Internal hernias through the falciform ligament: a case series and comprehensive literature review of an increasingly common pathology

Absence of Falciform Ligament Found During Laparoscopic Surgery: A Case Report

Anatomic variants of hepatic ligaments are rare, and complications attributable to these variants may be difficult to diagnose. Our aim is to contribute to the literature surrounding the incidental finding of a congenital absence of the falciform ligament. We report the case of a 37-year-old man who underwent a laparoscopic cholecystectomy for acute cholecystitis. During the operation, the patient was noted to have an apparent absence of the falciform ligament attachment to the liver. The round ligament was attached from the liver to the anterior abdominal wall at the level of the umbilicus. The round ligament is inserted into the inferior surface of the liver as a thick, cordlike structure encased in fat. In rare cases, the small intestine can pass through a falciform ligament defect and become trapped while remaining within the peritoneal cavity, leading to difficult-to-diagnose internal hernias. This condition can lead to intestinal obstruction, incarceration, and strangulation. This directed our decision to divide the remaining round ligament at the liver and close to the abdominal wall. When defects of hepatic ligaments are found incidentally during laparoscopic surgery, these investigators recommend that the operating surgeon consider dividing the remaining ligament as a protective procedure to prevent complications such as internal hernias, intestinal obstruction, incarceration, and strangulation.

Falciform ligament hernia: combination of key CT findings

A male patient in his early 90s with no history of abdominal surgery was referred to us for abdominal pain and vomiting. An abdominal computed tomography (CT) demonstrated dilated small bowel with a double beak sign and poorly enhanced wall, which indicated a closed-loop obstruction that leads to strangulation. A closed-loop bowel was located in front of the anterior and medial segments of the liver and to the right of the round ligament of the liver on axial images. Sagittal images revealed that the round ligament has deviated downward and 2 adjacent narrowed intestines were located at its cranial side. These CT findings suggested the hernia orifice was in the falciform ligament. Emergency surgery for highly suspected bowel ischemia revealed the falciform ligament hernia. A combination of the CT findings played a key role, including the double beak sign, the location of the closed-loop small bowel, and the downward deviation of the round ligament, although preoperative CT diagnosis of falciform ligament hernia is a diagnostic challenge.

A Case Report of a Rare Hernia: Incarcerated Falciform Ligament Hernia

Falciform ligament hernias are a rare type of internal hernia that occurs through an abnormal opening in the falciform ligament of the liver. This is the case of a 38-year-old female who presented with a symptomatic enlarging ventral bulge near her umbilicus and was treated with a robotic-assisted laparoscopic falciform hernia repair with mesh. The nonspecific clinical manifestation of a falciform ligament hernia and the low sensitivity of computerized tomography (CT) for these hernias make them hard to diagnose preoperatively. Falciform ligament hernias are mostly attributed to congenital defects, but recently an iatrogenic etiology has also been proposed, given the prior history of laparoscopic surgeries in more recent cases. In our case report, we demonstrate that a robotic-assisted laparoscopic approach is a safe and effective means of correcting this hernia, with an outline of the current literature.

Strangulated Falciform Hernia

Internal hernias are rare, and a delayed diagnosis can lead to dangerous complications. A 75-year-old male with no previous surgical history presented with right upper abdominal pain and vomiting. On examination, he had guarding in the right hypochondrium with a positive Murphy's sign. However, ultrasonography of the gall bladder was normal with dilated bowel loops. Contrast-enhanced CT (CECT) revealed a falciform hernia with evidence of obstruction. Segmental resection of the gangrenous ileum was done with a double-barrel stoma. Later on, stoma reversal was also done with no complications.

Falciform ligament hernia with specific abdominal symptom

Falciform ligament hernia is a very rare internal hernia and is difficult to diagnose before surgery. We report a case of falciform ligament hernia with a specific symptom and image findings, which led to an accurate diagnosis and subsequent laparoscopic surgery. A 15-year-old adolescent boy with no previous medical history showed epigastric pain and was referred to our hospital. The abdominal pain was strong in the supine position and was alleviated in the knee-chest position. Contrast-enhanced computed tomography showed that the round ligament was recognized as a cord-like structure, and the mesentery of the small intestine was located at the cranioventral side of the ligament. He was diagnosed as having falciform ligament hernia, and emergency laparoscopic surgery was performed. The small intestine passed through the falciform ligament; however, it showed no sign of ischemia, and bowel resection was not required. The malposed intestine was repositioned, and the falciform ligament was cut to prevent hernia recurrence. The specific abdominal symptom and computed tomography image finding were useful to make the correct diagnosis in this case.

