Videolaparoscopic treatment for isolated necrosis and abscess of the round ligament of the liver

Falciform ligament abscess with disseminated intrahepatic foci: a case report

Background

Falciform ligament abscess (FLA) is a rare disease, and its diagnosis can be challenging without typical image findings of an abscess. We report a patient with FLA that presented as a mass, with an indistinct border between it and the liver, in addition to disseminated foci within the liver. This made it difficult to determine whether it was FLA or a malignancy.

Case presentation

A 69-year-old man presented with epigastric pain. Contrast-enhanced computed tomography revealed a 25-mm mass below the middle of the diaphragm. Based on an initial diagnosis of infection of the falciform ligament, we administered conservative antibiotic treatment and there was initial improvement in the patient’s clinical condition and laboratory data. However, he continued to experience mild epigastric pain. A month later, imaging studies revealed enlargement of the falciform ligament mass and the emergence of a new nodule in the liver, whereas laboratory findings showed re-elevated C-reactive protein levels. Since conservative treatment had failed, we decided to perform surgery. Considering the imaging study findings, malignant disease could not be ruled out. Based on the operative findings, we performed combined resection of the falciform ligament, left liver, and gallbladder. Histopathological examination of the resected specimens revealed extensive neutrophil infiltration and the presence of giant cells and foam cells within the lesions. These findings were indicative of abscess. Pseudomonas aeruginosa was cultured from the pus in the falciform ligament mass and bile in the gallbladder. Although multiple abscesses postoperatively developed in the residual portion of the liver, they could be treated through antibiotic therapy.

Conclusions

FLA can spread to both adjacent and distant organs via its rich vascular and lymphatic networks. When FLA displays atypical image findings and/or an atypical clinical course, it can be difficult to distinguish it from malignant disease. In such cases, surgical treatment, with intraoperative pathological diagnosis, should be attempted.

Abscess of ligamentum teres hepatis post-endoscopic retrograde cholangiopancreatography: A case report and a literature review

Abscess of the ligamentum teres hepatis has been described in the medical literature as an extremely rare clinical entity, which often presents a diagnostic dilemma. A 68-year-old man was hospitalized for upper abdominal pain and obstructive jaundice. The patient presented with low-grade intermittent fever. Laboratory investigations showed a white blood cell count of 32.38 × 10⁹/L, a C-reactive protein level of 247.86 mg/L, abnormal liver enzyme and bilirubin levels, and elevated serum levels of amylase and lipase. He was first diagnosed with acute biliary pancreatitis. A computational tomography scan and magnetic resonance cholangiopancreatography revealed obstructive choledocholithiasis and cholecystolithiasis. The patient received preoperative antibiotics and symptomatic treatments for 5 days, followed by endoscopic retrograde cholangiopancreatography and a subsequent duodenal papilla incision to extract pigment and cholesterol gallstones. The patient recovered and was discharged on the fifth day after surgery. However, 10 days later, the patient was readmitted for the recurrence of acute calculous cholecystitis. Laboratory tests showed increases in total and direct bilirubin, γ-glutamyltransferase, and alkaline phosphatase, but not inflammatory parameters. After the patient’s nutritional status improved on the 11th day after admission, a laparoscopic cholecystectomy was performed. Intraoperative exploration revealed extensive abdominal adhesions; a thickened edematous gallbladder wall; and an unexpected abscess of the ligamentum teres hepatis. Pus aspiration was performed laparoscopically after laparoscopic cholecystectomy, and to ensure elimination of the abscess, ultrasound-guided pus aspiration was also performed 1 week later. Fortunately, the patient made an uneventful recovery and was discharged with a drain tube on the 16th day after surgery. Doppler ultrasound indicated that the abscess had completely disappeared 2 weeks after discharge. This case highlights an unusual presentation of a ligamentum teres hepatis abscess caused by obstructive cholangitis but that appeared after the choledocholithiasis was resolved. However, the mechanism of abscess formation remained uncertain.

Target region resection in patients undergoing cytoreductive surgery for peritoneal metastases-is it necessary in absence of visible disease?

BACKGROUND

The aim was to study the patterns of target region (greater omentum, lesser omentum, falciform and umbilical round ligament) involvement in patients undergoing cytoreductive surgery (CRS) from various primary tumors, factors affecting involvement and implications on surgical practice.

METHODS

All patients undergoing CRS from July 2018 to December 2018 were included in this prospective study. The incidence of target region involvement in presence and absence of visible disease and the impact of primary tumor site, PCI and other variables on target region involvement was evaluated.

