Ladd's Procedure (Malrotation)

CPT 44055 · 24.99 wRVU · 90-day global
CPT44055
wRVU24.99
Global90-day
ApproachOpen
ComplexityComplex
Add-on / Variant CPTs
  • 44120 wRVU: 20.3 — Small bowel resection with anastomosis (20.30 wRVU; for concurrent ischemic or necrotic bowel requiring primary anastomosis)
  • 44125 wRVU: 19.53 — Small bowel resection with enterostomy (19.53 wRVU; when ostomy created rather than primary anastomosis)
  • +44121 — Each additional small bowel resection and anastomosis at same session (4.33 wRVU, add-on; list with 44120 for each additional segment)
Preoperative Diagnosis:

Intestinal malrotation [with midgut volvulus / without volvulus]

Postoperative Diagnosis:

Same

Procedure Performed:

Ladd's procedure ([emergent for volvulus / elective]): division of Ladd's bands, duodenal mobilization, appendectomy, and intestinal repositioning

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident name]

Anesthesia:

General endotracheal. Orogastric tube placed.

Indications:

Patient is a [age]-old [male / female] presenting with [bilious emesis / abdominal distension / acute abdomen] and [upper GI series / ultrasound / CT] demonstrating [malrotation with midgut volvulus / malrotation without volvulus]. [Whirlpool sign on Doppler ultrasound.] [Bowel ischemia suspected given bloody stools / bilious emesis duration X hours.] Emergent [/ elective] surgical correction indicated. Risks including ischemic bowel loss, short gut syndrome, anastomotic leak, and prolonged ileus discussed with parents. Consent obtained.

Findings:

Clockwise 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, confirming malrotation. After Ladd's procedure: duodenum positioned on right side, cecum in left lower quadrant. [Bowel pink and peristaltic at end of case.]

Description of Procedure:

The patient was taken urgently to the operating room and positioned supine. A supraumbilical transverse 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 (color, peristalsis, Doppler) after detorsion.

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 separating the superior mesenteric artery from the superior mesenteric vein and dividing peritoneal attachments at the mesenteric root, broadening the mesenteric base. 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 in 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.

Complications:

None

Specimens:

[Appendix to pathology / Ischemic bowel to pathology / None]

Estimated Blood Loss:

[X] mL

Drains:

[None / OGT decompression only]

Disposition:

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 mobilization, appendectomy, intestinal repositioning
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal, OGT placed

INDICATIONS: The patient is a .PTAGE-old .PTSEX presenting with [bilious emesis / acute abdomen] and [UGI series / Doppler ultrasound / CT] demonstrating malrotation [with midgut volvulus]. [Bowel ischemia suspected.] Emergent [/ elective] 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 — resected.] Ladd's bands crossing duodenum; duodenojejunal junction to right of midline. After procedure: duodenum on right, cecum in left lower quadrant. Bowel [pink and viable / ischemic segment resected].

DESCRIPTION OF PROCEDURE:
Patient supine. Supraumbilical transverse incision. Abdomen entered. Midgut delivered. [Clockwise volvulus *** turns; reduced by counterclockwise detorsion.] Bowel viability assessed (color, peristalsis, Doppler). Ladd's bands divided sharply; duodenum freed completely. SMA/SMV separated; peritoneal attachments at mesenteric root divided; mesenteric base widened. Duodenum and proximal jejunum straightened and positioned on right. Cecum positioned in left lower quadrant. Appendectomy performed [with ligation and division 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
.TODAY
Variants

Volvulus with ischemic bowel

If bowel is frankly necrotic, resect and create ostomies rather than anastomosis (44125, 19.53 wRVU). Plan second-look laparotomy at 24-48 hours for borderline viability — use modifier -58 (planned staged). Document extent of ischemia and residual bowel length; short gut risk if residual small bowel <75 cm (term infant normal range 150-250 cm).

Laparoscopic Ladd's procedure

CPT 44238 (unlisted laparoscopy procedure, intestine) — no specific laparoscopic code exists for Ladd's. Cross-reference 44055 for fee benchmark in operative note. Laparoscopic approach was historically reserved for elective cases; recent evidence (2019-2025) supports laparoscopic technique even for volvulus in hemodynamically stable patients at experienced centers. Convert to open for hemodynamic instability, extensive ischemia, or inadequate visualization.

Charting Tips
  • Document direction and number of volvulus turns (midgut volvulus is essentially always clockwise; documented turns number guides detorsion)
  • {'Note bowel viability assessment after detorsion': 'color, peristalsis, capillary refill, and Doppler if used'}
  • Document division of Ladd's bands completely and SMA/SMV separation with mesenteric root widening
  • {'Document appendectomy and rationale': "(1) prevents future diagnostic confusion if appendicitis develops in an atypical left-sided position; (2) Ladd's band division may compromise appendiceal blood supply, making appendectomy appropriate"}
  • If bowel resected, document residual small bowel length — critical for short gut syndrome risk assessment
  • Include ultrasound whirlpool sign if present preoperatively; document time from symptom onset to OR for ischemia timeline
Billing Tips
  • Bill 44055 for Ladd's procedure (correction of malrotation by lysis of duodenal bands and/or reduction of midgut volvulus; 24.99 wRVU, 90-day global). 44055 covers the full Ladd procedure with or without associated volvulus, including band division, mesenteric widening, bowel repositioning, and incidental appendectomy. 44050 (reduction of volvulus by laparotomy, 15.13 wRVU) is for relief of obstruction without malrotation correction — not the correct code for a Ladd procedure.
  • 44055 covers both emergent (with volvulus) and elective (without volvulus) Ladd's procedures. Do not substitute 44005 (enterolysis) plus 44950 (stand-alone appendectomy) as an alternative coding strategy — these codes do not describe the Ladd procedure.
  • Incidental appendectomy during Ladd's procedure is bundled into 44055 and is NOT separately billable. 44955 (appendectomy add-on, 1.49 wRVU) applies only when appendectomy is performed for an independent indicated purpose during another primary procedure — not for the prophylactic appendectomy that is integral to the Ladd procedure.
  • If bowel resection is required for ischemic or necrotic midgut: bill 44120 (small bowel resection with anastomosis, 20.30 wRVU) when primary anastomosis is performed, or 44125 (small bowel resection with enterostomy, 19.53 wRVU) when ostomy is created. For each additional resection/anastomosis at the same session, add +44121 (4.33 wRVU, add-on). Document extent of ischemia, residual bowel length, and anastomosis vs. ostomy decision.
  • Second-look laparotomy: if planned at the first operation for borderline bowel viability, use modifier -58 (planned staged procedure in postoperative period). Modifier -78 is for unplanned return to the OR for a complication of the primary procedure — do not use -78 for a preemptively planned second-look.
  • Laparoscopic Ladd's procedure: there is no specific CPT code for laparoscopic Ladd's. The correct code is 44238 (unlisted laparoscopy procedure, intestine except rectum), with an operative note cross-referencing 44055 to establish the fee benchmark. Document port placement and full extent of band division and mesenteric widening.

General coding reference. Verify with your institution’s billing department before submitting claims.

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