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Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 75-78

Peritoneal encapsulation: A puzzling encounter during open and laparoscopic surgery

1 Department of Surgery, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
2 Department of Radiology, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
3 Department of Surgery, King Faisal Specialist and Research Center, Jeddah, Saudi Arabia

Date of Web Publication6-Sep-2019

Correspondence Address:
M Ezzedien Rabie
Department of Surgery, Armed Forces Hospital, Southern Region, P.O. Box 101, Khamis Mushait
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ssj.ssj_8_18

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The presence of an intraperitoneal membrane, encasing parts of the bowel, is a bizarre and rare condition. Three categories are recognized, peritoneal encapsulation, primary sclerosing encapsulating peritonitis (SEP), and secondary SEP, each with different etiology. Symptomatic cases may present with bowel obstruction while asymptomatic cases may only be discovered at surgery for an unrelated reason. In this report, we describe the clinical course of two patients, in whom the condition was discovered only during surgery. The first patient had peritoneal encapsulation and the condition was discovered during laparoscopic cholecystectomy. Due to a bizarre laparoscopic view, in which access to the general peritoneal cavity was hindered by the membrane, conversion to open surgery was necessitated. The second patient had idiopathic encapsulating sclerosing peritonitis, which was discovered at laparotomy for bowel obstruction. Both patients convalesced well after surgery and had an unremarkable postoperative course. In this report, we aim to highlight the existence of this rare entity, which can cause difficulty, particularly during laparoscopic surgery.

Keywords: Abdominal cocoon, peritoneal encapsulation, sclerosing peritonitis

How to cite this article:
Rabie M E, Elyas A, Bazeed M, Osama M, Alhashemy HA. Peritoneal encapsulation: A puzzling encounter during open and laparoscopic surgery. Saudi Surg J 2019;7:75-8

How to cite this URL:
Rabie M E, Elyas A, Bazeed M, Osama M, Alhashemy HA. Peritoneal encapsulation: A puzzling encounter during open and laparoscopic surgery. Saudi Surg J [serial online] 2019 [cited 2022 Jan 21];7:75-8. Available from: https://www.saudisurgj.org/text.asp?2019/7/2/75/266218

  Introduction Top

The presence of an intraperitoneal encasing membrane is an obscure and rarely encountered condition. Under this entity, three types have been recognized: peritoneal encapsulation and sclerosing encapsulating peritonitis (SEP) which may be primary (idiopathic) or secondary,[1],[2] The latter two are also known as encapsulating peritoneal sclerosis.[3] This classification is based on certain operative and histopathological findings. However, the hallmark of the condition is the presence of a membrane which encases parts of the bowel, mainly the small bowel.[1],[2]

  Case Reports Top

First case

A 60-year-old male, known asthmatic and diabetic on insulin, presented with 2 days history of severe right hypochondrial pain and nausea. Six months back, he had a similar attack of milder severity, which resolved with simple analgesics.

On examination, he was in pain with mild fever (37.5°C), and there was sever right upper abdominal tenderness.

Laboratory works showed leukocytosis (11.200/μl, normal range: 4000–10000/μl) and high C-reactive protein (92.9 mg/l, normal range: 0.0–10 mg/l) with normal liver and renal values.

Abdominal ultrasound (US) showed acute calcular cholecystitis with slightly dilated common bile duct. Magnetic resonance cholangiopancreatography was requested, but the patient could not tolerate the procedure, which was aborted.

Antibiotics and analgesics were started and the patient was consented for laparoscopic cholecystectomy. Pneumoperitoneum was created by the closed technique through the umbilicus and the camera was inserted through a 10-mm port. A bizarre view was then seen where only small bowel loops and mesentery surrounded the scope [Figure 1]. Despite tedious manipulations, other organs, including the liver, gallbladder, and anterior abdominal wall could not be seen. At that time, entrance into what seemed to be intraperitoneal adhesions was assumed. To clarify the situation, another 5-mm port was inserted in the right side of the abdomen to assist in manipulating the bowel, but the view remained very restricted. A decision for conversion was then taken and the abdomen was entered through a midline incision. Only then, we discovered the presence of a thin membrane encasing the bowel in the left side of the abdomen [Figure 2]. As the scope entered through this membrane during laparoscopy, the general peritoneal cavity could not be visualized.
Figure 1: Laparoscopic view. Only small bowel loops with its mesentery could be seen, with no access to the rest of the peritoneal cavity

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Figure 2: (a and b) A thin membrane is seen encasing part of the small bowel in the left side of the abdomen, with part of the bowel protruding through a rent (yellow arrow)

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The acutely inflamed gallbladder was excised in the standard way with suction drain insertion and the wounds were closed.

