Mazziotti M V, Strasberg S M, Langer J C
Washington University School of Medicine, Department of Surgery, St. Louis, MO, USA.
J Am Coll Surg. 1997 Aug;185(2):172-6. doi: 10.1016/s1072-7515(97)00058-6.
Intestinal rotation disorders may be discovered during investigation for abdominal symptoms. Two questions are raised in this setting: are the patient's symptoms from the rotation abnormality, and is the base of the small bowel mesentery so narrow that it places the patient at risk for midgut volvulus? Previously, laparotomy was necessary to answer these questions, and then it was necessary to do a Ladd procedure and appendectomy if necessary.
We used laparoscopic surgery to evaluate seven patients, ages 4 days to 23 years of age (median age 7 years), when upper gastrointestinal series revealed intestinal rotation abnormalities without volvulus.
Two patients had nonrotation. One had Ladd's bands across the duodenum that were divided, and the appendix was removed. The other had diffuse peritoneal soilage from a ruptured appendix; irrigation and appendectomy were performed. Three patients had duodenal malrotation and underwent laparoscopic Ladd procedure and appendectomy. Two patients had combined duodenal and cecal malrotation. One of these patients had a previous appendectomy for what in retrospect was primary peritonitis; malrotation was confirmed radiologically after the operation. She underwent a laparoscopic Ladd procedure 3 months later. The other patient was believed to have combined duodenal and cecal malrotation based on radiographic studies performed during workup for gastroesophageal reflux. At laparoscopy the small bowel mesentery was believed to have a broad enough base to prevent midgut volvulus, and an appendectomy was done. No patient required conversion to an open procedure. The sole complication was intra-abdominal abscess in the child with ruptured appendicitis that required prolonged hospitalization and operative abscess drainage. Operative times ranged from 1.25-3.25 hours (median 2 hours). Time to a regular diet was 1-20 days (median 2 days). Resolution of symptoms was seen in 5 of the 7 patients, with a median followup of 15 months.
Laparoscopy is an excellent technique for the evaluation and definitive management of patients without midgut volvulus with intestinal rotation abnormalities.
肠道旋转异常可能在对腹部症状进行检查时被发现。在这种情况下会出现两个问题：患者的症状是否源于旋转异常，以及小肠系膜根部是否过窄以至于患者有中肠扭转的风险？以前，必须通过剖腹手术来回答这些问题，然后如有必要进行Ladd手术和阑尾切除术。
当钡餐造影显示肠道旋转异常但无扭转时，我们采用腹腔镜手术对7例年龄在4天至23岁（中位年龄7岁）的患者进行评估。
2例患者存在肠不旋转。其中1例十二指肠有Ladd束带，予以切断并切除阑尾。另1例因阑尾破裂导致弥漫性腹腔污染；进行了冲洗和阑尾切除术。3例患者有十二指肠旋转不良，接受了腹腔镜Ladd手术和阑尾切除术。2例患者合并十二指肠和盲肠旋转不良。其中1例患者既往因回顾性诊断为原发性腹膜炎而行阑尾切除术；术后经放射学检查确诊为旋转不良。3个月后她接受了腹腔镜Ladd手术。另一例患者在因胃食管反流进行检查时，根据影像学研究被认为合并十二指肠和盲肠旋转不良。腹腔镜检查时，认为小肠系膜根部足够宽，可预防中肠扭转，遂行阑尾切除术。所有患者均无需转为开放手术。唯一的并发症是阑尾破裂患儿发生腹腔内脓肿，需要延长住院时间并进行手术脓肿引流。手术时间为1.25 - 3.25小时（中位时间2小时）。恢复正常饮食的时间为1 - 20天（中位时间2天）。7例患者中有5例症状缓解，中位随访时间为15个月。
对于无中肠扭转但有肠道旋转异常的患者，腹腔镜检查是一种评估和确定性治疗的极佳技术。
