Adult intestinal malrotation with Ladd's bands causing acute small-bowel obstruction in a virgin abdomen: a case...

Intestinal malrotation is a rare congenital anomaly that results from incomplete midgut rotation. Although 90% of cases present in infancy, adult presentations account for only 0.2%-0.5% of cases. Congenital peritoneal bands causing obstruction in a virgin abdomen are rarely considered, making this a clinically important and easily overlooked diagnosis.

A man in his early thirties presented to the emergency department with a 2-day history of severe colicky abdominal pain, nausea, vomiting, and abdominal distension, and without prior abdominal surgery. Contrast-enhanced CT demonstrated pathognomonic features of Type I intestinal malrotation (non-rotation). After resuscitation and nasogastric decompression, urgent open laparotomy confirmed Ladd's bands causing a complete small-bowel obstruction. Ladd's procedure, with appendectomy and prophylactic colopexy, was performed. The patient was discharged on postoperative day 6 and had complete symptom resolution at the 12-month follow-up.

CT achieved a prompt diagnosis via the characteristic CT triad of abnormal superior mesenteric vein-artery orientation, malpositioned duodenojejunal junction, and right-sided small-bowel clustering. The open operative approach was selected due to high-risk physiology, massively dilated bowel, and anticipated difficulty with laparoscopic visualization, consistent with published guidance favoring primary open laparotomy in this setting.

Congenital intestinal malrotation must be considered in adults with acute small-bowel obstruction, even in a virgin abdomen. Contrast-enhanced CT is diagnostic, and the open Ladd's procedure in the acute setting achieves excellent outcomes.