Control of the bleeding gallbladder bed using a pedicled falciform ligament flap based on the left inferior phrenic artery and middle segment hepatic artery.

A 45-year old woman presented with a 3-day history of right upper quadrant pain, which suddenly became generalized. On examination, the patient was septic, tachycardic and tachypnoeic with a distended, tender abdomen. There were no surgical scars, and hernial orifices were normal. Abdominal radio graphs showed dilated small bowel with leukocytosis on full blood count. We found a perforated gallbladder with acute cholecystitis and bilious peritonitis at laparotomy. After peritoneal toilet, we performed a standard cholecystectomy. However, there was a severe pericholecystic reaction, which left a briskly bleeding gallbladder bed. Twice, we packed the area with a large abdominal swab; however, on removal on both occasions, brisk bleeding recurred owing to the clot being pulled off along with the abdominal pack. No modern hemostatic agents such as gelfoam or surgicel were available at the time. We mobilized the falciform ligament on its pedicle, maintaining the vascular supply from the left inferior phrenic artery and middle segment hepatic artery (Fig. 1). We then applied it to the gallbladder bed and compressed the area with large abdominal packs, which we gently removed after about 10 minutes with extra caution not to disturb the flap (Fig. 2). This achieved hemostasis, and the patient recovered uneventfully.