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Pancreatic Ligaments: a Case of Two Unusual Inhabitants of the Omental Bursa and Their Clinical Implications

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Pancreatic Ligaments: a Case of Two Unusual Inhabitants of the Omental Bursa and Their Clinical Implications CASE REPORT Anatomy Journal of Africa. 2015. Vol 4 (1): 440 - 443 GASTRO-PANCREATIC AND GASTRO-DUODENO- PANCREATIC LIGAMENTS: A CASE OF TWO UNUSUAL INHABITANTS OF THE OMENTAL BURSA AND THEIR CLINICAL IMPLICATIONS *Ashaolu J.O.¹, Abimbola O.O.1, Ukwenya V.O2 1. Department of Anatomy, Faculty of Basic Medical sciences, Bowen University, Iwo, Osun State, Nigeria. 2. Department of Anatomy, Faculty of Basic Medical sciences, Ekiti State University, Ekiti State , Nigeria. *Corresponding Author to Ashaolu, James Olumide Department of Anatomy, Faculty of Basic Medical sciences, Bowen University, Iwo, Osun State, Nigeria. [email protected]+234-8137609462 ABSTRACT This paper reports a cadaveric case of two unusual peritoneal structures; namely, the gastro-pancreatic and gastro-duodeno-pancreatic ligaments. The gastropancreatic ligament is a broad peritoneal structure that holds the stomach and the pancreas together and has occasionally been reported while gastro-duodeno-pancreatic ligament is our new finding. It attaches the stomach, duodenum and the pancreas. The existence of these ligaments may create clinical conditions such as internal herniation or viscera kinking and they limit the movement easing function of the omenta bursa. It is important that such anatomical variations be brought to the knowledge of anatomists, surgeons and radiologists. Key words: gastro-pancreatic ligament, gastro-duodeno-pancreatic ligament, omenta bursa, peritoneum, variation, omental foramen, cystoduodenal ligament INTRODUCTION Usually there is no formation of Previous reports suggest that the GP ligamentous structures within the omenta ligament connects the stomach to the bursa but if they exist, their presence pancreas and lying within the omenta could hinder the movement easing bursa. Crymble first reported the function of the stomach, increase gastropancreatic ligament in 1913, tendencies of intestinal herniation and Erenbourg and Reggiani (1985) and volvulous. Peritoneal variant folds are Tsutsui et al. (1995) later reported on the most commonly reported around the same. To the best of our knowledge, no supracolic compartment of peritoneal existing literature has documented the cavity and they occasionally include occurrence of GDP ligament, which we cystocolic ligaments, cystogastrocolic currently report alongside the GP ligament, cystoduodenal ligament, jejunal ligament. congenital band, gastro-pancreatic ligament or anomalous fold joining the We report a case of combined occurrence greater omentum to liver, gall bladder, of the gastro-pancreatic (GP) and gastro- lesser omentum and kidney (Ashaolu et duodeno-pancreatic ligaments (GDP). al., 2011; Pamidi et al., 2008; Satheesa et al., 2009; Williams et al.,1995). CASE REPORT Aberrant peritoneal ligaments- the gastro- during routine supervision of Medical pancreatic (GP) and gastro-duodeno- students’ dissection in the Anatomy pancreatic ligaments (GDP)-were found in Department of the College of Health the abdominal region of a male cadaver Sciences, Bowen University, Iwo, Osun 440 Anatomy Journal of Africa. 2015. Vol 4 (1): 440 - 443 State, Nigeria. Following the removal of A large foramen was found between the the greater omentum. which suspended right and left part of the GP ligament, that on the greater curvature of the stomach. we herein name as post-omental foramen. The stomach was turned upwards to The right part attaches the body of reveal the omental bursa. We found these pancreas to the lesser curvature and unusual ligaments. The gastro-duodeno- contains diverging branching form left and pancreatic ligament was connecting the right gastric vessels and some fatty tissue. inferior aspect of the pylorus of the The left part of the GP ligament attaches stomach, inferior aspect of superior part the tail of pancreas to the greater of duodenum and medial aspect of the curvature of stomach and contains the left descending part of duodenum, and gastro-omental vessels. The inferior part distally, the superior part of head and of the GP ligament contains the splenic body of pancreas. artery. The GDP ligament possesses a thicker An inter-ligamental pouch was found medial border and a thinner lateral aspect. between the GDP and GP ligaments. A To the right of the ligament, the GP probe inserted through the omental ligament was found. The GP ligament is a foramen from the right was only visible relatively wider structure attaching the behind the post-omental foramen. GDP stomach to the pancreas. Meanwhile, we and GP ligaments divided the omental found the right gastro-omental vessel and bursa into a superficial part and a deep portal triad structures: inferior part of part. These ligaments were made up of portal vein, common bile duct and two layers that are continuous with the gastroduodenal artery in the GDP visceral peritoneum of neighboring ligament. structures and this infers that aberrant ligaments are not mere peritoneal adhesions. Figure 1. Photograph and illustions showing upwardly reflected stomach and the anterior aspect of the omental bursa. GP- gastro-pancreatic ligament, GDP-gastro-duodeno-pancreatic ligament, ST- stomach, D- duodenum, P- Pancreas, GO- greater omentum, TC –transverse colon, PR-probe, H-hand, Red star- post-omental foramen, B-blood vessel, Blue arrow- inter-ligamental pouch, F-Force 441 Anatomy Journal of Africa. 