Congenital band as a rare cause of small bowel obstruction: a case series and review of the literature

Abstract

Introduction

Small bowel obstruction (SBO) is a common surgical emergency, most often caused by adhesions, whereas congenital peritoneal bands (CPBs) represent a rare etiology in adults. Limited contemporary data exist, with most adult series reporting fewer than ten cases. This study describes seven adult patients treated for CPB-related SBO and compares their characteristics and outcomes with those in the literature.

Methods

A retrospective review was conducted of adult patients presenting with SBO due to congenital bands at a single tertiary center between 2010 and 2022. Inclusion criteria were age ≥ 18 years, imaging-confirmed SBO, intraoperative confirmation of a congenital band, and a virgin abdomen. Clinical, radiologic, and operative data were collected. A narrative review of the literature was performed for comparison.

Results

Seven of 269 SBO admissions (2.6%) involved congenital bands. Mean age was 37.1 years, and all patients presented with abdominal pain and vomiting. CT identified a transition point in all cases, though no band was visualized. All patients underwent laparoscopic exploration; six required simple band division, whereas one patient required conversion and ileal resection for ischemia. Mean hospital stay was 3.7 days, with no postoperative complications or recurrence. Compared with the literature, our series demonstrates a lower conversion and resection rate and represents one of the largest contemporary adult cohorts.

Conclusion

Congenital bands, though rare, should be considered in adult SBO when no prior abdominal surgery is present. Early laparoscopic exploration provides accurate diagnosis and effective treatment with low morbidity.

Introduction

Small bowel obstruction (SBO) is one of the most frequent surgical emergencies, accounting for 3% of all surgical admissions for acute abdomen and up to 50% of emergency laparotomies [1–3]. The most common etiologies include postoperative adhesions which account for 65–70% of cases in most series [4, 5]. In contrast, congenital anomalies are rare causes of intestinal obstruction in adults, and are typically diagnosed in the pediatric population. Congenital peritoneal bands (CPBs) are abnormal fibrous attachments formed during embryological development. They may arise from persistence of embryonic structures such as the vitelline duct or from abnormal fusion of peritoneal folds during intestinal rotation and fixation. These bands can cause obstruction through extrinsic compression, volvulus, or internal herniation of the small bowel. It is important to distinguish congenital bands from acquired adhesions, particularly those resulting from prior abdominal surgery or closed abdominal trauma. Post-traumatic bands represent a form of acquired adhesion and should not be considered congenital. Therefore, the diagnosis of CPB is typically considered in patients with a “virgin abdomen,” defined as the absence of prior abdominal surgery, trauma, or inflammatory disease [6].

Although numerous individual case reports have described SBO due to congenital bands in adults, published series remain scarce and typically include very small numbers of patients [7, 8]. Consequently, data regarding clinical presentation, radiologic features, operative findings, and outcomes remain limited. Increased awareness of this rare entity is essential for timely diagnosis and appropriate surgical management.

The aim of this study is to describe a series of seven adult patients with SBO due to congenital bands, to analyze their clinical, radiological, and surgical characteristics, and to compare these findings with the existing literature in order to better define diagnostic challenges and management strategies.

Materials and methods

We conducted a retrospective case series of adult patients diagnosed with small bowel obstruction (SBO) due to congenital bands at La Rabta University Hospital in Tunisia between January 2010 and December 2022.

Inclusion criteria were:

• Age ≥ 18 years at the time of presentation.

• Diagnosis of SBO confirmed by imaging and/or intraoperative findings.

• Intraoperative identification of congenital bands as the primary cause of obstruction.

• No prior history of abdominal surgery (virgin abdomen) or other predisposing causes of adhesion.

Exclusion criteria included:

• SBO due to postoperative adhesions, tumors, or inflammatory bowel disease.

• Patients younger than 18 years.

• Incomplete medical records.

Medical records were reviewed to collect the following data:

• Demographics (age, sex).

• Clinical presentation (symptoms, duration).

