There are two aspects to this disorder which require surgical intervention. The first and most important aspect is that of midgut volvulus. Any infant in whom malrotation is suspected based on clinical findings and radiological investigations should undergo laparotomy as a matter of urgency in order to minimize the risk of intestinal ischemia due to volvulus. At laparotomy blood-stained peritoneal fluid may indicate the presence of ischemic intestine. Any volvulus should be derotated (usually in the clockwise direction) and the intestine examined for viability. Non-viable bowel is resected and a primary anastomosis performed. If there is doubt about the viability of the remaining intestine a second-look laparotomy can be performed after 24 h.

In cases of malrotation not complicated by volvulus, the procedure of choice for most surgeons is the Ladd's procedure. This involves division of all adhesions or adhesive bands between the cecum, duodenum and parietal peritoneum, broadening of the mesenteric base around the superior mesen-teric artery and repositioning of the intestine within the abdominal cavity so that the duodenum is on the right and the cecum lies in the left upper quadrant. It has become customary to perform an appendectomy, owing to the difficulties of diagnosis, should appendicitis develop later in life.

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