malrotation of the midgut is an abnormality in embryological development of gastrointestinal tract . by the fourth intrauterine week the gastrointestinal tract is in the form of an endoderm lined tube divided into fore , mid- and hindgut . mid- and hindgut defined by their blood supply the superior and inferior mesenteric arteries respectively . by the fifth week of life the midgut begins a process of rapid enlargement , physiological herniation and rotation . with rapid expansion of liver and kidneys , expansion of the midgut intestinal loop can not be contained within the abdominal cavity ; this results in temporary physiological midgut herniation through the umbilical cord with superior mesenteric artery forming the axis . this process forms  c  of the duodenum and places it behind the superior mesenteric vessels . hernial reduction occurs by week 10 with the jejunum reducing first and lying to the left and subsequent distal portions lying progressively to the right . the ceacum descends from position in the right upper quadrant forming the descending colon with its mesentery gradually disappearing . a 17-year - old male was seen in the emergency department with 10-year history of abdominal colic which is relieved by vomiting , along with dehydration . there was no history of jaundice , fever , steatorrhea , or bleeding per rectum . the patient had been treated with proton pump inhibitors , prokinetic agents by general practitioners , without any relief . his ultrasound examination and standing x - ray of abdomen physical examination was normal except minimal abdominal tenderness in epigastric , right hypochondriac region along with mild dehydration . his liver function tests , renal function tests , amylase , hemogram , and urinalysis were normal . duodenum appeared connected to small intestine seen on right side giving a whirlpool appearance due to rotation of gut around the superior mesenteric artery . superior mesenteric vein was seen on left of superior mesenteric artery [ figures 1a and b ] . stomach and duodenum appear connected to small intestine seen on the right side giving a whirlpool appearance due to rotation of gut around the superior mesenteric artery . superior mesenteric vein is seen on the left of superior mesenteric artery surgical referral was made ; he was treated with four - port laparoscopic ladd 's procedure . the peritoneum to the right of the ascending colon and caecum was incised and the anteriorly situated bands were stripped to free the duodenum . he was discharged within 2 days eating a normal diet and made a good postoperative recovery . at 3 months he was gaining weight and had no further vomiting . midgut mal and nonrotation refers to failure in counter clockwise rotation of the midgut which results in misplacement of the duodeno jejunal junction to the right of the midline ; in addition the small bowel mesentery has narrow vertical posterior attachment which is prone to volvulus . other anatomical abnormalities include peritoneal ( ladd 's ) bands running from the right colon to the lateral abdominal wall and an extensively mobile ceacum that fails to descend . acute presentation is with volvulus of midgut or ileoceacum occurring most frequently in neonate with likelihood decreasing with age . in most of the reported cases of this presentation , patients present with bilious vomiting in the first month of life because of duodenal obstruction or a volvulus . pathophysiology of these chronic symptoms may relate to the compressive effects of peritoneal bands running from ceacum and ascending colon to the right lateral wall . the short mesentery allows the small bowel to twist around the narrowed sma pedicle to create a distinctive  whirlpool  appearance . surgical management of intestinal malrotation was first described by ladd in 1936 and remains mainstay of management today . it involves reduction of vovulus if present , division of abnormal peritoneal bands ( duodeno colic , dodenojejunal - ileocolic ) , and placement of the small bowel to the right of the abdomen and ceacum to the left . increasingly laparoscopic ladd 's procedures are being performed and have been shown to be effective where there is no acute volvulus.[79 ] this minimally invasive approach allows for earlier oral intake and discharge from hospital .