In the 2nd postoperative day, computerized axial tomography (CT) scan was obtained to document the presence of the peritoneal encapsulation [Figure 3]. The postoperative recovery was uneventful and the patient was discharged in the 5th postoperative day for follow-up. Three weeks later, he appeared in the clinic in good health.
Figure 3: Computed tomography of the abdomen, axial view showing collection of the small bowel in the central abdomen within a thin membrane (yellow arrows)

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Second case

A 35-year-old male presented with abdominal pain, distension, vomiting, and constipation for 3 days.

His past history was positive for chronic constipation and similar attacks which used to resolve spontaneously.

On examination, his vital signs were stable, and there was abdominal distension with mild generalized tenderness. Per rectal examination was aborted as it was painful.

Laboratory investigations showed normal hemogram as well as the liver and renal values.

Abdominal X-ray showed dilated small bowel loops with multiple fluid levels. CT scan showed dilated thick-walled ileal loops in the right side of the abdomen within a thin capsule [Figure 4], and the diagnosis of internal hernia was suggested.
Figure 4: A part of the small bowel is seen collected in the right iliac fossa within a thin membrane (yellow arrows), with proximal dilatation of the small bowel. (a) Sagittal view and (b) coronal view

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At laparotomy, no internal hernia was found, but dilated loops of the terminal ileum were found encased by a membrane made of adhesive layer of the peritoneum. Adhesiolysis was performed and the integrity of the whole gut was ascertained. Part of the resected adhesions was sent for histopathology, which later showed fibrous tissues with inflammatory changes.

In a joint discussion with the radiologist, the CT scan was reassessed and the encapsulating peritoneal membrane was recognized [Figure 4]. Based on the clinical and radiological findings, the diagnosis of primary SEP was thus established.

The patient tolerated surgery well and was discharged in good condition, for outpatient clinic follow-up.

  Discussion Top

Over the years, different terms were used to describe the presence of an intraperitoneal encasing membrane. In 1907, Owtschinnikow described the condition under the term peritonitis chronica fibrosa incapsulata[4] and in 1978, Foo et al. reported it in a series of 10 teenager girls under the term SEP.[5] For its perceived similarity to the insects' cocoon, it was named the “abdominal cocoon.”[5] Other similar terms also exist and although the word “peritonitis” is commonly used, no peritonitis in its known form is usually seen.

The classification of the condition into three categories is based on certain clinical, operative, and histopathological findings.[1]

The first type, which is termed peritoneal encapsulation, is believed to have a congenital origin, arising from the remnants of the yolk sac. The second type, termed primary or idiopathic SEP, has no known associated factors and is believed to result from subclinical bouts of peritonitis, which pass unnoticed, to be followed by the formation of the encapsulating membrane. In the third type, termed secondary SEP, many associated risk factors have been recognized. These include, among others, peritoneal dialysis,[6],[7] prolonged use of beta-blockers,[8] and abdominal tuberculosis [Table 1].[1] Due to this association with several risk factors, secondary SEP is more common than its primary counterpart.[1]
Table 1: Conditions associated with secondary sclerosing encapsulating peritonitis 1

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As for the characters of the encasing membrane, it is thin and lined with mesothelium in cases of peritoneal encapsulation. On the other hand, in both types of SEP, the membrane is a thick fibrocollagenous one with no mesothelial lining.[1]

Depending on its anatomical location, the condition may be divided into three types. In type I, only part of the small bowel is involved, in type II, the whole small bowel is involved, while in type III, in addition to the small bowel, the colon, ovaries, liver, and stomach may also be involved.[1] In our patients, only part of the small bowel was involved, which qualifies them for type one disease.

As for the clinical course of the disease, the congenital variety is usually asymptomatic and discovered incidentally during surgery for another reason. On the other hand, SEP usually causes bouts of subacute bowel obstruction, which will ultimately require surgery for its release.

Our first patient had no history suggestive of bowel obstruction and the condition was discovered during surgery. Moreover, the encasing membrane was thin with no apparent bowel compromise. These features are suggestive of the congenital variant of the disease, termed peritoneal encapsulation. On the other hand, our second patient was previously healthy apart from having bouts of small bowel obstruction and his membrane had no mesothelial lining. This qualifies him for the acquired variant of the condition, namely, idiopathic SEP.

