Ladd Procedure: A Surgical Solution for Intestinal Malrotation
Updated: 2 days ago
Medically reviewed by Dr. Baraa Alnahhal, MD | Last reviewed: October 7, 2026
Quick Answer: What is the Ladd procedure?
The Ladd procedure is the only surgical cure for intestinal malrotation [1], a condition present at birth in which the intestines are twisted or misplaced. Done laparoscopically or as open surgery, it untwists the intestines, cuts restrictive Ladd's bands, repositions the bowels and removes the appendix [1]. Babies stay in the hospital for several days to two weeks [1], and most develop typically.
What the research says
Laparoscopic Ladd’s surgery is linked to a faster recovery and fewer complications, but possibly more postoperative volvulus. A meta-analysis of 14 studies (444 laparoscopic and 1,422 open procedures) found that the laparoscopic group had a shorter hospital stay (mean difference −4.57 days, 95% CI −7.58 to −1.56), faster time to full feeds (−3.00 days) and fewer overall complications (OR 0.35, 95% CI 0.19–0.65), but more postoperative volvulus (OR 2.97, 95% CI 1.23–7.13). The authors note that more randomized trials with adequate follow-up are needed (Zhang et al., J Laparoendosc Adv Surg Tech A, 2022) [2].
In a large US database, the two approaches had similar volvulus and obstruction rates, and redo surgery was uncommon. Among 1,343 children (excluding newborns) who had elective Ladd’s procedures, 78% were done open and 22% laparoscopically. After matching, laparoscopy was associated with fewer 30-day readmissions (7% vs 16%), postoperative volvulus was similar (0% vs <1%), and redo Ladd’s procedure occurred in less than 4% of readmissions (Saberi et al., Journal of Pediatric Surgery, 2022) [3].
Not every laparoscopic Ladd’s procedure can be completed laparoscopically. A systematic review of 9 retrospective studies (1,003 patients) found that 25.3% of laparoscopic procedures were converted to open surgery; laparoscopy was linked to a shorter hospital stay (5.9 vs 11.2 days) and fewer complications (8% vs 21%), but postoperative volvulus was more frequent (3.5% vs 1.4%, p = 0.04) (Catania et al., Pediatric Surgery International, 2016) [4].
Overview of the Ladd Procedure
Intestinal malrotation is a congenital disorder that occurs during fetal development when the intestines do not rotate into their proper position within the abdomen. This can lead to severe complications, most notably volvulus, where the intestine twists on itself [1]. Volvulus can block the bowel and cut off blood flow to intestinal tissue, leading to tissue death (necrosis) [1]. The Ladd procedure is the standard surgical intervention designed to correct these issues and ensure the long-term health of the child’s digestive system.
Most babies are diagnosed with malrotation within their first year of life [1] and may have severe abdominal pain, vomiting bile, and significant distress. Depending on the symptoms, malrotation may be a medical emergency requiring surgery right away; a baby who vomits green or yellow-green (bile-stained) fluid needs emergency care immediately [1]. The Ladd procedure addresses both the malrotation itself and the associated “Ladd’s bands”—fibrous tissue that can further obstruct the small intestine [1].
Preparing for Pediatric Surgery
Most children requiring a Ladd procedure are infants under one year old. Preparation focuses on ensuring the baby is stable and that parents are supported through the process. The medical team will use a nasogastric (NG) tube to empty the baby’s stomach and an intravenous (IV) line to provide necessary fluids and medications [1].
Preparation Step | Purpose |
Nasogastric (NG) Tube | Empties the stomach to prevent complications during surgery. |
Intravenous (IV) Line | Delivers hydration, nutrition, and infection-preventing medications [1]. |
General Anesthesia | Ensures the baby remains asleep and pain-free throughout the procedure [1]. |
Parental Comfort Items | Bringing a favorite toy or blanket to help soothe the baby during recovery [1]. |
The Surgical Steps
The Ladd procedure can be performed using laparoscopic techniques, involving three or four tiny incisions in the abdomen, although most are still done as open surgery [1]. In some cases, an open surgery (laparotomy) may be necessary. The surgery typically takes about one hour to complete [1], depending on whether the surgeon does laparoscopic or open surgery.
