedicle [ 5 , 6 ]. However, in our case, the volvulus occurred around a Ladd’s band, which acted as a pathological axis for torsion. This represents an unusual and poorly described mechanism; to our knowledge, this is one of few reported cases of cecal volvulus around Ladd’s band in adults, with even fewer cases describing the band as the primary torsion axis rather than a compressive element. This finding emphasizes that peritoneal bands may play a more active role in volvulus formation than previously considered. The ectopic position of the cecum in the epigastrium further contributed to abnormal mobility and susceptibility to torsion. From a diagnostic perspective, this case underscores both the crucial role and limitations of CT in the emergency evaluation of intestinal malrotation. While CT demonstrates excellent diagnostic accuracy for abnormal duodenal positioning (sensitivity 97.3%, specificity 99%) [ 7 ], radiological signs are frequently subtle and may be overlooked—recent studies show that 67% of confirmed malrotation cases were missed on prior imaging [ 1 ]. The pathognomonic ‘whirlpool sign’ though highly specific (94%–100%) [ 7 , 8 ] for volvulus, demonstrates relatively low sensitivity (60%–64%) [ 7 , 9 ], and classic superior mesenteric vascular inversion occurs in only 8.4% of adult malrotation cases [ 10 ]. These findings emphasize the critical importance of maintaining high clinical suspicion for this rare entity in adults with atypical bowel obstruction, particularly in the absence of prior surgery. Early multidisciplinary collaboration remains essential to prevent catastrophic delays when ischemia is present. The surgical management of malrotation in adults remains controversial, particularly in emergency settings [ 5 ]. Whether formal Ladd’s procedure—comprising detorsion, division of Ladd’s bands, and mesenteric base widening [ 11 ]—should accompany resection when ischemia is present remains debated. In our case, priority was given to resection of necrotic bowel, the accepted cornerstone when viability is compromised [ 12 ]. While some advocate systematic correction regardless of presentation [ 13 ], only 35% of adults undergo formal Ladd’s procedure compared to most pediatric patients [ 5 ], reflecting concerns about operative risk in acute settings. Given the estimated 20% lifetime volvulus risk in asymptomatic malrotation [ 14 ] and our patient’s 45-year asymptomatic period despite two prior laparotomies, the risk–benefit ratio of prolonging emergency surgery remains unclear. This exemplifies the ongoing dilemma: should definitive correction be attempted in all emergency cases, or individualized based on patient stability and intraoperative findings? Current evidence remains insufficient to provide definitive guidance, prospective studies comparing outcomes of resection alone versus resection with concurrent Ladd’s procedure in adults are needed [ 6 , 10 ]. Another point of discussion relates to the choice of reconstruction. In this patient, a primary ileocolic anastomosis was performed despite the inflammatory context and necrotic bowel. Current evidence supports primary anastomosis in hemodynamically stable patients without gross peritoneal contamination [ 15 ], which was consistent with our intraoperative findings. However, the decision warrants careful consideration given several unique factors: the underlying malrotation with altered mesenteric vascular anatomy [ 10 ], the mobile residual small bowel with shortened mesenteric base remaining at risk for secondary volvulus [ 11 , 14 ], and the emergency setting with compromised bowel. The choice between primary anastomosis and staged reconstruction in the context of adult malrotation with volvulus lacks definitive evidence-based guidelines, emphasizing the critical role of intraoperative surgical judgment in assessing tissue perfusion, tension-free approximation, and patient physiologic reserve. This case raises questions about managing incidentally discovered adult malrotation. Should asymptomatic cases be corrected prophylactically? Opinion is divided [ 13 , 14 ]. While 0.17%–0.75% of adults harbor incidental malrotation [ 1 ] with 56.6% remaining asymptomatic [ 10 ], current guidelines suggest prophylactic surgery after age 20 may cause more harm than benefit [ 6 ]. However, our patient’s catastrophic presentation after 45 asymptomatic years and two prior laparotomies challenges this conservative approach, highlighting the unpredictability of volvulus risk and the need for prospective outcome registries [ 6 , 10 ].