What is the management and treatment of conditions involving the falciform ligament?

Falciform Ligament: Clinical Conditions and Management

Overview of Falciform Ligament Pathology

The falciform ligament is a double peritoneal fold extending from the umbilicus to the diaphragm that anatomically separates the right and left hepatic lobes and contains the obliterated umbilical vein. 1 While typically benign, several distinct clinical conditions can involve this structure requiring specific management approaches.

Primary Clinical Conditions

Falciform Ligament Torsion and Infarction (F-FLAT)

Conservative management with NSAIDs and analgesia is the initial treatment approach for falciform ligament torsion, with surgical excision reserved for patients with unresolving abdominal pain despite 48-72 hours of medical therapy. 2

Clinical Presentation

• Sudden onset epigastric or right upper quadrant abdominal pain radiating to the back 3, 1
• Associated nausea and vomiting 3
• Only 53% of patients present with elevated inflammatory markers, making laboratory tests potentially misleading 2
• Symptoms can mimic acute cholecystitis or other acute surgical pathologies 1

Diagnostic Approach

• Contrast-enhanced CT is the gold standard showing characteristic fat stranding in the falciform ligament 2, 3
• Ultrasound is typically the first-line investigation but has lower sensitivity 2, 3
• CT findings demonstrate torsion and fat necrosis of the ligament 1

Management Algorithm

1. Initial conservative management with NSAIDs and analgesia for all patients 2
2. Monitor for symptom resolution over 24-48 hours with serial abdominal examinations 2
3. Surgical intervention indicated if abdominal pain persists beyond 48-72 hours despite adequate analgesia 2
4. In the reviewed literature, 62% (8/13 patients) ultimately required surgical excision due to unresolving pain 2
5. All surgically excised specimens showed histological evidence of infarction and necrosis 2

Critical pitfall: Do not delay imaging in patients with persistent epigastric pain, as ultrasound alone may miss the diagnosis and contrast-enhanced CT is required for definitive diagnosis. 2

Surgical Utility: Falciformoplasty for Liver Hydatid Disease

The falciform ligament can be mobilized as a vascularized flap to obliterate residual cavities following partial cystectomy for hepatic hydatid disease, offering an anatomically superior alternative to omentoplasty. 4

Technique and Outcomes

• The falciform ligament is prepared as a flap during the initial operative step, then inserted into the cystic cavity after evacuation and fixed with sutures 4
• Mean operative time is 40 minutes (range 35-69 minutes) 4
• Mean postoperative hospital stay is 4 days (range 3-7 days) 4
• Duplex ultrasound at 1 week, 1 month, and 3 months postoperatively confirms flap viability with visible blood flow and complete cavity collapse 4
• Only 10% (2/20 patients) experienced persistent drainage for 7 days, which resolved spontaneously 4

Advantages over omentoplasty: The falciform ligament is more anatomically positioned for liver cysts and represents a better option for secondary cases where omentum may be scarred or unavailable. 4

Incidental Falciform Ligament Defects

When a large falciform ligament defect is discovered incidentally during laparoscopic surgery, the remaining ligament should be completely divided to prevent future small bowel herniation through the defect. 5

• Falciform ligament defects can be congenital or acquired 5
• Asymptomatic defects discovered during unrelated procedures (e.g., bariatric surgery) pose a risk for internal herniation 5
• Complete division of the remaining ligament eliminates the potential hernia orifice 5

Anatomical Considerations in Other Conditions

Fat Deposition and Sparing

• Fat deposition and sparing adjacent to the falciform ligament, portal vein, and gallbladder show characteristic isoenhancement throughout all vascular phases on contrast-enhanced ultrasound 6
• Lack of mass effect helps differentiate these benign findings from hypervascular lesions 6

Collateral Circulation in Portal Hypertension

• The falciform ligament contains para-umbilical veins that serve as potential portosystemic collateral pathways in cirrhosis 6
• These represent remnants of fetal umbilical circulation that can recanalize when portal pressure rises 6

Surgical Access Considerations

• During open abdomen management with negative pressure wound therapy, the falciform ligament should be taken down to allow the non-adherent interface layer to extend cranially onto the diaphragm 6
• This maximizes protection of exposed bowel and prevents adhesion formation 6

Key Clinical Pearls

• Torsion/infarction: Start conservative but have a low threshold for surgical intervention if pain persists beyond 48 hours 2
• Hydatid disease: Consider falciformoplasty as first-line for cavity management, particularly in redo cases 4
• Incidental defects: Always close or divide completely to prevent future herniation 5
• Imaging: Contrast-enhanced CT is essential for diagnosis of torsion; ultrasound alone is insufficient 2, 3