Laparoscopic resection of a gangrenous falciform ligament

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Background: Necrosis of the falciform and round ligament of the liver is a very rare condition. There are only 15 case reports describing this phenomenon in the literature. Patients typically present with acute abdominal pain and imaging demonstrating inflammation or gangrenous changes associated with the falciform ligament. No consensus has been reached on the pathogenesis or optimal management of this disease process. Herein we report a case of gangrenous falciform ligament managed by laparoscopic excision and debridement. Results: The patient is a 70-year-old Caucasian male with multiple comorbidities who presented with four days of epigastric and periumbilical abdominal pain. He described the pain as a dull, aching sensation associated with nausea, anorexia, and fevers. Patient’s medical history included severe coronary artery disease and ischemic cardiomyopathy with a depressed left ventricular ejection fraction. He was a 40-pack-year smoker and heavy drinker. On physical examination, he has mild tenderness from his epigastrium to his periumbilical region with mild bruising around the umbilicus. A computed tomography of the abdomen and pelvis revealed an inflammatory process in the subcutaneous tissue of the periumbilical region, which followed the course of the falciform ligamentum as it entered the liver. His laboratory values demonstrated leukocytosis and thrombocytopenia. He was started on broad-spectrum antibiotics and admitted to the hospital for observation. With persistent symptoms throughout the following day, he was recommended for a diagnostic laparoscopy. In the operating room, he was found to have a frankly necrotic falciform ligament that was excised off the anterior abdominal wall, fully mobilized to the liver, and ligated. Tissue culture of the specimen demonstrated Enterococcus faecium and Escherichia coli. The abdominal pain eventually improved after surgery, and patient was discharged to a rehabilitation center with a long-term course of intravenous antibiotics. Patient was readmitted 6 weeks postoperatively with an intra-abdominal abscess and a non-occlusive portal venous thrombus. He required underwent image-guided drainage, further antibiotics, and systemic anticoagulation. Conclusion: Due to the rarity of the disease, the pathogenesis is not well understood. The round ligament represents the obliterated left umbilical vein remnant and forms the free border of the falciform ligament. A complex network of lymphatics and vascular pathways are associated with the round ligament that may serve as a nidus for this pathology. Recanalization of the umbilical vein with subsequent thrombosis and infection, similar to a suppurative thrombophlebitis, is one plausible theory. Conclusion A diagnosis of a necrotic falciform ligament is a rare condition that may detected on cross-sectional imaging during the evaluation of acute abdominal pain. In cases that permit, we recommend laparoscopic excision and debridement of the falciform ligament to achieve source control.




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