Hepatobiliary and Pancreatic: Falciform ligament necrosis

The falciform (sickle-shaped) ligament is one of five ligaments that connect the liver to the under-surface of the diaphragm and to the anterior abdominal wall. It passes in an antero-posterior plane and is the embryonic remnant of the ligamentum teres and the para-umbilical veins wrapped within two layers of peritoneum. It may contain a variable amount of extra-peritoneal fat and represents a potential space. In infants, falciform ligament inflammation or necrosis can occur as a complication of omphalitis. In adults, a falciform ligament abscess is a rare complication of instrumentation during laparoscopic surgery. The ligament can also become canalized in patients with portal hypertension creating engorged veins which radiate from the umbilicus (caput medusae). Another rare complication is inflammation of the falciform ligament associated with acute cholecystitis. In the patient illustrated below, abdominal pain appeared to be caused by necrosis of the falciform ligament, perhaps related to mild cholecystitis or ischemia. A male, aged 88, was transferred to our hospital with a 2-week history of increasing pain in the right upper quadrant of his abdomen. On arrival, he was noted to be febrile (37.8°C) and hypotensive and required admission to an Intensive Care Unit. Blood tests revealed an elevated white cell count (24x10/l) and C-reactive protein (179 mg/l) and minor changes in liver function tests. An abdominal computed tomography (CT) scan showed dilated intrahepatic ducts and a thickened gallbladder wall with multiple stones (Figure 1). Endoscopic sphincterotomy was performed at the time of endoscopic retrograde cholangiopancreatography but only two very small stones were removed from the bile duct. Although his blood tests appeared to improve, he continued to have pain in the right upper quadrant with clinical features of localized peritonitis. Magnetic resonance cholangiopancreatography (MRCP) confirmed effective decompression of the biliary system but a fluid tract with subacute hemorrhage was seen extending from the portahepatis to the anterior abdomen (Figure 2). Review of the initial CT scan identified a fluid collection with no interval change in size compared to MRCP (Figure 1, arrow). At laparotomy, the falciform ligament was found to be necrotic with possible involvement of the posterior rectus sheath. The falciform ligament was excised and a cholecystectomy was performed although the gallbladder did not appear to be inflamed. Histology of the falciform ligament showed large areas of hemorrhagic necrosis with no evidence of abscess formation. Unfortunately, he died 7 days after surgery because of pulmonary complications.