intestinal malrotation is a congenital abnormal position of the bowel within the peritoneal cavity . in cases of midgut volvulus , it is critical to make a diagnosis and to intervene immediately to avoid the potentially life - threatening consequence of intestinal necrosis , which in severe cases may lead to short bowel syndrome . there is currently no gold standard for treatment of massive intestinal necrosis detected at laparotomy . in cases of midgut volvulus with extensive areas of bowel ischemia that did not recover after derotation , a second - look operation can be attempted to identify viable intestine ; however , the basis for predicting intestinal viability has yet to be described , and viability is difficult to define . we report a case of neonatal malrotation with midgut volvulus in which necrotic , not ischemic , bowel was preserved in second - look laparotomy . the preserved intestine , which appeared to be non - viable but had a moderate blood supply , was pathologically shown as full - thickness small bowel necrosis , distributed in a patchy fashion . fortunately , the preserved necrotic intestine was able to regenerate ; the patient survived and performs normal daily activities . we discuss issues regarding the management of non - viable small bowel with midgut volvulus . a baby boy was born at term , weighing 3136 g. he did well for the first ten days of life ; feeding was begun at 8 hours of age , and was well tolerated . he vomited several times on the tenth day , presenting the next day with persistent bilious vomiting at the emergency room of the municipal hospital . he was immediately intubated and resuscitated for pre - shock status , with initial laboratory findings of profound dehydration and marked metabolic acidosis ( ph 6.879 , be 25.8 ) . abdominal ultrasonography and computed tomography suggested midgut volvulus with ischemic bowel . at emergent laparotomy ( fig . 1a ) , a 630 clockwise volvulus of the midgut was found with an extensive area of ischemic and dusky - black bowel from the duodenum to the transverse colon . after derotation and ladd procedure , ischemic bowel between the distal part of the duodenum and the jejunum showed no improvement and was resected . the distal 75 cm of the terminal ileum , which was considered to have questionable recovery of blood flow , was preserved in the hope of regenerating viable intestine . the duodenostomy was completely necrotized but the proximal portion had maintained blood flow , and was divided , lying as a blind end in the sub - hepatic position . blood flow in the bowel between the ileum and transverse colon was markedly improved ; however , the ileum had many necrotic areas , identifiable as paper - thin intestine , distributed in a patchy and circumferential manner ( fig . a portion of paper - thin ileum was resected circumferentially by approximately 3 cm in width as specimen or intraoperative rapid histological diagnosis in order to determine the appropriate surgical plan . the distribution of these apparently non - viable and necrotic areas with a moderate blood supply was so widespread that we could not resect any other part of the intestine , and made the decision to wait and see . the resected ileum was anastomosed in an end - to - end manner and ileostomy was performed . after the second operation , ileostomy appeared viable and the patient s general condition had improved . aspirated gastric and bile juice to which was added a large amount of l - glutamine was administered through the ileostomy to the residual ileum and colon to confer mucosal immunity and reformation . contrast study of the gastrointestinal tract through the ileostomy on pod 25 showed poor peristalsis and varying ileal caliber . a small quantity of milk was then introduced through the ileostomy in addition to transparenteral nutrition ( tpn ) ; however , his body weight did not increase successfully . on pod 43 , closure of the ileostomy pathological study showed that the appearance of the ileal mucosa had returned to normal , although the muscle layers were damaged locally . on the fourth day after closure , oral intake and probiotics were started in addition to tpn ; there were no problems with the nutrient intake and the patient s body weight increased . he was discharged from the hospital at 3 months of age , weighing 4626 g and tolerating oral feeding . the survival rate of children with malrotation due to midgut volvulus is greater than 80% ; however , high mortality is still observed in patients with extensive necrotic bowel due to malrotation . the high mortality is due to the conventional management of patients with significant non - viable bowel by extensive resection , which may lead to life - threatening short bowel syndrome . extensive resection of the bowel remains a highly morbid condition , and has poor short- and long - term survival . our operational goal is to derotate the midgut , perform revascularization , assess bowel viability , and resect necrotic bowel . a second - look operation has been suggested to define areas of nonviable intestine and to improve decision - making . second - look laparotomy may be justifiable on initial surgery findings that include extensive areas of ischemic bowel , ambiguous margins of demarcation between well - vascularized and necrotic bowel , questionable viability of the bowel , and poor blood supply to the remaining bowel . we experienced a case of catastrophic neonatal midgut volvulus that underwent a second - look laparotomy . the first assessment showed extensive ischemic bowel , with no further improvement after derotation and division of ladd s band . at second - look laparotomy , the remaining small bowel appeared to be non - viable but had a moderate blood supply , and was pathologically shown to exhibit full - thickness small bowel necrosis with patchy distribution . resection of all of the necrotic intestine would have left very little remaining small bowel . the decision was made not to resect any intestine in the hope that the tissue would regenerate . we concluded that the bowel was non - viable and necrotic based on its paper - thin appearance . this diagnosis was confirmed by pathological examination ; however , the preserved intestine was able to regenerate , and normal function was restored over a period of 1 month . necrotic bowel with a patchy distribution may offer an ideal scaffold for intestinal regeneration if there is a sufficient blood supply . from this viewpoint , even when intestinal viability is questionable , preservation is worthwhile in the hope of regeneration , if there is sufficient blood flow . a previous report showed that extensive non - viable bowel recovered to some extent after withholding resection and waiting for normal function to return . non - viable intestine may recover with adequate blood flow and may change a fibrous band without lumen with the absence of blood flow . the preservation of seemingly non - viable intestine , however , represents a great challenge . ischemic reperfusion injury and necrotic change can induce severe systemic damage that can not always be regulated by intensive care and may even be fatal . there may be no gold standard for treating extensive necrotic bowel with midgut volvulus . preservation of involved bowel may offer a possible treatment method for catastrophic midgut volvulus in the case that the extensive areas of apparently non - viable intestine have moderate blood supply . now , we have no objective scientific criteria for judgment with regard to sufficient blood flow to recover from the necrotic bowel . we mainly decide whether the necrotic bowel is resected or not , dependent on the macroscopic or pathological appearance of it . many scientific data on the sufficient blood flow for regeneration of non - viable intestine need be accumulated . even when intestinal viability is questionable , preservation enables the chance of regeneration if there is macroscopic sufficient blood flow . schematic images for the operative procedures .   a  the first operative procedure .   b  the second - look operative procedure .   c  the third operative procedure . the appearance of the bowel is markedly improved compared with that after the first operation , suggesting a sufficient blood supply . the intestine is paper - thin and distributed in a patchy and circumferential manner ( arrows ) , appearing necrotic and non - viable . pathological findings of the paper - thin intestine ( h / e stain ) at second laparotomy showing full - thickness necrosis with hemorrhage .