Robotic-assisted laparoscopic Ladd's procedure placing the ports along the Pfannenstiel line: A case report

The application of robotic-assisted surgery to Ladd’s procedure in children has expanded in recent years, raising technical considerations regarding patient positioning and trocar placement. A 5-year-old boy with a history of intermittent abdominal pain presented with acute symptoms; imaging revealed intestinal malrotation with a high-positioned cecum, inversion of the mesenteric vessels, and a shortened mesenteric base. A robotic-assisted Ladd’s procedure was performed: an 8mm trocar was placed at the umbilicus, while three additional 8mm trocars were inserted through suprapubic incisions along the Pfannenstiel line - one to the left of the midline, one at the midline, and one to the right. The central suprapubic trocar was used as the camera port, the lateral trocars served as robotic working arms, and the umbilical port was used as an accessory trocar. Intraoperatively, Ladd’s bands were divided using monopolar curved scissors. The mesenteric root was broadened with the aid of the instrument. After the gastrocolic ligament was sectioned using a vessel sealer, the cecum was transferred to the left iliac fossa to complete the repositioning. The presented technique offered excellent exposure of the entire mesenteric root and optimal visualization of both upper and lower quadrants without the need for redocking. No appendectomy was performed at the surgeon’s discretion, as current guidelines do not mandate it and available evidence does not demonstrate a benefit from its routine removal. There were no intraoperative complications. Operative time was 120 minutes, with a docking time of 22 minutes. A nasogastric tube was left in place for the first 24 hours. Enteral feeding was resumed progressively, and the patient was discharged on postoperative day 3. Follow-up at one year was unremarkable. Robotic-assisted laparoscopic Ladd’s procedure placing the ports along the Pfannenstiel line seems to be a safe and effective approach for the elective management of intestinal malrotation in children.