RESULTS

In 191 patients, greater omentum was involved in over 15% of patients irrespective of the primary tumor type and in 15.7% in absence of visible disease. 75% of these had PCI <20. The involvement of the other three target regions was higher than 20% in ovarian cancer, appendiceal tumors and peritoneal mesothelioma. Involvement of these 3 regions was associated with a higher PCI (p < 0.001 for all) and omental involvement (p < 0.001for all). 2.1% of colorectal cancer patients had umbilical round ligament involvement, 4.2% had falciform ligament involvement and none had lesser omentum involvement.

CONCLUSIONS

Target region involvement varies according to primary tumour site and disease extent. Resection of the greater omentum should be performed during CRS for PM arising from all primary sites. Resection of other target organs may be performed for selected patients with ovarian cancer, peritoneal mesothelioma and mucinous appendiceal tumors in absence of visible disease. For other patients, it should be done only in presence of visible disease.

Four "fine" messages from four kinds of "fine" forgotten ligaments of the anterior abdominal wall: have you heard their voices?

On the posterior aspect of the anterior abdominal wall, there are four kinds of "fine" ligaments. They are: the round ligament of the liver, median umbilical ligament (UL), a pair of medial ULs, and a pair of lateral ULs. Four of them (the round ligament, median UL, and paired medial ULs) meet at the umbilicus because they originate from the contents of the umbilical cord. The round ligament of the liver originates from the umbilical vein, the medial ULs from the umbilical arteries, and the median UL from the urachus. These structures help radiologists identify right-sided round ligament (RSRL) (a rare, but surgically important normal variant), as well as to differentiate groin hernias. The ligaments can be involved in inflammation; moreover, tumors can arise from them. Unique symptoms such as umbilical discharge and/or location of pathologies relating to their embryology are important in diagnosing their pathologies. In this article, we comprehensively review the anatomy, embryology, and pathology of the "fine" abdominal ligaments and highlight representative cases with emphasis on clinical significance.

Falciform ligament abscess from left sided portal pyaemia following malignant obstructive cholangitis

Abscess formation of the falciform ligament is incredibly rare and perplexing when encountered for the first time. It is reported to occur in the setting of cholecystitis and cholangitis, but the pathophysiology is poorly understood.

In this case report, we present a 73-year-old man with falciform ligament abscess following cholangitis from an obstructive ampullary carcinoma. The patient was referred to the Royal Adelaide Hospital from a country hospital, with progressive jaundice, anorexia and nausea. Prior to transfer, he deteriorated with cholangitis, dehydration and renal failure. On arrival, his abdomen was exquisitely tender along the course of the falciform ligament. His blood tests revealed an elevated white cell count of 14.9 x 10³/μl, bilirubin of 291μmol/l and creatinine of 347 μmol/l. His CA 19-9 was markedly elevated at 35,000 kU/l. A non-contrast computed tomography (CT) demonstrated gross biliary dilatation and a collection tracking along the path of the falciform ligament to the umbilicus.

The patient was commenced on intravenous antibiotics and underwent an urgent endoscopic retrograde cholangiopancreatogram (ERCP) with sphincterotomy and biliary stent drainage. Cholangiogram revealed a grossly dilated biliary tree, with abrupt transition at the ampulla, which on biopsy confirmed an obstructing ampullary carcinoma. Following ERCP, his jaundice and abdominal tenderness resolved. He was optimized over 4 weeks for an elective pancreaticoduodenectomy.

At operation, we found abscess transformation of the falciform ligament. Copious amounts of pus and necrotic material was drained. Part of the round ligament was resected along the undersurface of the liver. Histology showed that there was prominent histiocytic inflammation with granular acellular eosinophilic components. The patient recovered slowly but uneventfully.

A contrast CT scan undertaken 2 weeks post-operatively (approximately 7 weeks after the initial CT) revealed left portal venous thrombosis, which was likely to be a delayed discovery and was managed conservatively.

We present this patient’s operative images and radiographic findings, which may explain the pathophysiology behind this rare complication. We hypothesize that cholangitis, with secondary portal pyaemia and tracking via the paraumbilical veins, can cause infectious seeding of the falciform ligament, with consequent abscess formation.

Abscess of the round ligament of the liver associated with acute obstructive cholangitis and septic thrombosis

A man with abscess of the round ligament of the liver associated with acute obstructive suppurative cholangitis and portal thrombosis is reported. A 63-year-old man was admitted with epigastralgia and high fever. Blood tests showed elevation of hepato-biliary enzymes and coagulopathy consistent with acute obstructive suppurative cholangitis and disseminated intravascular coagulation. Computed tomography revealed a small abscess of the round ligament of the liver and left portal thrombosis. After endoscopic biliary stenting, antibiotics and thrombolytic therapy, the high fever, disseminated intravascular coagulation and portal thrombosis rapidly improved, and the round ligament abscess was also later resolved.