During the procedure, the surgeon carefully untwists the intestines and examines them for signs of healthy blood flow [1]. Restrictive Ladd’s bands are cut to free the small intestine [1]. The healthy intestines are then repositioned on the left side of the abdomen [1]. As a standard part of the procedure, the surgeon also performs an appendectomy [1]. This is because the repositioned intestine moves the appendix to the left side of the body, which could make diagnosing future appendicitis very difficult for doctors expecting it on the right.
Sometimes the twisting has blocked the blood supply to the intestines. In that case, the baby may need an additional operation within 24 to 48 hours to confirm that the intestine is healthy [1].
Post-Operative Recovery and Monitoring
After the surgery, infants are monitored closely in a recovery room. A hospital stay of several days to two weeks is typical [1]. During this time, the focus is on pain management and waiting for the digestive system to resume normal function.
Recovery Milestone | Estimated Timeline | Signs of Progress |
Initial Stabilization | 24–48 Hours | Stable vital signs, recovery from anesthesia. |
Digestive Resumption | 2–3 Days | Passing gas, bowel movements, nursing or bottle-feeding [1]. |
Wound Healing | 1–2 Weeks | Incisions closing, reduction in redness/swelling. |
Follow-up Visit | 2–3 Weeks | Surgeon checks weight and incision site health [1]. |
Long-Term Outlook and Success
Cleveland Clinic cites an analysis of both open and laparoscopic procedures in which the Ladd procedure successfully treated malrotation in more than 90% of babies who had the surgery [1], though data vary between studies. Most children who undergo the procedure experience typical growth and development [1]. In some cases, however, malrotation symptoms can come back and children will need more surgery, so the medical team will monitor for signs of volvulus or intestinal issues during follow-up appointments.
Potential Risks and Complications
As with any major surgery, the Ladd procedure carries some risks. These can include infection at the incision site, paralytic ileus (a temporary lack of bowel movement), or short bowel syndrome [1] if a significant portion of the intestine was damaged before surgery. In some cases, the volvulus can recur, requiring further surgical intervention [1].
Conclusion
The Ladd procedure remains a cornerstone of pediatric surgery, offering a definitive treatment for a potentially life-threatening congenital condition. By restoring the proper flow and position of the intestines, it provides infants with a healthy foundation for growth and nutrition. For parents, understanding the steps of the procedure and the recovery process can help alleviate the anxiety associated with their child’s surgery.
Next Steps
If your baby has been diagnosed with intestinal malrotation, discuss the surgical approach with a pediatric surgeon. Ensure you understand the specific steps of the recovery process and have a support system in place for the duration of the hospital stay. Early intervention is the most effective way to prevent complications and ensure a smooth recovery for your child.
Frequently Asked Questions
What is the main goal of the Ladd procedure?
The primary goal is to untwist the intestines, cut restrictive tissue bands, and reposition the bowels to prevent future obstruction.
Why is the appendix removed during this surgery?
The appendix is removed because the surgery moves it to the left side of the body, which would make diagnosing appendicitis very difficult in the future.
How long does the surgery typically take?
The procedure usually takes about one hour to complete.
Is the Ladd procedure always an emergency?
Not always, but if the intestines are twisted (volvulus) and blood flow is blocked, it becomes a medical emergency.
How long will my baby stay in the hospital?
A hospital stay of several days up to two weeks is typical for most infants.
When can my baby start feeding again after surgery?
Most babies can resume nursing or bottle-feeding within two to three days once the bowels show signs of working.
What is the success rate of the Ladd procedure?
Cleveland Clinic cites an analysis of both open and laparoscopic procedures in which the Ladd procedure successfully treated malrotation in more than 90% of babies; data vary depending on the study.