Excision of the membrane and release of the adhesions, with or without bowel resection, is necessary in SEP, as was performed in the second patient. However, excision of the membrane was omitted in the first patient for several reasons. First, there was no evidence of the recent or past history of bowel obstruction. Second, there were no intraoperative findings suggestive of bowel obstruction. Third, excision of the membrane which extended into the lower abdomen would mandate downward extension of the wound. For these reasons, excision of the membrane was abandoned.

Although the condition has suggestive CT features,[9] the diagnosed is frequently made only at surgery,[10] happened in our second patient, in whom the diagnosis was missed despite the presence of suggestive CT features. Obviously, awareness of the potential existence of such membrane is needed before surgery, particularly laparoscopic surgery. This may be possible only if the conditions, with its suggestive features and risk factors, are remembered.

In our first patient, we unwittingly entered the abdomen through the membrane, which was then inflated with gas, transforming it into a tent- or dome-like structure. Beneath this dome, the laparoscope was entrapped, with no access to the rest of the peritoneal cavity. However, contrary to the difficulty we faced in this case, which necessitated conversion to open surgery, laparoscopic surgery has been performed with success by others, even in the presence of bowel obstruction.[11] Nevertheless, extreme care should be exercised to avoid bowel perforation in such cases.

In both cases presented here, neither the surgeons nor the radiologists were quite familiar with the condition, which highlights its rarity and the need for raising awareness of its existence. The major problem in this regard is the entrapment of the laparoscope under the unsuspected membrane during laparoscopic surgery, as happened in our first patient.

  Conclusion Top

The presence of an encapsulating intraperitoneal membrane may create radiologic and operative difficulties, especially during laparoscopic surgery. Although rare, its possible existence should be remembered. In the presence of risk factors, a preoperative CT scan may be of help. If found, entering the abdomen during laparoscopy away from the encasing membrane should be performed. However, in many cases, the condition is only discovered during surgery. If found during laparoscopy, conversion to open surgery is the safest alternative.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Machado NO. Sclerosing encapsulating peritonitis: Review. Sultan Qaboos Univ Med J 2016;16:e142-51.  Back to cited text no. 1
Akbulut S. Accurate definition and management of idiopathic sclerosing encapsulating peritonitis. World J Gastroenterol 2015;21:675-87.  Back to cited text no. 2
Kawanishi H, Kawaguchi Y, Fukui H, Hara S, Imada A, Kubo H, et al. Encapsulating peritoneal sclerosis in japan: A prospective, controlled, multicenter study. Am J Kidney Dis 2004;44:729-37.  Back to cited text no. 3
Owtschinnikow PJ. Peritonitis chronica fi brosa incapsulata. Arch Klin Chir 1907;83:623-34. In: Machado NO. Sclerosing encapsulating peritonitis: Review. Sultan Qaboos Univ Med J 2016;16:e142-51.  Back to cited text no. 4
Foo KT, Ng KC, Rauff A, Foong WC, Sinniah R. Unusual small intestinal obstruction in adolescent girls: The abdominal cocoon. Br J Surg 1978;65:427-30.  Back to cited text no. 5
Nakao M, Yamamoto I, Maruyama Y, Morishita M, Nakashima A, Matsuo N, et al. Risk factors for encapsulating peritoneal sclerosis: Analysis of a 36-year experience in a university hospital. Nephrology (Carlton) 2017;22:907-12.  Back to cited text no. 6
Alatab S, Najafi I, Pourmand G, Hosseini M, Shekarchian S. Risk factors of severe peritoneal sclerosis in chronic peritoneal dialysis patients. Ren Fail 2017;39:32-9.  Back to cited text no. 7
Noh SH, Ye BD, So H, Kim YS, Suh DJ, Yoon SN, et al. Sclerosing encapsulating peritonitis in a long-term propranolol user. Intest Res 2016;14:375-8.  Back to cited text no. 8
Lim MC, Chotai NC, Giron DM. Idiopathic sclerosing encapsulating peritonitis: A Rare cause of subacute intestinal obstruction. Case Rep Med 2016;2016:8206894.  Back to cited text no. 9
Rajagopal AS, Rajagopal R. Conundrum of the cocoon: Report of a case and review of the literature. Dis Colon Rectum 2003;46:1141-3.  Back to cited text no. 10
Ertem M, Ozben V, Gok H, Aksu E. An unusual case in surgical emergency: Abdominal cocoon and its laparoscopic management. J Minim Access Surg 2011;7:184-6.  Back to cited text no. 11


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


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