Case report

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For citation purposes: Nayak SB, George BM, Mishra S, Ashwini LS, Marpalli S. Omento-cystic peritoneal fold and rudimentary quadrate lobe: a case report. OA Case Reports 2013 Jun 21;2(5):46.

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Omento-cystic peritoneal fold and rudimentary quadrate lobe: a case report

SB Nayak*, BM George, S Mishra, LS Ashwini, S Marpalli

and also the spread of the diseases. Abnormal folds connecting the gall-bladder to the neighbouring viscera are very rare. They may result in reducing the size and functioning of the gallbladder1,2. Variation in the liver such as presence of additional lobes, sulci or hypoplasia of any part of the liver has been reported. We report here, the presence of an abnor-mal peritoneal fold attached to the gallbladder and an associated varia-tion of the quadrate lobe of the liver. Awareness of this variation might reduce the radiological diagnostic errors and minimise the confusions during laparoscopic cholecystectomy.

Case reportDuring routine dissection classes for medical undergraduates, we noted an abnormal peritoneal fold (omento-cystic fold) extending from the right end of the greater omentum

AbstractIntroductionAbnormal peritoneal folds are often found in the abdomen. They may cause serious problems like obstruc-tion of the intestine. This report dis-cusses a case of an omento-cystic peritoneal fold in a male cadaver. Case reportWe report an omento-cystic peri-toneal fold seen in an adult male cadaver. The fold extended upwards from the right end of the greater omentum to the gallbladder. It enclosed the gallbladder completely. The gallbladder was slightly larger than its normal size. The quadrate lobe was rudimentary and was rep-resented as a small bar of hepatic tissue between the gallbladder and the fissure for ligamentum teres. ConclusionThe knowledge of this variation may be of importance during radiological diagnosis, liver transplant surgery and laparoscopic cholecystectomy.

IntroductionPeritoneum is the largest among the serous membranes in the body and is most complexly arranged com-pared to any other such membranes. It forms folds called omenta, mesen-teries and ligaments to support the viscera, allow their movements and to carry blood vessels to them. Most of the peritoneal folds are derived from the embryonic mesenteries. They determine the direction of the flow of fluids in the peritoneal cavity

*Corresponding authorEmail: nayaksathish@gmail.com

Melaka Manipal Medical College (Manipal Campus), Manipal University, Karnataka, India

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Figure 1: Abdominal viscera covered by the greater omentum. Note the omento-cystic fold (OCF) of peritoneum extending from the greater omentum to the gallbladder. Right lobe of the liver (RLL) can also be seen.

to the gallbladder. Viewed from the anterior side, it appeared to be tri-angular (Figures 1 and 2); but as it approached the gallbladder, it totally enclosed the gallbladder within it. The fold did not carry any observable blood vessels. The gallbladder was slightly larger than its normal size and was 9 cm long and 4 cm broad. The quadrate lobe was rudimentary. It was represented as a narrow bar of liver tissue between the gallbladder and the fissure for ligamentum teres (Figure 3). These variations were found in an adult male cadaver aged 65 years, approximately.

DiscussionThe development of an abnormal peritoneal fold such as the omento-cystic fold is a complex embryonic event. Usually, during the develop-ment of the mesenteries, the cranial part of the ventral mesogastrium

Case report

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For citation purposes: Nayak SB, George BM, Mishra S, Ashwini LS, Marpalli S. Omento-cystic peritoneal fold and rudimentary quadrate lobe: a case report. OA Case Reports 2013 Jun 21;2(5):46.

greater omentum is a derivative of the dorsal mesogastrium, the fold is probably a derivative of the dorsal mesogastrium. Explanation of such a fold is lacking in the literature. Abnormal peritoneal folds might result in intestinal obstruction. There is a report on such a fold which pro-duced a constriction on the duode-nal wall4. Abnormal peritoneal folds connecting the greater omentum with the falciform ligament of the liver5 and jejunum to the root of the mesentery6 have also been reported. In the present case the gallblad-der was situated in the gallbladder fossa, but there are reports on float-ing gallbladders with mesenteries. In one of the studies performed on 27 patients, there were 13 lumbar, nine pelvic and five iliac gallbladders, with poor function in 20 of them7. When gallbladder floats in a mesen-tery or any abnormal fold like the one being reported here, there is a high chance of volvulus formation8.

