Midgut volvulus with malrotation remains a surgical emergency in neonates and infants and requires immediate surgical intervention . The Ladd procedure is the gold standard surgical technique for midgut volvulus as described by William Ladd in 1936 . The Ladd procedure involves reducing the volvulus by rotating the bowel in a counterclockwise direction, dividing the mesenteric (Ladd) bands, placing the small bowel in the right abdomen and the large bowel in the left abdomen, and performing an appendectomy. An appendectomy is performed to circumvent the diagnostic error of acute appendicitis later in life since it would otherwise be relocated to the left upper quadrant in patients with malrotation . However, the safety and efficacy of appendectomy in the Ladd procedure remain controversial. An appendectomy for midgut volvulus with malrotation is incidental; that is, the appendix is removed during non-appendiceal surgery . As incidental appendectomy has advantages and disadvantages, a single standard management approach is lacking.
The appendix was recently suggested to play an important role in maintaining and replenishing the microbiota of the colon after a diarrhea episode . Moreover, the appendix consists of lymphoid tissue resembling Peyer’s patches and is the primary site of immunoglobulin A production . Moreover, appendectomy may be associated with a higher risk of ulcerative colitis, Crohn’s disease, Clostridium difficile infection, and colorectal cancer .
Previous studies indicated that incidental appendectomy may be associated with morbidity [9, 10]. In our cases, bowel obstruction was more likely to occur in patients who underwent appendectomy using the Ladd procedure. In one case, adhesion between the terminal ileum and the abdominal wall caused a strangulated bowel obstruction that required ileocecal resection. Therefore, appendectomy with the Ladd procedure may cause unnecessary adhesions that induce postoperative bowel obstruction requiring surgical intervention.
There are some limitations to our study. First, it was a single-center, retrospective, observational study with a small sample size. No cases of appendicitis were confirmed in either group. Appendicitis most commonly occurs in the second decade of life, and fewer than 5% of patients diagnosed with it are 5 years of age or younger . The median follow-up period after the Ladd procedure in this study was 80 and 46 months in the appendectomy and non-appendectomy groups, respectively. Therefore, a longer follow-up period might be required to confirm the rate of bowel obstruction after the Ladd procedure.
In conclusion, our findings suggest that concomitant appendectomy with the Ladd procedure increases the risk of postoperative bowel obstruction.