Research code: 1403-2-4-31735
Ethics code: IR.IUMS.FMD.REC.1403.308
Clinical trials code: 0000000000
Iran University of Medical Sciences , hamidrezaasgari99@gmail.com
Abstract: (220 Views)
Abstract:
Introduction: The peritoneum, besides providing a protective covering for intraperitoneal organs, can form bands and ligaments that connect and support these organs. Occasionally, the peritoneal covering creates additional broader layers around certain visceral organs, which may lead to minor or major functional disorders. The lesser omentum is a crucial part of the peritoneal membrane in the abdominal cavity, positioned between the hilum of the liver, the lesser curvature of the stomach, and the first part of the duodenum. It consists of two peritoneal ligaments: the hepatogastric and hepatoduodenal ligaments.
On the right side of the hepatoduodenal ligament, the free edge of the lesser omentum is visible. Posterior to the free edge, lies the epiploic foramen (also known as Winslow foramen), which serves as a communication pathway to the lesser sac. Notably, the free edge of the lesser omentum contains key components of the hepatic pedicle, including the hepatic artery, portal vein, and common bile duct. In some cases, the lesser omentum extends laterally and connects to the right colic flexure via a peritoneal fold originating from the gallbladder to the superior aspect of the first portion of the duodenum. This fold is called the cystoduodenocolic ligament, which will be explained in this report.
Methodology: During the dissection of a 50-year-old male cadaver for medical student training at the Faculty of Medicine, Iran University of Medical Sciences, the presence of the cystoduodenocolic ligament was observed (Ethics code: IR.IUMS.FMD.REC.1403.308). The dissection was performed following Cunningham’s dissection manual of practical anatomy. The cadaver showed no signs of prior abdominal surgery, trauma, visceral adhesions or pathological conditions.
Findings: The cystoduodenocolic ligament was identified along the right (free) border of the lesser omentum, serving as a peritoneal ligament linking the liver and gallbladder to the duodenal bulb, the right colic flexure, and the proximal part of transverse colon.
Discussion & Conclusion: To better understand this ligament, the evolutionary development of the lesser omentum was examined. The lesser omentum, composed of the hepatogastric and hepatoduodenal ligaments, originates from the ventral mesogastrium during gut development. As the liver develops within the septum transversum, the portion of the septum between the liver and foregut forms the lesser omentum, while the portion between the liver and anterior abdominal wall forms the falciform ligament. Together, these structures establish the connection between the foregut and anterior abdominal wall, shaping the ventral mesogastrium.
During embryonic development, both the anterior and posterior mesogastrium facilitate the gut's attachment to the abdominal walls. Enlargement of the anterior mesogastrium between the duodenum, gallbladder, and colon contributes to the formation of the cystoduodenocolic ligament.
Embryologists suggest that this ligament originates from abnormal adhesions between the ventral and dorsal mesogastrium during primitive gut rotation. Adhesions formed during the gastric rightward rotation may obstruct the epiploic foramen, impairing the drainage of peritoneal inflammatory secretions from the lesser sac, which could be dangerous.
Studies indicate that this ligament may pose clinical complications. Gregory et al. reported instances of severe duodenal obstruction (in first and second part) leading to patient fatalities. Ashaola introduced a classification system for the cystoduodenocolic ligament and describes two types of this ligament.
Type I: The ligament incompletely attaches to the neck and proximal body of the gallbladder. This type may alter gallbladder morphology and impede its evacuation into the duodenum.
Type II: The ligament fully adheres to the entire body and neck of the gallbladder. This type forms strong attachments to the inferior surface of the liver, potentially obstructing bile flow into the gallbladder. Studies show that gallbladder walls are typically thickened when Type II ligament is present.
From a medical imaging perspective, radiologists have associated the presence of cystoduodenocolic ligament with the Phrygian cap sign, where a groove between the fundus and body of the gallbladder creates a hat-like appearance. This condition may result in improper biliary drainage, altering the gallbladder’s mucosal integrity.
From a surgical standpoint, the cystoduodenocolic ligament may obstruct access to the epiploic foramen, complicating procedures involving the hepatic vessels, portal vein and bile duct. The ligament’s presence can also thicken the gallbladder walls and in severe cases, contribute to intestinal torsion.
Given its surgical relevance, awareness of this ligament is critical. Understanding its anatomy enables surgeons to take necessary precautions when accessing the lesser sac cavity, choosing appropriate operative techniques. The ligament may also limit laparoscopic visibility during cholecystectomy, obstructing access to the cystic duct or cystic vessels, key components of Calot’s triangle.
Surgeons, surgical residents, and radiologists should be informed about this ligament to anticipate variations that may influence procedures related to gallbladder, biliary ducts, colon, and liver transplantation. Increased awareness can enhance preparedness for encountering this anatomical variation, allowing for rapid and effective solutions to patient complications.
Radiologists should also recognize the impact of this ligament on gallbladder imaging and highlight its presence in diagnostic reports.
In conclusion, from the authors' point of view given its potential clinical and surgical significance, greater awareness of the cystoduodenocolic ligament is essential for surgeons and radiologists, in addition to anatomists and we have found that, during investigation on of anatomical variations, given their origin and evolution, it can provide valuable insights to experts.