• Preoperative investigations (abdominal X-ray, CT scan findings).

• Operative details (approach, site and type of congenital band, need for bowel resection).

• Postoperative outcomes (complications, length of hospital stay, recurrence).

All patients underwent surgical management, either open laparotomy or laparoscopic exploration, depending on clinical stability, imaging findings, and surgeon preference. The congenital band was identified, divided or excised, and bowel viability assessed. Resection was performed when bowel ischemia or necrosis was present.

In addition to the case series, a structured narrative literature review was performed following established methodological recommendations for narrative reviews [9]. Electronic databases including PubMed, Scopus, and Google Scholar were searched using combinations of the following keywords: “small bowel obstruction,” “congenital band,” “adult,” and “virgin abdomen.”

Only studies published in English involving adult patients (≥ 18 years) with surgically confirmed congenital bands were included. Pediatric series and cases related to postoperative or inflammatory adhesions were excluded. Reference lists of relevant articles were manually screened to identify additional studies.

The selected studies were analyzed and categorized according to clinical presentation, imaging findings, anatomical characteristics of the bands, surgical management, and outcomes. The findings were then compared with those of our case series.

Results

During the study period, a total of 269 patients were admitted with small bowel obstruction. Of these, only 7 patients (2.6%) met the inclusion criteria for congenital bands. The mean age was 37.1 years (range 18–61 years), and there were 5 males and 2 females.

All patients presented with abdominal pain (100%). Bilious vomiting was reported in 5 patients (71.4%), and abdominal distension was present in 4 patients (57.1%). Two patients (28.6%) had tympanism on physical examination. Clinical findings were individually assessed; diffuse tenderness with guarding was noted in one patient, while localized tenderness (most frequently in the right iliac fossa) was observed in the others.

All patients presented with a first episode of bowel obstruction, with no previous history of similar episodes. The mean time from symptom onset to hospital consultation was 14.6 h (range 8–36 h).

Plain abdominal radiographs demonstrated air-fluid levels in all patients (100%). Preoperative contrast-enhanced CT scans were performed in every case and showed progressive dilatation of small bowel loops with a transition point in all patients, most commonly located in the ileal region (n = 4), followed by the jejunum (n = 2) and distal jejunum (n = 1).

All patients underwent urgent laparoscopic exploration. In one patient with ischemic ileum, conversion to open surgery was required, and a 60 cm ileal resection was performed. In the remaining six patients, simple band division or excision was sufficient. The anatomical distribution of congenital bands was heterogeneous, with precise localization including ileum–mesocolon (n = 3), omentum–mesentery (n = 2), jejunal mesentery–omentum (n = 1), and a vitelline remnant connecting the ileum to the umbilicus (n = 1). The mean postoperative hospital stay was 3.7 days (range 2–6 days). No postoperative complications or mortality were observed in this series.

Clinical examination and operative findings of all patients are summarized in Table 1.

Table 1.

Patients characteristics and operative findings—SBO due to congenital bands (n = 7)

Pt	Age	Sex	Symptoms	Duration	Physical examination	CT scan findings	Operative findings (band localization)	Procedure	Hospital stay (days)
1	18	M	Abdominal pain, vomiting	8 h	Tenderness RIF	Transitional level in the right iliac fossa	Terminal ileum–right mesocolon (Fig. 1)	Laparoscopic Band resection	3
2	24	M	Crampy abdominal pain, bilious vomiting	12 h	Distended abdomen, tenderness peri-umbilical	Dilated small bowel loops, transition at mid-ileum	Fibrous band between mesentery and anterior abdominal wall (Fig. 2)	Laparoscopic Band division, no resection	4
3	31	M	Pain, nausea, no stool	24 h	Mild distension, no tympanism, no soft abdomen	Transition zone in distal jejunum	Congenital band from jejunal mesentery to ileum (Fig. 3)	Laparoscopic Band division, no resection	2
4	45	F	Intermittent colicky pain, vomiting	36 h	Diffuse tenderness, mild guarding	Transition in left lower abdomen	Band crossing sigmoid mesocolon to ileal loop, ischemic ileum (Fig. 4)	Open adhesiolysis and band excision + 60 cm ileal resection	6
5	52	M	Severe pain, vomiting, no stool or gas	18 h	Mild distension	Closed-loop obstruction, transition at proximal ileum	Tight band between mesentery and retroperitoneum causing ischemia (Fig. 5)	Laparoscopic Band division	5
6	29	M	Pain, vomiting, no stool	10 h	RIF tenderness, no guarding	Ileal transition, whirl sign	Vitelline remnant band (ileum–umbilicus)	Laparoscopic Band excision	3
7	61	F	Abdominal pain, bilious vomiting	20 h	Diffuse distension	Transition in proximal jejunum	Band between omentum and mesentery	Laparoscopic band division	3

