Malrotation

Malrotation sometimes leads to conditions that can be life threatening: 

• Ladd’s bands – These are bands of tissue that may attach the first part of the small intestine (duodenum) to the large intestine (colon). This can block the duodenum and keep food from passing through.
• Volvulus – In this condition, the bowels twist sharply. The twist can squeeze the blood vessel that carries blood to the bowels. If blood flow is cut off, the bowels can be damaged and the tissue can die.

Some children born with malrotation may also have: 

• Heart defects
• Heterotaxia, where other organs are not in the normal place
• More than 1 spleen or none at all

The doctor may take a series of X-rays to see where the bowels are and if they are blocked. Most likely your child will have an upper GI (gastrointestinal) series (PDF). Less often, children have a lower GI series (PDF).

First, we give your child a contrast liquid that shows up on X-ray. Your child may get the liquid: 

• As a drink
• Through a tube from their nose to their stomach (nasogastric tube or NG tube)
• Through a tube placed in your baby’s rectum, if they have the lower GI series

Before surgery, your baby’s doctors will: 

• Insert a tube through your child’s nose into their stomach. This is called a nasogastric tube or NG tube. The tube empties their stomach.
• Place an intravenous (IV) line into a vein to give your child fluids, nutrients and medicine to prevent infection (antibiotics). This will be part of your child’s care before, during and after surgery.

At the time of surgery, we give your child medicine to make them sleep without pain (general anesthesia).

The surgeon: 

• Makes a small cut (incision) above the belly button.
• Brings the bowels out through this opening.
• Untwists the bowels.
• Cuts the Ladd’s bands, if these are present. These are bands of tissue that can block the small bowel.
• Checks that the bowels look healthy and pink, which shows that blood flow is good.
• Places the bowels back into the belly so they are not likely to twist in the future.
• Removes your child’s appendix. The new placement of the bowels affects the location of your child’s appendix. If your child ever got appendicitis, it might be hard to diagnose. So your surgeon takes out your child’s appendix. It has no clear function, and your child can live normally without it.
• Closes the incision with stitches. 

If it is not clear that the bowels have good blood flow, your child may need another surgery within 48 hours. If part of the bowels does not look healthy, the surgeon may remove that part.

Part of the bowels may be damaged, or the tissue may die if it is not getting good blood flow. The surgeon will remove any damaged part while keeping as much of the bowels as possible. After making the cut in your child’s belly, the surgeon: 

• Cuts out the damaged section.
• Connects the remaining parts of the bowels with stitches, if they look healthy. This is called primary anastomosis (pronounced an-as-toe-MOE-sis).
• Sews closed the cut in the belly wall.

If the rest of the bowels do not look healthy or a large part was removed, surgeons might not connect the 2 remaining parts. Instead, they may make an ostomy.

Instead of connecting the remaining parts of the bowels, the surgeon makes 2 small openings (stoma) in your child’s belly wall. This procedure is called an ostomy (pronounced OST-uh-mee). The surgeon: 

• Sews the upper end of the bowels to 1 opening in the belly wall. This lets bowel movements come out into a plastic pouch on the outside of your child’s body.
• Sews the lower end of the bowels to the other opening. This opening lets out normal mucus made in the bowels. 

If your child needs this procedure, we will teach you how to care for the openings.

In most cases, an ostomy is temporary. Later, the surgeon does another procedure to attach the ends of the bowels to each other and to close the openings in your baby’s belly. Usually this is about 6 to 8 weeks later, when the bowels are healthier.

If surgeons had to remove a large segment of your child’s bowels, the ostomy might be permanent. This is not common.

If your child had a large segment of their bowels removed, the rest may not absorb nutrients from food properly. This is called short bowel syndrome. It can cause serious problems with growth and development. Our team will keep as much of your child’s bowels as possible to try to prevent this.

After surgery, your child will be in the recovery room for about an hour and then go to a hospital room. Some children may need to stay in our pediatric intensive care unit (ICU) or Level IV Neonatal Intensive Care Unit (NICU), where they get the high level of care they need. We have the state’s first Level IV NICU. When your baby is ready, they move to a regular hospital room. 

• We will give your child pain medicine to make them comfortable.
• If your child is at risk for infection, we will give them antibiotics.
• Right after surgery, your child will get all their nutrition through a tube that goes into a vein. This is called an intravenous (IV) line. This is because it takes a few days for the bowels to work again after surgery.
• After your child starts passing gas, doctors will know the bowels are working again and feedings may be started.
• Some babies may have to get feedings through a tube that goes into the stomach from their nose (nasogastric tube or NG tube) or mouth (orogastric tube or OG tube). 

We keep a careful watch on your baby to be sure they are growing well. Most children who have surgery for malrotation stay in the hospital about 1 week. It depends on how quickly their bowels heal from surgery and how soon your child can start eating again.

The surgeon will stay closely involved in your child’s care while they are in the hospital. Your child will have a follow-up visit 2 to 3 weeks after the surgery.

The surgeon will check that: 

• The incision is healing.
• Your child is gaining weight and growing well.
• There are no other health issues.

• We have all the experts your family needs. Your child’s healthcare team will include specialists in pediatric surgery, nutrition and others as needed.
• Our surgery team is experienced performing procedures needed to move or repair your baby’s bowels. We are skilled at treating more serious problems that sometimes affect babies with this condition, including volvulus.
• Seattle Children’s has the state’s first Level IV Neonatal Intensive Care Unit (NICU), the highest level of care. We are skilled and equipped to care for the sickest newborns.

• Children differ from adults in how they react to illness, medicine, pain and surgery. They need – and deserve – care designed just for them. That is why our surgeons are all board certified in pediatric surgery.
• We only do the tests, radiation and surgery that your child needs. We use lower radiation doses than recommended by the American College of Radiology.
• The anesthesiologists at Seattle Children’s all have extra years of training in how to give children anesthesia safely and effectively. Seattle Children’s is 1 of just 5 hospitals in the nation recognized by ChildKind International for how well we prevent and treat pain in children.

• At Seattle Children’s, you have a full team behind you before, during and after surgery. We work together to meet all your child’s health needs. We take time to explain your child’s condition and help you fully understand your treatment options.
• Our doctors, nurses, child life specialists and social workers help your family through the challenges of this condition. We connect you to community resources and support groups.
• We work with many children and families from around the Northwest and beyond. We can help with financial counseling, schooling for kids in the family, housing, transportation, interpreter services and spiritual care. Learn about our services for patients and families.