A laparotomy is performed through a right transverse incision
above the level of the umbilicus. Viscera are gently
exteriorized and examined. Because of the volvulus, the
colon (which now lies posteriorly) is obscured by the small
bowel loops. While maintaining the intestinal loops moist
and warm, the volvulus is untwisted by turning the intestinal
mass in a counter-clockwise fashion. The torsion may be
more than 360°, and the intestinal mass must be gently and
methodically untwisted until the colon comes into view. This
should release vascular constriction and allow the ischemia
to improve. In reality, a midgut volvulus is often confusing at
first and care must be taken not to cause additional bowel
damage during detorsion. In some patients, further confusion
may be caused by the presence of situs ambiguus or situs
inversus, whereby the stomach may be on the right and the
liver midline or on the left. In these cases, the duodenum
may be on the left and the colon on the right.