|Year : 2022 | Volume
| Issue : 1 | Page : 60-63
Hepato-duodeno-colic fold and sessile sigmoid colon – Rare peritoneal bands in abdomen
V Dinesh Kumar1, R Rajprasath2, Magi Murugan3
1 Assistant Professor, Department of Anatomy, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Assistant Professor, Department of Anatomy, Pondicherry Institute of Medical Sciences, Puducherry, India
3 Professor, Department of Anatomy, Pondicherry Institute of Medical Sciences, Puducherry, India
|Date of Submission||30-Oct-2021|
|Date of Decision||06-Jan-2022|
|Date of Acceptance||12-Jan-2022|
|Date of Web Publication||01-Feb-2022|
V Dinesh Kumar
Assistant Professor, Department of Anatomy, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
Source of Support: None, Conflict of Interest: None
The presence of aberrant peritoneal folds is one of the differential diagnoses of intestinal obstruction in the pediatric population. Therefore, knowing the variations in the attachment pattern of peritoneum and its folds is essential. In this context, we report a rare peritoneal fold found during the routine human cadaveric dissection of the abdomen, which is attached superiorly to the liver including the gallbladder and inferiorly extended as a bilaminar fold with one attaching to duodenum and other to transverse colon. In addition, the sigmoid colon was completely plastered to the posterior pelvic wall. This variant peritoneal fold is named as hepato-duodeno-colic ligament and is described in detail with its clinical context. The knowledge regarding this abnormal peritoneal fold would be highly useful for surgeons while planning laparoscopic procedures in the upper quadrant of the abdomen.
Keywords: Cystoduodenal recess, peritoneal bands, redundant colon
|How to cite this article:|
Kumar V D, Rajprasath R, Murugan M. Hepato-duodeno-colic fold and sessile sigmoid colon – Rare peritoneal bands in abdomen. Natl J Clin Anat 2022;11:60-3
|How to cite this URL:|
Kumar V D, Rajprasath R, Murugan M. Hepato-duodeno-colic fold and sessile sigmoid colon – Rare peritoneal bands in abdomen. Natl J Clin Anat [serial online] 2022 [cited 2022 Jul 1];11:60-3. Available from: http://www.njca.info/text.asp?2022/11/1/60/337042
| Introduction|| |
While working upon the diagnosis of intestinal obstruction, especially in the pediatric population, it is often considered wise enough to consider aberrant peritoneal bands as one of the differential diagnoses. These congenital bands are signs of failed regression of embryologic structures, and it is not uncommon to encounter them during radiological evaluations and cadaveric demonstrations. When present, they make the intestinal structures vulnerable for kinking between the band and mesentery, leading to intestinal necrosis, or increase the propensity for internal herniation., By definition, a congenital band is intraperitoneal and mostly having de novo origin.
The developing gut is enclosed and suspended from the posterior body wall by double fold of serous membrane. On further development, the mesentery subdivides into dorsal and ventral mesogastrium. Liver primordium develops in the ventral mesogastrium dividing it into lesser omentum and falciform ligament. At the end of this dynamic process, embryonic forms of mesenteries, formed during intermediary stages, get obliterated. In primates, the adhesions and fusions of mesothelial layers normally take place in few organs and make them retroperitoneal. However, remnants of intermediary mesenteries in the aberrant locations of ventral mesogastrium give rise to congenital intraperitoneal bands extending between liver, stomach, and proximal portions of the duodenum. Similarly, the dorsal mesentery, which extends from pharynx to hindgut, gets altered so as to allow mobility of intestines. Persistence of dorsal mesentery might manifest as adhesion of segments of the colon to the pelvic wall.
Over here, we report a set of unique aberrations related to the peritoneum which we had witnessed in the same cadaver. One was a peritoneal band extending between gallbladder, liver, first part of duodenum, and transverse colon, while the other was the aberrant mesentery anchoring the sigmoid colon to the dorsal pelvic wall (sessile sigmoid colon).
