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Abdominal cocoon: precipitated by laparoscopic gas insufflation
Karingattil George Mathew1, Shakeel Akhtar2, Saajan Ignatius Pius3
1General Surgery, Emirates Hospital, Dubai, UAE mathkg@gmail.com.
Abstract:
A young male in his early 30s presented to us with increasing swelling at the umbilicus, and an umbilical hernia was diagnosed. At laparoscopic intraperitoneal onlay mesh (IPOM) repair, an unexpected finding of a thin innocuous-looking fibrous film over the small bowel was noted. This finding presented a dilemma as to the probable pathology of this material, and a decision had to be made on whether laparoscopic IPOM could be continued. It was prudently decided to abandon the plan of placing a mesh intraperitoneally and an open repair of the umbilical hernia was done. In retrospect this was a wise decision, as, after 7 months he had to have a laparotomy for intestinal obstruction, when the classic thick fibrous encapsulating abdominal cocoon was seen. Hence here we have followed the evolution of the abdominal cocoon from its original asymptomatic phase to the classic encapsulating sclerosing peritonitis with probably laparoscopic gas insufflation being the precipitating factor.
Insights
A rare abdominal cocoon, a cause of intestinal obstruction, was incidentally found during umbilical hernia repair. This case highlights the condition's evolution and potential link to laparoscopic procedures.
Area of Science:
- Gastroenterology
- Surgical Pathology
- Abdominal Imaging
Background:
- Abdominal cocoon is a rare condition characterized by a fibrous cocoon encasing the small bowel.
- It can lead to intestinal obstruction and is often diagnosed intraoperatively.
- The exact etiology remains unclear, but associations with tuberculosis and foreign body reactions have been suggested.
Purpose of the Study:
- To report a unique case of abdominal cocoon diagnosed incidentally during umbilical hernia repair.
- To discuss the diagnostic challenges and management decisions in such cases.
- To explore the potential role of laparoscopic insufflation as a precipitating factor.
Main Methods:
- Case presentation of a young male with umbilical hernia.
- Intraoperative findings during laparoscopic intraperitoneal onlay mesh (IPOM) repair.
- Subsequent open repair and long-term follow-up.
- Review of literature on abdominal cocoon and sclerosing peritonitis.
Main Results:
- An asymptomatic fibrous film over the small bowel was unexpectedly found during laparoscopic umbilical hernia repair.
- Laparoscopic IPOM was abandoned due to the uncertain nature of the finding.
- The patient later developed intestinal obstruction and was diagnosed with a classic abdominal cocoon.
- The condition evolved from an asymptomatic phase to symptomatic encapsulating sclerosing peritonitis.
Conclusions:
- Abdominal cocoon can present insidiously and may be incidentally discovered during unrelated abdominal surgeries.
- Abandoning mesh placement in suspected cases is a prudent approach.
- Laparoscopic insufflation may be a potential precipitating factor in the development of abdominal cocoon.
- Early recognition and appropriate management are crucial for favorable outcomes.
