Laparoscopic treatment of intestinal obstruction due to a vitelline vascular remnant and simultaneous appendicitis: a case report

A vitelline duct remnant is a rare condition that is reportedly present in approximately 2% of the general population [1, 2], and a vitelline vascular remnant is even more rare [3]. The definitive diagnosis of a vitelline duct or vascular remnant is often difficult, and its presence is an infrequent cause of intestinal obstruction. Surgeons sometimes encounter a vitelline duct or vascular remnant during emergency laparotomy for intestinal obstruction [4, 5].

Despite recent improvements in imaging studies, achieving an accurate preoperative diagnosis of acute abdomen remains difficult. Laparoscopic surgery, which allows for simultaneous exploration of the abdominal cavity and definitive diagnosis, has become a popular technique for patients with acute abdomen. However, reports of the simultaneous occurrence of intestinal obstruction caused by a vitelline vascular remnant and appendicitis treated with laparoscopic surgery are extremely rare. We herein report a case of intestinal obstruction caused by a vitelline vascular remnant with chronic appendicitis successfully treated with laparoscopic surgery.

Vitelline or omphalomesenteric duct remnants are rare congenital anomalies associated with the primitive yolk stalk. The vitelline duct is an embryologic communication between the primary yolk sac and the embryonic midgut, which gradually narrows and finally closes by week of 9 gestation [1–8]. Incomplete closure of the vitelline duct on the antimesenteric side can persist as a variety of anomalies. Meckel’s diverticulum is the most common, but others include vitelline duct fistula, sinus tract, cysts, and fibrous cords from the intestine to the umbilicus [7, 8]. Vitelline arteries originate from the primitive dorsal aorta and travel with the vitelline duct, and its remnant persists as fibrous bands covered by peritoneum. Rutherford et al. [3] have found that the vitelline vascular remnant coursed along the side of mesentery and insert into Meckel’s diverticulum or the posterior wall at the umbilicus. Furthermore, a vitelline vascular remnant sometimes occurs without Meckel’s diverticulum [9]. Thus, the patient was diagnosed with vitelline vascular remnant.

A vitelline duct remnant can result in several complications such as gastrointestinal tract bleeding, intestinal obstruction, abdominal pain, and umbilical discharge [1–8]. A vitelline vascular remnant may lead to intestinal infarction or necrosis resulting either from volvulus around the band or entrapment of the intestine [5]. Vane et al. [6] evaluated 217 children with vitelline duct remnants and found that 85 (40%) of the patients were symptomatic, whereas the remaining 132 were incidentally found to have an asymptomatic Meckel’s diverticulum. Complications of a vitelline duct remnant usually occur in young patients, and the presence of the remnant is associated with a high rate of mortality [1, 4]. Thus, surgical resection of an incidentally found vitelline duct or vascular remnant should be considered at the time of surgery for other conditions [6].

A vitelline duct remnant often contains heterotopic mucosa which can result in some clinical manifestations such as infection and bleeding [10]. Furthermore, several cases of malignant neoplasms arising in a vitelline duct remnant have been reported [11, 12]. Complete surgical resection of vitelline duct remnant is curative [10], and thus, segmental resection of the ileum might sometimes be required. Although deciding appropriate treatment intraoperatively might be difficult, especially for symptomatic vitelline duct remnant patients, careful intraoperative and histological examination is needed to achieve complete resection.

In the present patient, the preoperative diagnosis was mild appendicitis. Although this diagnosis was pathologically confirmed, the main symptom might have been caused by the intestinal obstruction secondary to the vitelline vascular remnant. Although suspected appendicitis with acute lower abdominal pain is one of the most common indications for emergency surgery in young patients, achieving an accurate preoperative diagnosis remains difficult despite recent improvements in imaging technology. Actually, Aitken [1] reported that the preoperative diagnosis was appendicitis in 28 of 73 patients with a symptomatic vitelline duct remnant. Laparoscopic surgery for a patient with acute abdomen might be useful for obtaining a definitive diagnosis during the operation, leading to appropriate treatment. Giri et al. [13] reported that additional laparoscopy during open appendectomy in patients with a normal-looking appendix helped to make a precise diagnosis and administer appropriate treatment. In the present patient, laparoscopic surgery allowed for a definitive diagnosis of intestinal obstruction and appropriate treatment. Laparoscopic surgery might be considered when a patient exhibits unusual symptoms, as in the present patient.

Several cases of vitelline duct remnants successfully treated with laparoscopic surgery were recently reported [14, 15]. Although laparoscopic surgery is reportedly useful for intestinal obstruction [16, 17], careful consideration is needed in patients with intestinal obstruction because of the surgical difficulty caused by the limited working space in the abdominal cavity. Although our patient was successfully treated with laparoscopic surgery because his abdomen was not distended, severe abdominal distention or peritoneal signs suggesting peritonitis, which necessitates prompt completion of the procedure, might be contraindications to laparoscopic surgery.

In conclusion, this is believed to be the first case report of the simultaneous occurrence of intestinal obstruction caused by a vitelline vascular remnant and appendicitis successfully treated with laparoscopic surgery. Achieving a definitive preoperative diagnosis of a vitelline vascular remnant might be difficult, especially in patients with coexisting appendicitis. When young patients demonstrate unusual symptoms, surgeons should consider the possibility of a vitelline vascular remnant, and laparoscopic surgery should be considered because it allows for simultaneous diagnosis and treatment.