Operative images of the cases 1 to 5 are shown in Figs. 1, 2, 3, 4 and 5.

Fig. 1.

Case1: Intraoperative laparoscopic view showing congenital band causing small bowel obstruction (black arrow)

Fig. 2.

Case 2: Laparoscopic photo showing congenital band (yellow arrow) between the abdominal wall and the mesentery

Fig. 3.

Case 3: Laparoscopic image showing congenital band between ileum and jejunal mesentery (black arrow)

Fig. 4.

Case 4: Intraoperative laparoscopic view showing the congenital band (black arrow), ischemic small bowel (blue arrow) and transitional level (red arrow)

Fig. 5.

Case 5: congenital band (blue arrow), stricture level (black arrow)

Discussion

Small bowel obstruction in adults most frequently arises from postoperative adhesions, while congenital bands represent a distinctly uncommon etiology, especially in patients with a “virgin abdomen.” In our study, congenital bands accounted for only 2.6% of all SBO admissions, aligning with the low incidence reported by Perry et al. (2.8%) in their study of 388 case of SBO [10].

Given their rarity and the absence of prior abdominal surgery, congenital bands often escape early diagnostic consideration, contributing to the diagnostic delay well described throughout the literature.

The presentation of congenital bands-related SBO is notoriously non-specific. In our series, all seven patients reported abdominal pain and vomiting, consistent with findings from Abdelwahed, Dimitrios, Sozen, Nicolas, and others, where abdominal pain was universally present [7, 11–13]. Unlike some reports describing intermittent or recurrent episodes in the months preceding the acute obstruction—suggestive of intermittent internal herniation—our patients uniformly presented with a first-time acute episode. This distinction highlights that congenital bands-related SBO may remain completely asymptomatic until sudden irreversible obstruction occurs.

Physical examination findings in congenital band obstruction are generally unreliable. Guarding or focal tenderness may mimic appendicitis, diverticulitis, or other inflammatory conditions. In our cohort, only one patient had signs of diffuse peritonism; similar variability has been reported by Habib et al. and Sozen et al. where clinical examination misdirected the preoperative diagnosis in more than half of patients [7, 14].

Contrast-enhanced CT plays a pivotal role in modern evaluation of SBO. In our study, CT identified a clear transition point in every patient, most commonly in the ileal region, consistent with adult literature where the ileum is the most frequent site of band-related obstruction.

In most cases of small bowel obstruction caused by congenital bands, the band itself is not directly visible on CT scans. The CT will show signs of obstruction—such as dilated loops, a transition point, or a closed-loop pattern—but it usually cannot show the actual fibrous band that is causing the obstruction. This is because congenital bands are typically thin, avascular or minimally vascular fibrous structures that blend with surrounding tissues and are below the spatial resolution of routine CT imaging.

This pattern is confirmed by many reports in the literature [11, 13, 15, 16].

all point out that the congenital band cannot be seen on CT, and thus the diagnosis is indirect. Radiologists conclude a congenital band only after excluding other causes (no tumor, no hernia, no postoperative adhesions, no inflammatory mass). This is why we say the diagnosis is “one of exclusion.”

