Falciform ligament appendagitis after Roux-en-Y bypass surgery mimicking acute cholecystitis

Abstract

Fatty falciform ligament appendage torsion (F-FLAT) is a rare type of intraperitoneal focal fat infarction that involves torsion of a fatty appendage of the falciform ligament. It may cause severe pain, mimicking an acute abdomen, but is typically self-limited and does not require hospitalisation or surgery. As a type of intraperitoneal focal fat infarction, it shares many of the same physiological, clinical and radiological features of epiploic appendagitis. To our knowledge, F-FLAT has not previously been reported in a patient following a laparoscopic Roux-en-Y gastric bypass surgery. Identifying falciform ligament appendagitis is critical because it can prevent unnecessary hospitalisation, follow-up studies and surgery.

A Case Report of Falciform Ligament Appendagitis

“…The falciform ligament is a double fold of peritoneum separated by extraperitoneal fat that divides the left and right liver lobes [ 1 ]. The falciform ligament contains the ligamentum teres which is a cord-like remnant of the obliterated umbilical veins, paraumbilical veins, and variable amounts of extraperitoneal fat [ 3 , 5 ]. It receives arterial supply from a vessel coming from the left inferior phrenic artery and the middle segmental artery of the liver [ 3 ].…”

“…Falciform ligament appendagitis is caused by torsion of the long lipomatous appendage leading to ischemia and ultimately aseptic fat necrosis [ 3 ]. It is slightly more frequent in males than in females (ratio close to 1:1) with a median age of 59.5 years and the only documented risk factor is obesity, specifically increased abdominal visceral adipose tissue although limited literature is available [ 3 , 5 ].…”

“…Clinical presentation includes right upper quadrant and epigastric pain, usually non-radiating, low-grade fever, and leukocytosis [ 3 , 5 ].…”

Hepatic falciform ligament appendagitis evaluated by ultrasound: A report of 2 cases

“…Similarly, FLA is considered to have 2 types: (1) circulatory disturbance secondary to torsion, infarction, or direct compression of the appendage and (2) inflammatory spillover from the falciform and round ligaments of the liver. Inflammatory spillover rarely causes FLA, but a case of FLA secondary to Roux-en-Y bypass surgery has been reported [3] .…”

Torsion of the fatty appendage of the falciform ligament

“…However, torsion, infection and infarction of the fatty appendage are described. After abdominal surgery iatrogenic internal hernia through the ligament can occur [3] .…”