Published on August 10, 2014

Author: humaskhan

Source: authorstream.com


DISORDERS OF INTESTINAL ROTATION AND FIXATION: DISORDERS OF INTESTINAL ROTATION AND FIXATION DR. HUMA SABIR KHAN DR. SHADAB ALI HISTORY: HISTORY The first meaningful description of the embryology was written in 1898 by Mall professor of anatomy at Johns Hopkins University. In 1923 Dott published his classic paper on the embryology and surgical aspects of anomalies of intestinal rotation . In 1936 Ladd wrote the classic article on the treatment of this condition and described 21 cases. EMBRYOLOGY: EMBRYOLOGY PHYSIOLOGICAL HERNIATION: PHYSIOLOGICAL HERNIATION PowerPoint Presentation: Physiological herniation occurs in 6 th week of development. Reduces back induring 10 th week. NORMAL ANATOMY: NORMAL ANATOMY LIGAMENT OF TREITZ: LIGAMENT OF TREITZ TRANPYLORIC PLANE: TRANPYLORIC PLANE NORMAL ROTATION AND FIXATION: NORMAL ROTATION AND FIXATION Rotation may be described according to how it affects the two ends of the intestinal tract P roximal duodenojejunal loop D istal cecocolic loop and the simultaneous rotation of these two components. CONCEPT OF ROTATION: CONCEPT OF ROTATION Direction: anticlocwise Axis: SMA View: observers view Orientation: patient’s Right is right, left is left ROTATION OF PROXIMAL DUODENOJEJUNAL LOOP: ROTATION OF PROXIMAL DUODENOJEJUNAL LOOP PowerPoint Presentation: 270 CECOCOLIC LOOP: CECOCOLIC LOOP PowerPoint Presentation: 270 SIMULTATANEOUS ROTATION: SIMULTATANEOUS ROTATION ABNORMALITIES OF ROTATION: ABNORMALITIES OF ROTATION Malrotation : All abnormalities of intestinal position and attachment PowerPoint Presentation: Atypical malrotation : Ligament of treitz is in midline or to below gastric outlet on upper GI studies Typical malrotation : Lig . Of treitz is to r ight of midline or a bsent. PowerPoint Presentation: NON-ROTATION INCOMPLETE ROTATION REVERSE ROTATION: REVERSE ROTATION Reverse rotation: Clockwise Transverse colon lies behind the vessels ABNORMALITIES OF FIXATION: ABNORMALITIES OF FIXATION ASSOCIATED ABNORMALITIES: ASSOCIATED ABNORMALITIES Situs Inversus Heterotaxia / situs ambiguous Congenital diaphragmatic hernia Gastroschisis , omphalocele Duodenal atresias Hirshsprung disease Mesenteric cysts CLINICAL MANIFESTATIONS: CLINICAL MANIFESTATIONS ACUTE VOLVULUS Gut is prone to iscahemia . Needs emergency management. PowerPoint Presentation: Chronic midgut volvulus Acute Duodenal obstruction secondary to congenital bands Chronic Duodenal obstruction secondary to congenital bands Reverse rotation with colonic obstruction INTERNAL HERNIATION: INTERNAL HERNIATION A right mesocolic hernia is produced when the prearterial limb fails to rotate around the superior mesenteric artery and the bowel loops are entrapped by the mesentery of the cecum and colon A left mesocolic hernia is produced when the unsupported area of the descending mesocolon between the inferior mesenteric vein and the posterior parietal colonic attachment is ballooned out by the small intestine as it migrates to the left superior portion of the abdominal cavity . PowerPoint Presentation: Volvulus of Caecum SIGNS AND SYMPTOMS: SIGNS AND SYMPTOMS Symptoms of Obstruction –vomiting; crampy abdominal pain; distention • Symptoms of Volvulus –vomiting (bilious or nonbilious ) most common symptom –Sepsis caused by bowel necrosis Signs: Abdominal tenderness if peritonitis due to bowel ischaemia Scaphoid abdomen WORKUP: WORKUP Routine baseline blood tests Serum LDH, CPK Chest ray X-ray abdomen scout film Ultrasound examination Upper GI series CT- scan abdomen PLAIN X-RAY ABDOMEN: PLAIN X-RAY ABDOMEN Double bubble sign Absence of normal colonic gas Gasless abdomen PowerPoint Presentation: Ultrasound abdomen Whirlpool appearance Fluid filled distended duodenum Dilated bowel loops on right side of abdomen Position of duodenum and superior mesenteric artery CT SCAN: CT SCAN CONTRAST STUDIES: CONTRAST STUDIES Ligament of treitz Caecal position Z sign Corkscrew appearance PowerPoint Presentation: COCKSCREW APPEARANCE Z-BAND TREATMENT: TREATMENT LADDS PROCEDURE 1) Evisceration of bowel and inspection of mesentry 2 ) Counterclockwise derotation of volvulus 3 ) Lysis of peritoneal bands 4 ) Appendectomy 5 ) Placement of caecum in left lower quadrant LOCATION OF ABNORMALITY: LOCATION OF ABNORMALITY Supraumbilical right transverse incision Two most constant anatomic points Pylorus Splenic flexure Locate ileocecal valve Ileal mesentry PowerPoint Presentation: Signs of rotational anomaly Abnormal peritoneal bands Fixation of duodenum or upper jejunum to colon Visualization of entire duodenum Abnormal position and mobility of caecum or duodenum along right gutter Rule out intrinsic obstruction Fixation of duodenum and colon Inversion-ligation appendectomy PowerPoint Presentation: Laparoscopic Ladd Procedure •Only performed in the absence of volvulus or bowel ischemia. Also useful for diagnosis in asymptomatic patients. PowerPoint Presentation: THANK YOU

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