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Pancreaticoduodenectomy in adults with congenital intestinal rotation disorders
Rod Mateo1, Maria Stapfer, Gagandeep Singh
1Department of Surgery, Division of Hepatobiliary/Pancreatic and Abdominal Transplant Surgery, Keck/USC School of Medicine, Los Angeles, CA, USA. rod.mateo.usc@tenethealth.com
Insights
Congenital intestinal malrotation alters anatomy for pancreaticoduodenectomy (PD). Modified surgical approaches in 3 adult cases with malrotation yielded favorable outcomes, highlighting the need for careful vascular identification.
Area of Science:
- Surgical Oncology
- Developmental Biology
- Anatomy
Background:
- Congenital intestinal malrotation is a rare developmental anomaly affecting midgut embryogenesis.
- This condition significantly alters the normal vascular and anatomical relationships crucial for pancreaticoduodenectomy (PD).
Observation:
- Presents 3 adult cases requiring PD due to congenital intestinal rotation disorders.
- Two patients had bilio-pancreatic tumors; one underwent total pancreatectomy for allograft procurement.
- Observed significant arterial and venous anomalies and abnormal positioning of midgut and hindgut structures.
Findings:
- Standard PD landmarks are unreliable in patients with malrotation.
- Modified surgical techniques were successfully employed.
- Meticulous identification of vascular structures based on their projected anatomy was critical.
Implications:
- Surgical planning for PD in patients with congenital malrotation requires adaptation.
- Careful pre-operative and intra-operative anatomical assessment is essential for patient safety.
- These modified approaches can be applied to similar complex surgical scenarios involving vascular anomalies.
Abstract:
Congenital intestinal malrotation is a developmental anomaly resulting from interruption of the physiological herniation and return to the abdominal cavity of the midgut during the 6th to 10th week of embryological development. Normal vascular and anatomic relationships used as landmarks during pancreaticoduodenectomy (PD) are altered in patients with congenital malrotation. We present 3 cases of PD in adults with congenital intestinal rotation disorders. Three adult patients with congenital rotational disorders required PD. Two of these patients had bilio-pancreatic tumors, and 1 cadaveric donor underwent total pancreatectomy during pancreas allograft procurement. All patients had arterial and venous anomalies around the celiac trunk and mesenteric vessels, respectively. The midgut and hindgut in each case were shifted toward opposite sides of the abdominal cavity. Modifications to the standard approach to PD were made, and outcomes were favorable in each case. Each patient showed anatomic abnormalities with the need for identifying vascular structures through their expected (or projected) course and location before parenchymal division or ligation of any vessel. This approach becomes crucial in cases of vascular anomalies, such as ones occurring in congenital malformations, and can be used in similar situations encountered during pancreaticoduodenectomy.