However, there are rare exceptions:

• Niang et al. reported a case where a hyperdense, linear structure was visible on high-resolution CT, corresponding precisely to a congenital band [17].

• Wettasinghe et al. also described a situation where imaging suggested a vitelline remnant, a form of congenital band [18].

These unusual cases show that although congenital bands are almost never visible on CT, it is occasionally possible, especially with unusual anatomy, high-resolution scanners, or larger/vascularized bands.

CT therefore remains excellent for confirming mechanical obstruction and detecting complications such as ischemia or closed-loop obstruction—features that were crucial in one of our cases requiring conversion to open surgery and ileal resection. This reinforces the value of CT in early operative decision-making, rather than definitive etiologic diagnosis.

The embryological origin of congenital bands remains incompletely understood but is generally attributed to abnormalities occurring during intestinal rotation and mesenteric fixation. During embryogenesis, the midgut undergoes a 270° counterclockwise rotation followed by fixation to the posterior abdominal wall. Disruptions in this process may result in persistent peritoneal attachments or abnormal fusion of mesenteric layers.

In some cases, congenital bands originate from remnants of embryonic structures such as the vitelline duct, vitelline vessels, or mesourachus. These remnants can persist as fibrous cords capable of compressing or entrapping bowel loops. Alternatively, non-specific fibrous bands may arise from anomalous peritoneal fusion without a clearly identifiable embryologic origin.

Our series demonstrated heterogeneous band anatomy: ileum–mesocolon (3 cases), omentum–mesentery (2 cases), jejunal mesentery–omentum (1 case), and a vitelline remnant (1 case). This distribution parallels the variability described by Sozen, Habib, and Dimitrios, where bands commonly originate between the ileum, mesentery, colon, and omentum [7, 12, 14]. This is also correlated by some pediatric cohorts of congenital band-related SBO [8, 19, 20].

Importantly, our series included no cases of midgut malrotation, unlike Low et al. who described obstruction from a congenital band in the setting of malrotation [15].

This distinction emphasizes the need for careful intraoperative assessment to exclude associated congenital anomalies.

Early operative intervention remains the cornerstone of management for congenital bands-related SBO. In contrast to older series where laparotomy predominated—Habib’s 16-patient cohort included only one laparoscopic approach [14]—recent literature and our findings support the safety and efficacy of laparoscopy-first.

Abdelwahed, Wu, Nicolas, and Tepelenis each reported excellent outcomes with laparoscopic division of the band, even in cases with closed-loop obstruction [11, 13, 16, 21].

In our study, all seven patients were initially managed laparoscopically, with only one conversion due to ischemia requiring a limited ileal resection. This conversion rate is considerably lower than the 20–40% traditionally reported for laparoscopic management of SBO [22, 23]. Our low threshold for early laparoscopy likely contributed to shorter operative times, reduced morbidity, and avoidance of extensive bowel resection in most patients.

Postoperative outcomes were uniformly favorable, with a mean hospital stay of 3.7 days and no complications or recurrence. These outcomes compare favorably to Sozen’s and Habib’s series, where necrosis and resection were more common, likely reflecting delayed presentation and open surgery predominance.

Our findings are consistent with the existing literature, where congenital bands are rarely identified preoperatively and are most often diagnosed intraoperatively in the setting of small bowel obstruction without prior surgical history.

The comparative analysis of published adult cases (Table 2) demonstrates that congenital bands remain a rare but clinically important cause of small bowel obstruction in the virgin abdomen. Large adult series such as those by Habib and Sozen reveal relatively high rates of bowel ischemia and frequent need for open surgery, reflecting the diagnostic delays historically associated with this entity. More recent reports—including Abdelwahed, Nicolas, Wu, and our current series—highlight the growing role of cross-sectional imaging and minimally invasive surgery, with laparoscopy achieving excellent outcomes and minimal morbidity. Compared with the broader literature, our 7-case cohort stands out for its uniform early laparoscopic exploration, low conversion rate, and limited ischemic burden, supporting early operative intervention in stable patients and reinforcing the importance of considering congenital bands in all cases of SBO without prior abdominal surgery.