2015. Vol 4 (1): 440 - 443 DISCUSSION The GP and GDP, attach the duodenum stomach and duodenum or in their and posterior aspect of the stomach volvulus formation. Low et al., (1992) (about the lesser curvature) to the reported an anomalous fold that caused a pancreas in the posterior abdominal wall constriction of the wall of the duodenum, and they could delimit the movement- notable radiologically. A case of easing function of the omenta bursa. obstruction of the proximal part of the Nonetheless, the post-omental foramen jejunum by a congenital band has also and the inter-ligamental pouch contained been reported (Liu, 2005). The two in and around these variant ligaments aberrant ligamental structures are made render the omental bursa as a susceptible up of two layers that are continuous with region for internal herniation. Herniation the visceral peritoneum of neighboring of abdominal viscera into omental bursa structures and this infers that aberrant could occur through the omental foramen ligaments are not mere peritoneal or deficiencies in the greater omentum adhesions. while a more difficult clinical condition may arise when such hernia progress into The pancreas develops from two either the inter-ligamental pouch or the evaginations of the foregut- dorsal and post-omental foramen. ventral pancreatic buds, which fuse to form a single organ (Williams et al., Tsutsui et al., (1995), in their clinical case, 1995). The dorsal pancreatic bud develops reported the entrapment of intestinal within the dorsal mesogastrium while the structures in the hole that exist around ventral pancreatic bud develops in the the gastropancreatic ligament and they ventral mesogastrium (Williams et al., performed surgical resection that 1995). The dorsal pancreatic duct ameliorated the pre-operative symptoms develops as a thickening of the experienced by their patient. Since the endodermal tube while the ventral occurrence of the GP ligament could cause pancreatic bud evaginates in close a clinical condition, requiring surgical proximity to the liver primordium as an operation, it becomes imperative for evagination of the bile duct itself. abdominal surgeons to understand the Differential growth of the wall of the vascularization of the structures. The left duodenum results in movement of the and right gastro-omental vessels were ventral pancreatic bud and bile duct to the found in the GP and GDP respectively. The right side and ultimately to the dorsal branches of left and right gastric vessels position (Williams et al., 1995). The were also found in the superior aspect of ventral pancreatic duct and the bile duct GP ligament, the splenic artery also run in rotate from a position within the ventral the inferior aspect of the GP ligament. mesogastrium to one in the dorsal Portal triad is mainly contained within the mesogastrium, which is destined to hepatoduodenal ligament but in this case become fixed unto the posterior the inferior aspect of portal triad is abdominal wall (Williams et al., 1995). contained in the GDP ligament. These are The ligament joining the pancreas and structures of significant clinical implication, duodenum commonly obliterates (Williams an iatrogenic damage to the portal triad et al., 1995). The GP ligament might be a structures may cause necrosis to the persistence of part of mesogastrium duodenum, affect bile passage into the attaching the pancreas to the stomach in duodenum and damage to the portal vein. development. The GDP ligament might have been formed as a remnant of the These aberrant ligaments could also be ventral mesogastrium carried from the involved in kinking of pyloric part of ventral region to the dorsal right region 442 Anatomy Journal of Africa. 2015. Vol 4 (1): 440 - 443 especially since it contains the portal triad. will only end in the bursa omenti The GP ligament and GDP ligament might profundus. The inter-ligamental pouch also have been formed from unusual might also accumulate peritoneal fluid in folding of the greater omentum attaching inflammatory conditions. to the pancreas. Moreover, these folds may cause difficulty Furthermore, the two ligaments separate in diagnosis around the pancreas, the omental bursa into two potential
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