Introduction: The peritoneum, besides providing a protective covering for intraperitoneal organs, can form bands and ligaments that connect and support these organs. Occasionally, the peritoneal covering creates additional broader layers around certain visceral organs, which may lead to minor or major functional disorders. The lesser omentum is a crucial part of the peritoneal membrane in the abdominal cavity, positioned between the hilum of the liver, the lesser curvature of the stomach, and the first part of the duodenum. It consists of two peritoneal ligaments: the hepatogastric and hepatoduodenal ligaments.
On the right side of the hepatoduodenal ligament, the free edge of the lesser omentum is visible. Posterior to the free edge, lies the epiploic foramen (also known as Winslow foramen), which serves as a communication pathway to the lesser sac. Notably, the free edge of the lesser omentum contains key components of the hepatic pedicle, including the hepatic artery, portal vein, and common bile duct. In some cases, the lesser omentum extends laterally and connects to the right colic flexure via a peritoneal fold originating from the gallbladder to the superior aspect of the first portion of the duodenum. This fold is called the cystoduodenocolic ligament, which will be explained in this report.
Methodology: During the dissection of a 50-year-old male cadaver for medical student training at the Faculty of Medicine, Iran University of Medical Sciences, the presence of the cystoduodenocolic ligament was observed (Ethics code: IR.IUMS.FMD.REC.1403.308). The dissection was performed following Cunningham’s dissection manual of practical anatomy. The cadaver showed no signs of prior abdominal surgery, trauma, visceral adhesions or pathological conditions.
Findings: The cystoduodenocolic ligament was identified along the right (free) border of the lesser omentum, serving as a peritoneal ligament linking the liver and gallbladder to the duodenal bulb, the right colic flexure, and the proximal part of transverse colon.
Discussion & Conclusion: To better understand this ligament, the evolutionary development of the lesser omentum was examined. The lesser omentum, composed of the hepatogastric and hepatoduodenal ligaments, originates from the ventral mesogastrium during gut development. As the liver develops within the septum transversum, the portion of the septum between the liver and foregut forms the lesser omentum, while the portion between the liver and anterior abdominal wall forms the falciform ligament. Together, these structures establish the connection between the foregut and anterior abdominal wall, shaping the ventral mesogastrium.
During embryonic development, both the anterior and posterior mesogastrium facilitate the gut's attachment to the abdominal walls. Enlargement of the anterior mesogastrium between the duodenum, gallbladder, and colon contributes to the formation of the cystoduodenocolic ligament.
Embryologists suggest that this ligament originates from abnormal adhesions between the ventral and dorsal mesogastrium during primitive gut rotation. Adhesions formed during the gastric rightward rotation may obstruct the epiploic foramen, impairing the drainage of peritoneal inflammatory secretions from the lesser sac, which could be dangerous.
Studies indicate that this ligament may pose clinical complications. Gregory et al. reported instances of severe duodenal obstruction (in first and second part) leading to patient fatalities. Ashaola introduced a classification system for the cystoduodenocolic ligament and describes two types of this ligament.
Type I: The ligament incompletely attaches to the neck and proximal body of the gallbladder. This type may alter gallbladder morphology and impede its evacuation into the duodenum.
Type II: The ligament fully adheres to the entire body and neck of the gallbladder. This type forms strong attachments to the inferior surface of the liver, potentially obstructing bile flow into the gallbladder. Studies show that gallbladder walls are typically thickened when Type II ligament is present.
From a medical imaging perspective, radiologists have associated the presence of cystoduodenocolic ligament with the Phrygian cap sign, where a groove between the fundus and body of the gallbladder creates a hat-like appearance. This condition may result in improper biliary drainage, altering the gallbladder’s mucosal integrity.
From a surgical standpoint, the cystoduodenocolic ligament may obstruct access to the epiploic foramen, complicating procedures involving the hepatic vessels, portal vein and bile duct. The ligament’s presence can also thicken the gallbladder walls and in severe cases, contribute to intestinal torsion.
Given its surgical relevance, awareness of this ligament is critical. Understanding its anatomy enables surgeons to take necessary precautions when accessing the lesser sac cavity, choosing appropriate operative techniques. The ligament may also limit laparoscopic visibility during cholecystectomy, obstructing access to the cystic duct or cystic vessels, key components of Calot’s triangle.
Surgeons, surgical residents, and radiologists should be informed about this ligament to anticipate variations that may influence procedures related to gallbladder, biliary ducts, colon, and liver transplantation. Increased awareness can enhance preparedness for encountering this anatomical variation, allowing for rapid and effective solutions to patient complications.
Radiologists should also recognize the impact of this ligament on gallbladder imaging and highlight its presence in diagnostic reports.
In conclusion, from the authors' point of view given its potential clinical and surgical significance, greater awareness of the cystoduodenocolic ligament is essential for surgeons and radiologists, in addition to anatomists and we have found that, during investigation on of anatomical variations, given their origin and evolution, it can provide valuable insights to experts.
Type of Study: case report |
Subject:
Anatomy
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