Table 2.

Comparison of adult series and representative case reports of congenital band–related small bowel obstruction

Study	Country	n	Mean age	Band location	CT visible?	Necrosis/resection	Surgical approach	Outcome
Habib et al. [14]	France	16	59	Omentum–mesentery, ileal/colic bands	No	5 necrosis, 1 death	Open	No recurrence
Sozen et al. [7]	Turkey	10	18–72	Vitelline, ileal, Meckel-associated	No	2 resections	Open	Uneventful
Dimitrios et al. [12]	Greece	1	20	Jejunum→mesentery	No	None	Open	Good recovery
Abdelwahed et al. [11]	Tunisia	1	56	GB→transverse mesocolon	No	None	Laparoscopic	POD2 discharge
Low et al. [15]	Malaysia	1	48	Ladd-type ileal band	No	None	Open	Uneventful
Nicolas et al. [13]	Lebanon	3	18–33	Jejunum, Treitz, ileum	No	No resections	Laparoscopic	No recurrence
Niang et al. [17]	Senegal	1	45	Omentum→ant. peritoneum	Yes	None	Open	No recurrence
Wettasinghe [18]	Sri Lanka	1	69	Vitelline remnant	Possible	None	Open	Uneventful
Tepelenis et al. [21]	Greece	1	54	Mesentery↔ileum	No	None	Laparoscopic	Uneventful
Sarraf et al. [24]	Lebanon	1	41	Ileal mesentery	No	Ossification later	Lap→Open	Recurrence
Wu et al. [16]	Taiwan	1	33	Omental→ileum	No	None	Laparoscopic	No recurrence
Our 7-case series	Tunisia	7	37.1	Ileum–mesocolon, omentum–mesentery, vitelline, jejunal mesentery	None	1 resection	Lap→1 conversion	No recurrence

This study contributes to the limited contemporary literature by providing one of the largest recent adult series and supports a laparoscopic-first strategy in the management of congenital band-related SBO.

Conclusion

Small bowel obstruction caused by congenital bands remains an exceptionally rare but clinically significant diagnosis in adults, particularly in those presenting with a virgin abdomen. Clinical and radiologic findings are often non-specific, and although CT reliably identifies the obstruction and evaluates ischemia, it rarely visualizes the band itself. Early operative management is therefore essential. In our study, a laparoscopic-first strategy proved both safe and effective, with a very low conversion rate and excellent outcomes, including the absence of postoperative complications or recurrence.

Our series adds valuable contemporary data to a sparsely documented pathology. While most prior studies include fewer than ten adult cases, our seven-patient cohort represents one of the larger single-center experiences published in the last decade, reinforcing the relevance of our findings. When placed in context with the existing literature, our results support early minimally invasive exploration in stable patients, highlight the need for a high index of suspicion in the virgin abdomen, and underscore timely surgical intervention as the key factor in preventing bowel ischemia.

Further multicenter studies with standardized reporting are needed to better characterize anatomic variants, improve diagnostic accuracy, and refine operative strategies for this uncommon but potentially serious cause of intestinal obstruction.

Author contributions

Souhaib ATRI: project administration, conceptualization, data curation, writing review and editingMahdi HAMMAMI: conceptualization, data curation, writing original draftAhmed BEN MAHMOUD: methodology Amine SEBAI: methodologyHoucine Maghrebi: Investigation Wael REBAI: InvestigationYoussef CHAKER: VisualizationAmine Makni: visualization Amine DAGHFOUS: VisualizationRachid KSANTINI: Supervision, ValidationAnis Haddad: methodologyMohamed JOUINI: Supervision, Validation.

Funding

No funding.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval

Not applicable. Our institutions require no ethical approval for retrospective studies.

Consent for publication

Not applicable. Retrospective studies do not require informed consent in our institution.

Competing interests

The authors declare no competing interests.