Abnormality in lobes and fis-sures of liver has been reported9–11. Absence of lobes or presence of additional lobes might result in clinical misdiagnosis and errors in surgery. It is extremely rare to have a total absence of any lobe of the liver. Recently, a case of total absence of quadrate lobe has been reported12.

ConclusionThe present case is unique in having an omento-cystic fold and almost total absence of the quadrate lobe. Awareness of these variations may be of importance to the radiologists and surgeons to minimise the errors in radiologic diagnosis and to pre-vent iatrogenic injuries during liver transplant surgery and laparoscopic cholecystography.

References1. Pamidi N, Nayak S, Vollala VR. Cysto-gastrocolic fold and associated atrophy of the gallbladder. Singapore Med J. 2008 Sep;49(9):e250–1.

Figure 2: A closer view of the omento-cystic fold (OCF). Note the posterior part of the fold enclosing the gallbladder (RLL, right lobe of the liver).

Figure 3: Gallbladder exposed after the removal of the omento-cystic fold (RLL, right lobe of the liver; LLL, left lobe of the liver; QL, rudimentary quad-rate lobe of the liver; LT, ligamentum teres).

gets divided by the developing liver to form the lesser omentum and the falciform ligament and its cau-dal part degenerates. The dorsal mesogastrium gets divided into gas-trophrenic ligament, gastrosplenic ligament, lieno-renal ligament and

the greater omentum3. Rarely the caudal part of the ventral mesogas-trium fails to degenerate and persists as cystogastrocolic ligament1. In the present case, the omento-cystic fold extended from the greater omen-tum to the gallbladder. Since the

Case report

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Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

Com

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For citation purposes: Nayak SB, George BM, Mishra S, Ashwini LS, Marpalli S. Omento-cystic peritoneal fold and rudimentary quadrate lobe: a case report. OA Case Reports 2013 Jun 21;2(5):46.

2. Nayak SB. Abnormal peritoneal fold connecting the greater omentum with the liver, gallbladder, right kidney and lesser omentum. Bratisl Lek Listy. 2009 Aug;110(11):736–7.3. Moore KL, Persaud TVN. The develop-ing human – clincially oriented embry-ology. 7th ed. Philadelphia: Saunders; 2003.p256–75.4. Low VH, Davis SJ, Yoong MF. Anoma-lous peritoneal folds of the duodenum – a normal variant simulating disease. Australas Radiol. 1992 May;36(2):135–6.5. Colak T, Dalçik C, Ozbek A, Filiz S, Sahin M, Dalçik H. A rare multiple variation of the greater omentum.

Okajimas Folia Anat Jpn. 2002 Dec;79(5): 159–62.6. Liu C, Wu TC, Tsai HL, Chin T, Wei C. Obstruction of the proximal jejunum by an anomalous congenital band - a case report. J Pediatr Surg. 2005 Mar;40(3):E27–9.7. Tzardinoglou E, Prousalidis J, Apos-tolidis S, Katsohis C, Aletras H. Hang-ing noncalculous gallbladder. HPB Surg. 1996;9(3):137–9.8. Shaikh AA, Charles A, Domingo S, Schaub G. Gallbladder volvulus: report of two original cases and review of the literature. Am Surg. 2005 Jan;71(1):87–9.9. Joshi SD, Joshi SS, Athavale SA. Some interesting observations on the surface

features of the liver and their clinical implications. Singapore Med J. 2009 Jul;50(7):715–9.10. Fitzgerald R, Hale M, Williams CR. Case report: accessory lobe of the liver mimicking lesser omental lymphadenopa-thy. Br J Radiol. 1993 Sep;66(789):839–41.11. Llorente J, Dardik H. Symptomatic accessory lobe of the liver associated with absence of the left lobe. Arch Surg. 1971 Mar;102(3):221–3.12. Nayak SB, Mishra S, George BM, Shetty SD, Kumar N, Guru A, et al. A pecu-liar liver with surgically and radiologi-cally important variations: a case report. Anat Cell Biol. 2013 Mar;46(1):82–4.