Ladd's Procedure (Malrotation)
4405044950wRVU: 10.34 — Appendectomy (incidental, performed as part of Ladd's procedure)44120wRVU: 20.3 — Small bowel resection (if ischemic bowel requiring resection)44005wRVU: 18.0 — Enterolysis (if performed without volvulus)
Intestinal malrotation [with midgut volvulus / without volvulus]
Same
Ladd's procedure ([emergent for volvulus / elective]), division of Ladd's bands, duodenal Kocherization, appendectomy, and intestinal repositioning
[Attending name], MD
[Resident name]
General endotracheal. NGT placed.
Patient is a [age]-old [male / female] presenting with [bilious emesis / abdominal distension / acute abdomen] and [upper GI series / CT] demonstrating [malrotation with midgut volvulus / malrotation without volvulus]. [Bowel ischemia suspected given bloody stools / bilious emesis duration X hours.] Emergent surgical correction indicated. Risks including ischemic bowel loss, short gut syndrome, anastomotic leak, and prolonged ileus discussed with parents. Consent obtained.
[Clockwise / counterclockwise] midgut volvulus [X] turns. [Ischemic bowel ([viable after detorsion / frankly necrotic, requiring resection]).] Ladd's bands crossing duodenum from cecum to right upper quadrant. Duodenojejunal junction [to right of midline / confirmed malrotated]. After Ladd's procedure, duodenum positioned on right side, cecum in left lower quadrant. [Bowel pink and peristaltic at end of case.]
The patient was taken urgently to the operating room and positioned supine. A transverse [/ right upper quadrant] incision was made and the abdomen entered.
The midgut was delivered from the abdomen. [A clockwise volvulus of [X] turns was present and reduced by counterclockwise detorsion.] The bowel was assessed for viability ([pink and viable throughout / ischemic segments noted and assessed]).
Ladd's bands (peritoneal attachments from the cecum and right colon crossing the duodenum) were divided with sharp dissection, completely freeing the duodenum. The mesenteric base was widened by dividing adhesive bands at the base of the mesentery, broadening the mesenteric root. The duodenum and proximal small bowel were straightened and positioned along the right side of the abdomen. The cecum and right colon were positioned in the left side. The bowel was returned to the abdomen with this non-rotation position.
An incidental appendectomy was performed by ligating and dividing the appendiceal base and mesoappendix with [electrocautery / 3-0 Vicryl / Endo GIA stapler].
[Ischemic bowel resected with primary anastomosis / ostomy creation. See concurrent note.]
Fascia closed with [running 0-PDS / figure-of-eight 0-Vicryl]. Skin closed. Patient tolerated the procedure well.
None
[Appendix to pathology / Ischemic bowel to pathology / None]
[X] mL
[None / NG decompression only]
Patient taken to pediatric ICU / NICU in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Intestinal malrotation [with midgut volvulus / without volvulus]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Ladd's procedure ([emergent / elective]): division of Ladd's bands, duodenal Kocherization, appendectomy, intestinal repositioning
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal, NGT placed
INDICATIONS: The patient is a .PTAGE-old .PTSEX presenting with [bilious emesis / acute abdomen] and [UGI series / CT] demonstrating malrotation [with midgut volvulus]. [Bowel ischemia suspected.] Emergent correction indicated. Risks including bowel loss, short gut, and anastomotic complications discussed with parents. Informed consent obtained.
FINDINGS: [Clockwise midgut volvulus *** turns.] [Ischemic bowel: viable after detorsion / necrotic.] Ladd's bands crossing duodenum. After procedure: duodenum on right, cecum in left lower quadrant. Bowel [pink and viable / ischemic segment resected].
DESCRIPTION OF PROCEDURE:
Patient supine. Transverse [/ RUQ] incision. Abdomen entered. Midgut delivered. [Volvulus reduced by counterclockwise detorsion.] Bowel viability assessed. Ladd's bands divided with sharp dissection. Duodenum freed completely. Mesenteric base widened by dividing adhesive bands. Duodenum and proximal jejunum straightened and positioned on right. Cecum positioned in left. Appendectomy performed [with ligation of appendiceal base and mesoappendix]. [Ischemic bowel resected. See concurrent note.] Bowel returned to abdomen in non-rotation position. Fascia closed with 0-PDS. Skin closed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: [Appendix to pathology / Resected bowel to pathology / None]
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient to [peds ICU / NICU] in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Volvulus with ischemic bowel
If bowel is frankly necrotic, resect and create ostomies rather than anastomosis. Plan second-look laparotomy at 24-48 hours for borderline viability. Document extent of ischemia and residual bowel length (short gut risk if <75 bowel cm ileocecal p small valve).< without>
Laparoscopic Ladd's procedure
For elective malrotation without volvulus in stable patients. Document port placement, extent of band division, and mesenteric base widening. Conversion to open required for volvulus or ischemia.
Charting Tips
- Document direction and number of volvulus turns
- Note bowel viability assessment after detorsion (color, peristalsis, Doppler)
- Document division of Ladd's bands completely and widening of mesenteric base
- Always document appendectomy and rationale (prevents future confusion if appendicitis develops in atypical location)
- If bowel resected, document residual small bowel length, as this is critical for short gut risk assessment
Billing Tips
- Bill 44050 for reduction of volvulus (9.29 wRVU, 90-day global) when performed for midgut volvulus. Bill 44130 for small bowel resection if ischemic bowel is resected. Ladd's procedure itself (division of Ladd's bands, duodenal mobilization, appendectomy, bowel repositioning) does not have a dedicated CPT and is coded based on the primary procedure performed.
- When Ladd's procedure is performed without volvulus (elective malrotation repair), code the most complex component: duodenal mobilization (44005, enterolysis) plus appendectomy (44950). Document each step performed.
- Appendectomy performed as part of Ladd's procedure (incidental, to prevent future misdiagnosis of appendicitis in atypical location) is separately billable with 44950 (appendectomy, other than incidental). Document that appendectomy was performed and the rationale.
- If bowel resection is required for ischemic/necrotic midgut, bill 44120-44130 for small bowel resection. Document extent of ischemia and whether primary anastomosis or ostomy was performed. Second-look laparotomy may be required.
- 90-day global: postoperative ileus management, TPN, and follow-up imaging are bundled. Second-look laparotomy within global period uses modifier -78.