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Intestinal Malrotation Discovered During LRYGB
Abstract & Commentary
By Helen Sohn, MD, Assistant Professor, Surgery, Department of Surgery, USC. Dr. Sohn reports no financial relationship to this field of study.
Synopsis: This study presents four cases, and offers recommendations should this unusual congenital defect be discovered at the time of laparoscopic gastric bypass.
Source: Palepu RP, et al. Intestinal malrotation discovered at the time of laparoscopic Roux-en-Y gastric bypass. J Gastrointest Surg. 2007;Epub ahead of print.
Four morbidly obese women who met the NIH criteria for bariatric surgery had laparoscopic Roux-en-Y gastric bypass. At operation, each was found to have intestinal malrotation. Two cases were completed laparoscopically, and 2 were converted to open operation because of difficulty defining the anatomy. All 4 operations were successful, with no immediate complications, and the patients tolerated the procedures well. We present the 4 cases and offer recommendations should this unusual congenital defect be discovered at the time of laparoscopic gastric bypass. (J Gastrointest Surg. 2007 May 9; epub ahead of print)
Palepu and colleagues report their experience of operating on 4 patients with malrotation discovered at the time of laparoscopy for bariatric surgery. They paint a detailed description of what they found, along with illustrations to make it easy for the readers to understand what was going on. We can sense the surprise of Palepu et al, as we all have been faced with surprising or unexpected findings during an operation at one point or another. Then, they go further into how they approached the problem, again in a detailed description. They went on to perform either a complete or a partial Ladd's procedure prior to safely completing the intended operation. Some modifications of the gastrojejunostomy are necessary, depending on the degree of the malrotation encountered. They conclude by sharing what they learned from these cases.
I enjoyed very much reading this case report, and believe that many readers will, too, as it was a light read with just the right amount of details, physiology, embryology, and illustrations to get their point across. And they were not afraid to report that they failed to remove the appendices in the first 2 patients. They stressed the point of performing the Ladd's procedure in order to prevent potential complications of intestinal malrotation, such as obstruction from volvulus or compression leading to ischemia. When in doubt while performing a laparoscopic procedure, the safe thing is to convert to an open procedure for clearer delineation of the anatomy.
These are good lessons for any surgeon to practice during all cases. It is easy to panic when faced with a rare unexpected finding. As long as patient safety is foremost in mind, the outcome should not differ. Another lesson not discussed by Palepu et al is to take advantage of intraoperative consults, granted that they are available, especially in rare findings, and especially for the less experienced surgeons.