Keyhole surgery for infant malrotation was tied to fewer repeat operations

Intestinal malrotation is a congenital twist in how the bowel is anchored in the abdomen, and its danger is that the midgut can rotate on its narrow stalk and cut off its own blood supply — a volvulus, which in an infant is a surgical emergency. The operation that fixes it, the Ladd's procedure, has been performed for decades through an open incision. Whether doing it laparoscopically changes the risk of the two things surgeons most want to avoid afterwards — a recurrent volvulus, or a later bowel obstruction from adhesions — has been debated on thin evidence. A multicentre study published in the Journal of the American College of Surgeons on 6 October set out to compare them [s1].

The study

Researchers from the Western Pediatric Surgery Research Consortium assembled a retrospective cohort of patients aged 15 years or younger who underwent a Ladd's procedure between January 2014 and September 2021 across 10 children's hospitals [s1]. They compared demographic, clinical, perioperative and postoperative outcomes within three years by operative approach, and built a multivariable logistic model to identify predictors of reoperation for postoperative small bowel obstruction [s1].

Among 697 patients, 495 (71.0%) had an open operation and 202 (29.0%) a laparoscopic one [s1]. The laparoscopic route was not always completed as planned: 72 of those cases (35.6%) were converted to open surgery [s1].

The groups were not alike

The two groups differed in ways that matter for interpreting the results. Patients operated on openly were younger — a median of 1.7 months (IQR 0.2–12.0) against 9.5 months (IQR 2.0–60.0) for laparoscopic cases (p<0.001) [s1]. They also more often presented with a volvulus already in progress (31.0% versus 9.2%, p<0.001) and more often needed a length of bowel removed (7.2% versus 0.0%, p=0.002) [s1].

That is the signature of a sicker, more urgent population being steered toward open surgery — exactly the situation in which a straightforward comparison of raw outcomes would be misleading. A newborn with an acute volvulus is not a candidate for a leisurely laparoscopic repair, so the open group is enriched for emergencies. This is why the authors' adjusted analysis carries more weight than the crude percentages.

What differed, and what did not

On the outcome that first motivates the operation — a recurrent volvulus serious enough to require reoperation — the approaches were indistinguishable. Reoperation for postoperative volvulus was uncommon overall, at 2.2%, and did not differ by approach [s1].

The difference appeared in the other complication. Reoperation for small bowel obstruction was more frequent after open surgery, at 6.7% versus 1.5% (p=0.017) [s1]. After adjustment, the laparoscopic approach was associated with lower odds of reoperation for small bowel obstruction, with an odds ratio of 0.216 (95% CI 0.050–0.934, p=0.040) [s1]. The confidence interval is wide and its upper bound sits just below 1, so the result is statistically significant but not precise; it is consistent with anything from a large reduction to only a slight one.

The direction is biologically plausible. Open abdominal surgery tends to generate more adhesions than laparoscopic surgery, and adhesions are the usual cause of later obstruction. A finding that keyhole repair leaves fewer of them fits what is known from abdominal surgery more broadly.

How much it settles

This is a retrospective cohort, and the authors frame it as filling a gap left by studies drawn from administrative databases [s1]. Its strength is that it pools detailed, contemporary records from 10 paediatric centres rather than billing codes. Its limitation is the one every observational surgical comparison carries: the choice of approach was made by surgeons responding to how sick each child was, and no statistical adjustment fully removes that. The one-in-three conversion rate also means a share of the "laparoscopic" group ultimately had open surgery, which blurs the comparison [s1].

What the study does not claim is that laparoscopic repair is safer for the child presenting in extremis. The reassurance it offers is narrower and more useful: in children stable enough for either approach, choosing laparoscopy was not associated with more recurrent volvulus, and was associated with fewer operations for later obstruction [s1].

What to watch

The result invites a prospective comparison in children who are genuinely eligible for both operations, which is the only design that can settle whether the obstruction difference is caused by the approach or by the kind of patient who receives it. Until then, the finding is a point in favour of laparoscopy where it is feasible — not a verdict against open repair where it is needed.

This article describes research findings and is not medical advice.

Sources

• [s1] Laparoscopic vs Open Ladd's Procedure: A Multicenter Study of Postoperative Volvulus and Small Bowel Obstruction Rate. Journal of the American College of Surgeons, 6 October 2026. https://doi.org/10.1097/XCS.0000000000002242