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Mr Awan and his colleagues (July 2004 JRSM1) report a case of malrotation in an adult. As they point out, this condition is much more often encountered in childhood. Paediatric surgeons would not agree that the operation done in this case, with an attempt to restore normal anatomy, was the correct one. The standard operative procedure is based on that described by Ladd 70 years ago—detorsion of the volvulus, division of adhesions, broadening of the small-bowel mesentery and positioning of the duodenum down the right side of the abdomen and the caecum into the left iliac fossa. There was a brief vogue in the 1960s for stabilization, as performed by Awan and colleagues, but this was never accepted by the paediatric surgical community; indeed a study by Shier et al.2 in 1987 confirmed that it has a higher morbidity than the Ladd procedure.
As non-paediatric surgeons dealing with an adult, we took a pragmatic approach to an emergency situation. Placing the caecum in the left iliac fossa was not an option, since it had been removed, and the intestines were placed in the position in which they lay most easily.