Cystoduodenal ligament as an abnormal fold and the accompanying anatomical and clinical implications

Complete enclosure of gall bladder inside the lesser omentum - a rare anomaly

Gall bladder is known for many congenital anomalies such as duplication, intrahepatic position, floating position etc. Most of its anomalies can be detected in ultrasound examination and radiography. We report an extremely rare congenital anomaly of gall bladder as observed in a male cadaver during dissection classes. The gall bladder was totally enclosed in the right free margin of the lesser omentum, in front of the usual contents of the right free margin of lesser omentum. The size, shape and blood supply of the gall bladder were normal. Though this anomaly might not cause any functional disturbances, it might result in complications during laparoscopic cholecystectomy.

Cysto-duodeno-colic ligament and its clinical relevance

During a routine dissection class for the undergraduate students at All India Institute of Medical Sciences, New Delhi, a rare uncommon variation of the peritoneal ligament was found. Information regarding variation in such type of accessory peritoneal reflections is necessary for anatomists, surgeons, and radiologists. Normally there was no peritoneal reflection between gallbladder, duodenum and transverse colon, but in the present case report, it was present and termed as cysto-duodeno-colic ligament. Knowledge of such variation is necessary during gallbladder surgeries and liver transplantation surgeries.

The Prevalence and Classification of the Cystoduodenal Ligament

Variant patterns of peritoneal folds could be formed due to the complex nature of the embryology of the peritoneum and the gastrointestinal tract. When uncommon peritoneal folds are formed, they could influence aberrant formation of surrounding gastrointestinal structures and create spaces that may harbour peritoneal fluids in cases of infection or malignant tumor. One of such variant peritoneal folds is the cystoduodenal ligament which is a doubled peritoneal membrane attaching the gallbladder to the duodenum. Yet no study was found that had reported the frequency of occurrence of the cystoduodenal ligament. The current study determined the prevalence of the cystoduodenal ligament in forty adult cadavers. The ligament was reported in 35% of cases. The ligament was further classified as types I and II. Type I cystoduodenal ligament was attached partially to the gallbladder (neck and proximal part of body) while type II was attached to the entire extent of the gallbladder. Type I occurrence was found in 44% and type II was found in 56% of the occasions of cystoduodenal ligament formation. It is concluded that the cystoduodenal ligament could be commonly found, it possesses important vascular structures, and it could affect the shape of the gallbladder. Surgeons, radiologists, and anatomists should be kept abreast of these findings.

Rare peritoneal bands and recesses: incidental findings in a cadaveric dissection

Variable arrangement of the visceral peritoneum would result in the formation of unexpected peritoneal bands and associated recesses. These could confound the unsuspecting clinician in both the diagnostic and therapeutic approach to the abdomen. It is thus imperative to be alert to the surprises the peritoneum may throw up and, however rare, abdominal conditions resulting from such aberrations must be kept in mind. Cadaveric dissection of an elderly female revealed a number of peritoneal anomalies. Apart from a cysto-duodenal extension of the lesser omentum, there was a bilaminar, avascular band passing from the inferior surface of the right lobe of liver to both the duodenum and the transverse colon. This anomalous band lay posterior to and distinct from the lesser omentum. The epiploic foramen was thus delimited by two unconventional folds. Further, the distal half of the transverse mesocolon failed to reach the posterior abdominal wall and instead formed an arched continuity with an aberrant mesentery of descending colon. An unusual type of peri-caecal recess was also present.

Peritoneal Bands: A Review of Anatomical Distribution and Clinical Implications

The complexity of embryological development of the gastrointestinal tract and mesentery provides a platform for the formation of a wide variety of variant veils, folds, and membranes, collectively termed peritoneal bands. These structures, which represent anatomically unabsorbed portions of the omentum and mesentery, although often benign, have the potential to cause clinically significant manifestations in both the neonate and adult. Although these deviant structures may be identified over a broad range of the abdominal cavity, they are most commonly identified in the regions of the duodenum, duodenojejunal flexure, ileocecal junction, and ascending colon. As a result of the diverse location of these variant structures, clinical manifestations are highly variable, ranging from acute presentations of intestinal necrosis as a result of strangulated midgut volvulus to chronic, vague abdominal pain. This article seeks to highlight the importance of a thorough anatomical understanding of the distribution of the various abnormal peritoneal folds, bands, and ligaments, which may result from aberrations in embryonic gastrointestinal development and their respective clinical implications. Moreover, to advance the knowledge of peritoneal bands, this article discusses the appropriate diagnostic studies and treatment interventions required for these variant structures.

Fetal intrahepatic gallbladder and topographical anatomy of the liver hilar region and hepatocystic triangle

The fetal gallbladder (GB) is embedded in a deep fossa surrounded by the liver parenchyma. Using 15 specimens with intrahepatic GB (crown-rump length 45-92 mm; approximately 9-13 weeks of gestation), we assessed the fetal topographical anatomy of the hepatocystic triangle and the porta hepatis. The cystic duct displayed a long upward course (0.9-4.5 mm along the supero-inferior axis) from the GB, along the duodenum, to the common bile duct in the hepatoduodenal ligament, via an independent mesentery separated from liver parenchyma by a recess of the peritoneal cavity. Notably, the course varied in length among specimens, not among stages. At the porta hepatis, we were able to distinguish the supraportal course of the posterior right hepatic duct overriding a portal vein branch to segment 8 (6/15) from the other, infraportal course (9/15). In the latter type, the portal vein bifurcation was superior to the cystic duct course. Two margins of the hepatocyctic triangle were very long in fetuses because of the inferiorly located intrahepatic GB. Thus, the triangle seems to be difficult to identify in prenatal ultrasound. During changes in location after 9 weeks, the GB fundus remains attached to the liver because the cystic artery was often embedded in the liver parenchyma. A failure in the embedding and re-exposure process of the GB may result in anomalous peritoneal folds around the GB.

Multiple abdominal peritoneal and intestinal variations and their accompanying clinical implications

Accessory peritoneal sac and cystoduodenal ligament as peritoneal variations were observed in a cadaver in our laboratory. Slender stomach, thin transverse colon, redundant sigmoid colon, absent ascending colon and doubly distended gall bladder were also reported in the same cadaver. Relevant anatomical and clinical implications are discussed.