Can malrotation come back after surgery?
Recurrence after surgery is uncommon, but symptoms can recur, and some children need additional surgery. Contact your baby’s surgical team if your baby develops belly cramps or vomiting.
What are “Ladd’s bands”?
Ladd’s bands are bands of fibrous tissue that can form during development and block the first part of the small intestine.
Is the surgery performed laparoscopically?
Surgeons may use a laparoscopic approach with three or four tiny incisions or open surgery; in large studies, most Ladd procedures are still done open. Your baby’s surgeon will recommend the approach they believe is best.
What should I bring to the hospital for my baby?
Comfort items like a favorite toy or blanket are highly recommended to help soothe the baby during recovery.
Will my child be able to eat normally after the surgery?
Once the small intestine is working, babies can nurse, bottle feed or eat solid food, and most children go on to typical growth and development. Ask your surgeon about any specific instructions for your child.
What are the signs of a surgical site infection?
Signs include fever (38 °C / 100.4 °F or higher on a rectal thermometer), thick or cloudy discharge from the wound, an opening in the incision, or redness that spreads beyond the edge of the incision.
How soon is the first follow-up appointment?
The first follow-up visit is usually scheduled for two to three weeks after surgery.
Who was the Ladd procedure named after?
The Ladd procedure was named after William E. Ladd, a pioneer in the field of pediatric surgery.
How do I prepare my baby for the Ladd procedure?
Your baby may not be fed or nursed for several hours before surgery, so confirm the exact timing with the surgeon [1]. Before the operation the team places a nasogastric tube through the nose to empty the stomach and starts an IV for fluids and medication, including medicine to help prevent infection [1]. Plan for a hospital stay of several days up to two weeks, stay with your baby as much as you can, arrange familiar family or friends to cover your breaks, and bring a favorite toy or blanket [1].
Does the Ladd procedure hurt, and what anesthesia is used?
Your baby receives general anesthesia, so they are asleep and feel no pain during the operation, which typically takes about an hour [1]. Afterward your baby goes to a recovery room for monitoring, and pain medication is given through the IV along with fluids and nutrition until the intestine heals [1]. If the blood supply to the bowel was compromised, a second surgery may be needed within 24 to 48 hours [1].
When should I call my doctor after the Ladd procedure?
Call the surgeon for a rectal temperature above 100.4 to 102.2 F (38 to 39 C), thick, cloudy, white or cream-colored discharge from the wound, an incision that opens or becomes deeper, longer or wider, or redness or skin color change spreading beyond the incision edge [1]. Also call for belly cramps or vomiting, which may signal that the malrotation has recurred [1]. A follow-up visit about two to three weeks after surgery checks the incision and your baby's weight [1].
Sources
Cleveland Clinic. Ladd Procedure. Cleveland Clinic. Last updated November 11, 2024. https://my.clevelandclinic.org/health/procedures/ladd-procedure
Zhang Z, Chen Y, Yan J. Laparoscopic versus open Ladd’s procedure for intestinal malrotation in infants and children: a systematic review and meta-analysis. J Laparoendosc Adv Surg Tech A. 2022;32(2):204-212. PMID: 34609912. DOI: 10.1089/lap.2021.0436
Saberi RA, Gilna GP, Slavin BV, et al. Outcomes for Ladd’s procedure: does approach matter? J Pediatr Surg. 2022;57(1):141-146. PMID: 34657741. DOI: 10.1016/j.jpedsurg.2021.09.016
Catania VD, Lauriti G, Pierro A, Zani A. Open versus laparoscopic approach for intestinal malrotation in infants and children: a systematic review and meta-analysis. Pediatr Surg Int. 2016;32(12):1157-1164. PMID: 27709290. DOI: 10.1007/s00383-016-3974-2
Related Reading
Medical disclaimer
This content is for informational purposes only and does not constitute medical advice. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition or surgical procedure.
Comments