PMC6796602_01
A. Scout film of abdomen taken prior to CT imaging upon admission in 2018 showing dilated loops of small bowel (green arrow). B. CT Abdomen and Pelvis upon admission demonstrating an obstructed and dilated loop of jejunum (green arrow). Multiple parallel fine linear densities consistent with Ladd bands (blue arrows) are seen extending from ascending colon and cecum.
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The patient underwent a CT scan of the abdomen and pelvis without contrast, which showed a large dilated loop of proximal jejunum with evidence of mesenteric twist concerning for a closed loop SBO (Fig. 1).
A. Intraoperative image taken prior to detorsion and repositioning of abdominal contents, showing dilated loop of jejunum (green arrow) seen on preoperative CT imaging. Ladd bands (blue arrow) seen extending from cecum (white arrow), which is visualized in right upper quadrant as opposed to its normal location in the right lower quadrant. B. Intraoperative image taken upon repositioning of abdominal contents during Ladd procedure. Duodenum (black arrow) now straightened out and located in right hemiabdomen. Cecum (white arrow) now visualized in left upper quadrant, along with appendiceal stump secondary to appendectomy (yellow arrow).
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Moreover, the cecum was visualized in the right upper quadrant instead of its usual anatomical location in the right lower quadrant of the abdomen (Fig. 2A). It became apparent that the adhesions were in fact Ladd bands (Fig. 2A), and that our patient had an intestinal malrotation. After straightening out and relocating the duodenum to the right hemiabdomen, the final position of abdominal contents was consistent with that seen after a completed Ladd procedure (Fig. 2B).
Coronal and sagittal images from non-contrast CT Abdomen and Pelvis obtained during postoperative period. A. (Coronal) Yellow arrow demonstrating root of mesentery that is no longer twisted. B. (Sagittal) New anterior and left hemi-abdomen position of ileocecal junction (white arrow). The stomach (red arrow) and heart (blue arrow) are seen supporting left-sided positioning. Appendix not visualized secondary to appendectomy.
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Initial high-volume bilious output from her nasogastric tube prompted a CT scan that showed no evidence of SBO, and confirmed the new position of the cecum on the left (Fig. 3).