| Case Report|| |
The observations were coincidentally made during routine educational dissection in an approximately 60-year-old formalin-preserved male cadaver in the gross anatomy laboratory. No significant medical history was available because of the unclaimed origin of the cadaver. There were no signs of scarring, pathological lesions, or trauma in the abdominal wall. When the supracolic compartment was dissected, we encountered a fat laden peritoneal fold extending from the inferior surface of the liver, up to the neck of gallbladder and to the right end of transverse colon [Figure 1]. The superior attachment of the bilaminar fold was at the inferior surface of the liver, to the right of segment IV, related to the fissure for ligamentum venosum, extending to porta hepatis and not attached to falciform ligament. There were no gross alterations in the structures traversing through porta hepatis. On meticulous exposure, we were able to visualize the cystoduodenal extension. The inferior attachment, at the first part of duodenum, was bilaminar. One lamina constituted the lesser omentum and other lamina extended to the right end of the transverse colon [Figure 2]. There were no significant alterations of structures in the free margin of lesser omentum, and there were no grossly aberrant vessels to the duodenum near the site of inferior band attachment. The colonic attachment of the band was related to the tinea omentalis, and there were no grossly aberrant vessels near it. The colonic attachment was distinct from the greater omentum, which was hanging superior to it. The attachment of ligament is described schematically in [Figure 3]. The band measured 5.2 cm in length and 1.6 cm in width. We were able to pass one gloved finger on the posterior aspect of the band which confirms the presence of cystoduodenal recess. The edge of the ligament constituted the posterior margin of epiploic foramen. No gross neurovascular constituents were noted in the band under simple examination. In addition to the above-mentioned anomalies, the sigmoid colon was sessile and completely plastered to the posterior pelvic wall up to the right sacroiliac joint. Further dissection of the abdominal cavity did not show any gross pathologies or anatomical variations.
|Figure 1: The attachment of ligament from liver to the right end of transverse colon|
Click here to view
|Figure 2: The bilaminar attachment of ligament to duodenum and transverse colon|
Click here to view
|Figure 3: Schematic description of attachment of hepato-duodeno-colic ligament|
Click here to view
| Discussion|| |
The congenital adhesion bands in the supracolic compartment are quite frequent and exist in approximately 35% of the population. Ashaolu et al. classified the peritoneal bands, which were variable in nature, into two types. Type 1 included cystoduodenal ligaments that were partially attached and type 2 included those that are completely attached to the gall bladder. Our case could not be included in the above-said classification because the superior attachment of the peritoneal band spanned beyond the fossa of gallbladder into the right lobe of liver and the inferior attachment, which was bilaminar, extended from the first part of duodenum to the right end of transverse colon. The contiguous bilaminar appearance of the band rules out the possibility of postinflammatory or pathologic adhesions. This case was similar to the rare peritoneal band observed by Sharma et al., who named it as hepato-duodeno-colic ligament. In the report documented by Deshmukh et al., the superior attachment of the ligament was only up to the gallbladder and hence was termed as cysto-duodeno-colic ligament.
German anatomists proposed a concept of “adhesion and fixation” whereby the cranial end of the ascending colon initially attaches to the ventral side of the duodenum. Similarly, greater omentum attaches to the ventral side of the transverse colon. According to this theory, mesothelium of visceral and parietal layers of the peritoneum remains intact during the phase of adhesion and later gets irreversibly fused. Applying this concept, we could presume that the persistence of these two peritoneal layers has resulted in the aberrant band between liver, duodenum, and transverse colon. On the other hand, studies based on molecular biology hypothesized three pathways for peritoneal adhesion formation: (a) imbalance between fibrin formation and degradation; (b) elevation of inflammatory moieties such as cytokines and transforming growth factor-β; and (c) localized tissue hypoxia leading to increased expression of vascular endothelial growth factor. While the first two pathways are more pertinent for the postinflammatory adhesions, the third pathway appear to be seemingly plausible for molecular origin of congenital peritoneal adhesions.
Yang et al. compared the clinical characteristics of 251 pediatric and adult cases presenting with small bowel obstruction due to congenital adhesion bands. They found that the manifestations could range from mild asymptomatic presentation to bowel strangulation and making a preoperative diagnosis is often serendipitous, after ruling out all differential diagnosis. Especially, pediatric population with anomalous congenital bands might even present with mild abdominal distension and failure to thrive. In one such case, laparoscopic resection and histological examination revealed that such bands are composed of loose connective tissue with interspersed mature blood vessels. Of the four types of congenital peritoneal adhesion bands, Ladd's band which extends from cecum to the right upper quadrant has the higher degree of clinical manifestation because of the duodenal obstruction. In such cases where the duodenal obstruction could either be due to band per se or the midgut volvulus associated with it, surgical de-rotation of volvulus along with resection of band and widening of mesentery has been shown extremely helpful.