Internal herniation through the falciform ligament of the liver: a case report

Background: An internal abdominal hernia is defined as the protrusion of a viscus through a mesenteric or peritoneal aperture within the peritoneal cavity. A less common type of internal herniation is a small bowel herniation through a defect in the falciform ligament of the liver. This defect can be congenital or iatrogenic after penetration of the falciform ligament with a trocar during laparoscopic surgery. Methods: We present a case report illustrating an internal herniation through an iatrogenic defect in the falciform ligament of the liver. Results: A 78-year-old man comes to the emergency department with severe abdominal pain for several hours. Laparoscopic exploration shows a small bowel herniation through an iatrogenic defect of the falciform ligament after laparoscopic cholecystectomy. Reduction of the internal herniation is performed. Due to subsequently small bowel necrosis, a small bowel resection with primary anastomosis has to be performed too. Conclusion: Small bowel herniation through an iatrogenic defect in the falciform ligament is very rare. However, it can lead to severe complications such as small bowel necrosis. To prevent internal herniation, we strongly suggest immediate repair or division of the falciform ligament when an iatrogenic defect is created during laparoscopic procedures.

[Internal hernia through the falciform ligament: a rare cause of intestinal obstruction]

Internal hernias are a rare cause of acute intestinal obstruction. Hernias through the falciform ligament is uncommon. Diagnosis is often made intraoperatively. Abdominal CT scan, performed in an emergency situation, can enable preoperative diagnosis and guide the therapeutic approach. In this respect, we here report a case whose data were collected in the Department of Visceral Surgery at the University Hospital Hassan II in Fez. The study involved a 48-year old patient, with no particular previous history, admitted to the Emergency Department with occlusion evolving over 4 days. Abdominal x-ray without treatment objectified multiple hydroaeric levels in small bowel some of which projected towards the hepatic region as well as the presence of a flat intestinal loop in continuity with distended intestinal segment. Abdominal CT scan was not performed due to altered renal function. The patient then underwent emergency surgery after stabilization of his condition and the diagnosis of internal hernias through the falciform ligament was made intraoperatively. In adults, internal hernia through the falciform ligament is a rare cause of acute intestinal obstruction in our daily practice. The diagnosis is most often made intraoperatively. It is necessary to suspect it in young patients with no history of abdominal surgery or intraperitoneal infectious process and with hydroaeric levels in the right upper quadrant.

[Diagnosis of a sonographically negative extensive defect of the lig.falciforme hepatis]

This study assess the US diagnose of very rate extensive trapezoidal defect lig.falciforme hepatis. 2 patients with this condition were examined. Transabdominal ultrasound of this condition was unsuccessful, specific sonographic features of the defect is not revealed.

Case series of two falciform ligament incisional hernias and their laparoscopic repair

Incisional hernias involving the falciform ligament have only been reported in two case reports in the English literature. This is the first reported case series of two falciform ligament incisional hernias. Both patients had undergone a prior cholecystectomy. Laparoscopic transabdominal pre-peritoneal repair was performed with an uneventful recovery in both patients. In the previously published reports both patients underwent an open herniorrhaphy with an underlay mesh repair. These are the first two documented laparoscopic repairs of a falciform ligament incisional hernia. The laparoscopic repair also included intra-corporeal suturing of the hernia necks with a non-absorbable suture. We extrapolated this data from the component separation technique which reconstituted the abdominal musculature in their normal anatomical position resulting in a reduced hernia recurrence rate.

Congenital internal hernia through defect in the falciform ligament in adult: A case report and review of the literature

INTRODUCTION

The incidence of occlusion syndrome caused by internal hernia is very rare, in particular when the defect is congenital discovered in adults with no previous abdominal surgery.

PRESENTATION OF CASE

We present a case of a 31 year-old female patient who presented with acute abdominal pain and mechanical obstruction. The patient had never undergone abdominal surgery.

DISCUSSION

On diagnostic laparoscopy, it was found a herniation of a loop of small bowel through a hole in the falciform ligament. The obstruction was solved by the division of part of falciform ligament without intestinal resection.

CONCLUSION

Internal hernia is a very uncommon pathology, most often discovered in pediatric age because of congenital abnormalities, it must be included in the differential diagnosis in adults. Preoperative diagnosis is difficult. The diagnostic laparoscopic approach has shown to be the best.

Internal Hernias in the Era of Multidetector CT: Correlation of Imaging and Surgical Findings

Clinical diagnosis of internal hernias is challenging because of their nonspecific signs and symptoms. Many types of internal hernias have been defined: paraduodenal, small bowel mesentery-related, greater omentum-related, lesser sac, transverse mesocolon-related, pericecal, sigmoid mesocolon-related, falciform ligament, pelvic internal, and Roux-en-Y anastomosis-related. An internal hernia is a surgical emergency that can develop into intestinal strangulation and ischemia. Accurate preoperative diagnosis is crucial for appropriate management. Multidetector computed tomography (CT), with its thin-section axial images, high-quality multiplanar reformations, and three-dimensional images, currently plays an essential role in preoperative diagnosis of internal hernias. The diagnostic approach to internal hernias at multidetector CT includes detecting an intestinal closed loop, identifying the hernia orifice, and analyzing abnormal displacement of surrounding structures and key vessels around the hernia orifice and hernia sac. At each step, multidetector CT can depict pathognomonic findings. A saclike appearance suggests an intestinal closed loop in several types of internal hernias. Convergence, engorgement, and twisting of mesenteric vessels in the hernia orifice can be seen clearly at multidetector CT, especially with use of multiplanar reformations. For definitive diagnosis of an internal hernia, analysis of displacement of anatomic landmarks around the hernia orifice is particularly important, and thin-section images provide the required information. Detailed knowledge of the anatomy, etiology, and imaging landmarks of the various hernia types is also necessary. Familiarity with the appearances of internal hernias at multidetector CT allows accurate and specific preoperative diagnosis. (©)RSNA, 2015.

Small bowel obstruction via herniation through an iatrogenic defect of the falciform ligament following laparoscopic cholecystectomy

Internal herniation of the small bowel through a defect in the falciform ligament and subsequent small bowel obstruction is exceedingly rare with the majority of previous cases being attributed to congenital abnormalities. As laparoscopic techniques approach the forefront of modern surgery, an iatrogenic source for a falciform ligament defect has emerged over the last decade. In this case, a 50-year-old patient presented with signs of acute small bowel obstruction 10 days after a laparoscopic cholecystectomy. On diagnostic laparoscopy, part of the jejunum was found to have herniated through an opening in the falciform ligament. This was likely to have been caused by trauma during the cholecystectomy. Following relief of the obstruction, the defect was closed with polyglactin sutures.

Concurrent Spigelian hernia and falciform ligament hernia in a 67-year-old female

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We present a case of a concurrent Spigelian hernia and internal hernia through the falciform ligament.

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We discuss the clinical presentation and management of this case.

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We suggest methods to decrease mortality from internal hernias such as a raised awareness and a laparoscopic approach for adequate internal examination of the abdominal contents.

Introduction

Internal abdominal hernias account for 1% of all hernias but 5.8% of all bowel obstructions and hence are of significant clinical importance. Similarly Spigelian hernias account for only 0.12–2% of all abdominal wall hernias.

Case presentation

We present and discuss the management of a case that presented with concurrent falciform ligament internal abdominal hernia and Spigelian hernia. We believe this is the first reported case of such an occurrence in the literature.

Conclusion

Due to the advancements in computer topography (CT) imaging many internal and Spigelian hernias are diagnosed pre-operatively though these scan are not always available or indicated in cases of suspected small bowel obstruction. Due to the high mortality rate of undiagnosed internal hernias a high clinical suspicion must be maintained. The authors recommend laparoscopic trans-abdominal repair of Spigelian hernias in order to examine the abdominal contents and exclude rare, though potentially serious internal hernias.

Chilaiditi's syndrome associated with colonic volvulus and intestinal malrotation-A rare case

INTRODUCTION

Chilaiditi's syndrome (symptomatic hepatodiaphragmatic interposition of the colon) is an exceptionally rare cause of bowel obstruction and may present difficulty in diagnosis and management. This is the first reported case of colonic volvulus occurring in Chilaiditi's syndrome in association with intestinal malrotation and this case study describes its successful management.

PRESENTATION OF CASE

An 18 year old male presented as an emergency with vague abdominal pain and a past history of gastroschisis repair with intestinal malrotation. CT scanning showed a closed loop obstruction due to a volvulus of the colon herniating under the falciform ligament. The patient was successfully treated by surgical reduction of the hernia, anatomical correction of the malrotation and caecopexy with a tube caecostomy. At six month follow up the patient was well and asymptomatic.

DISCUSSION

In nine of the previously reported cases of Chilaiditi's syndrome with colonic volvulus, treatment was by partial colonic resection of which a third underwent stoma formation. One patient died as a consequence of anastomotic leak following primary anastomosis. We therefore suggest an alternative approach to management.

CONCLUSION

Chilaiditi's syndrome with colonic volvulus in association with intestinal malrotation has not previously been described. As there is no consensus in the literature as to how to manage such a case we suggest that reduction of the volvulus, anatomical correction of the malrotation and fixation of the caecum by tube caecostomy results in a successful outcome. This approach avoids the need for colonic resection and possible stoma formation.