The previous case reports, have documented the association between cystoduodenal ligaments and anomalies related to gut-mesentery formation such as absence/atretic colon segments and sessile sigmoid colon. In the present case report, the redundancy of sigmoid colon could thus be envisaged as an associated feature of the case spectrum. The pattern that we observed is similar to the pattern in pediatric age group, where the sigmoid colon is frequently redundant., Apart from this, the entire colon was apparently normal without any atretic segments. Hence, this could be considered as a resultant of minor fixation error during the development of hindgut and presumably congenital in origin.
| Conclusion|| |
This case report documents one of the rare forms of congenital adhesion band, hepato-duodeno-colic ligament, in the supracolic compartment along with sessile sigmoid mesocolon. Our cardinal aim is to share this information with surgeons, who might encounter this enigmatic structure during laparoscopic procedures and radiologists, who might get puzzled during the interpretation of abdominal scans. Furthermore, this band might cause aberrant pockets for accumulation of exudates and serve as sites of internal herniation. Congenital adhesion bands should also be kept as one of the differential diagnoses in children presenting with persistent abdominal pain, loss of weight, and impending signs of obstruction.
The author earnestly thank the individuals who gave their bodies to science so physical exploration could be performed. Results from such exploration might conceivably build humanity's generally information that can then work on tolerant consideration. Consequently, these givers and their families merit our most elevated appreciation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Festen C. Postoperative small bowel obstruction in infants and children. Ann Surg 1982;196:580-3.
Ashaolu JO, Ukwenya VO, Adenowo TK. Cystoduodenal ligament as an abnormal fold and the accompanying anatomical and clinical implications. Surg Radiol Anat 2011;33:171-4.
Ashaolu JO, Ukwenya VO, Opabunmi OA. Multiple abdominal peritoneal and intestinal variations and their accompanying clinical implications. Surg Radiol Anat 2012;34:377-80.
Akgür FM, Tanyel FC, Büyükpamukçu N, Hiçsönmez A. Anomalous congenital bands causing intestinal obstruction in children. J Pediatr Surg 1992;27:471-3.
Oelhafen K, Shayota BJ, Muhleman M, Klaassen Z, Shoja MM, Tubbs RS, et al
. Peritoneal bands: A review of anatomical distribution and clinical implications. Am Surg 2012;78:377-84.
Ashaolu JO, Olayinka J, Ukwenya VO. The prevalence and classification of the cystoduodenal ligament. Anat Res Int 2015;2015:742621.
Sharma NA, Sharma A, Garud RS. Rare peritoneal bands and recesses: Incidental findings in a cadaveric dissection. Surg Radiol Anat 2013;35:359-63.
Deshmukh VR, Singh S, Sehgal R. Cysto-duodeno-colic ligament and its clinical relevance. Biomed J 2016;39:414-6.
Hikspoors JP, Kruepunga N, Mommen GM, Peeters JP, Hülsman CJ, Eleonore Köhler S, et al
. The development of the dorsal mesentery in human embryos and fetuses. Semin Cell Dev Biol 2019;92:18-26.
Coccolini F, Ansaloni L, Manfredi R, Campanati L, Poiasina E, Bertoli P, et al
. Peritoneal adhesion index (PAI): Proposal of a score for the “ignored iceberg” of medicine and surgery. World J Emerg Surg 2013;8:6.
Yang KH, Lee TB, Lee SH, Kim SH, Cho YH, Kim HY. Congenital adhesion band causing small bowel obstruction: What's the difference in various age groups, pediatric and adult patients? BMC Surg 2016;16:79.
Etensel B, Ozkisacik S, Döger F, Yazici M, Gürsoy H. Anomalous congenital band: A rare cause of intestinal obstruction and failure to thrive. Pediatr Surg Int 2005;21:1018-20.
Saxena AK, Sodhi KS, Tirumani S, Mumtaz HA, Narasimha Rao KL, Khandelwal N. Position of a sigmoid colon in right iliac fossa in children: A retrospective study. J Indian Assoc Pediatr Surg 2011;16:93-6.
] [Full text]
Tan CK. Observations on some anomalies of the sigmoid colon. Singapore Med J 1972;13:146-50.
Iwanaga J, Singh V, Ohtsuka A, et al.Acknowledging the use of human cadaveric tissues in research papers: Recommendations from anatomical journal editors. Clin Anat 2021;34:2-4. Available from: https://doi.org/10.1002/ca.236714IWANAGAET AL
[Figure 1], [Figure 2], [Figure 3]