The Importance of Variant Insertions of the Ligamentum Teres Hepatis in the Cruveilhier-Baumgarten Syndrome

Abstract

Within the framework of a prospective study, we were able to establish that in 50 per cent of 220 patients submitted to laparoscopy, the ligamentum teres hepatis did not run from the porta hepatis directly to the umbilicus, but to a point of insertion craniad to the umbilicus in the median line of the anterior abdominal wall. As a rule, this topographic variant has no clinical relevance. It is, however, of importance in patients with cirrhosis of the liver and portocaval collateral channels. In our group, 25 per cent of the patients revealed complete cirrhotic transformation of the liver; in a quarter of these, the Cruveilhier-Baumgarten syndrome presented, and thus also the possibility that large-caliber porto-femoral "umbilical" vessels might be running a course to the left of the umbilicus. The danger of injuring such a vessel during laparoscopy can, however, be prevented: in seven out of eight patients with portofemoral collaterals, this situation was established by ultrasonic examination, and in three cases, the periumbilical course of these vessels was accurately determined prior to carrying out the procedure. In our opinion, the definition of the Cruveilhier-Baumgarten syndrome needs to be extended. The results of our investigation show that, within the framework of portal neo-vascularisation, direct umbilical vein recanalisation is a relatively rare occurrence (approximately 15 per cent), while porto-femoral collateral formation is considerably more common (about 70 per cent).

Morphologic Variations of the Umbilical Ring, Umbilical Ligaments and Ligamentum Teres Hepatis

“…The ligament has also been reported to reach the umbilicus and a supra-umbilical site in 50% and 49% of cases, respectively 4. However, the present study has shown that LTH is frequently divided into several branches before it reached the UR, which is consistent with a report of the lower third of the umbilical vein undergoing breakdown and completely dividing into vascular fibro-elastic strands in early childhood 7.…”

“…2). The discrepancy among these studies might be due to inter-racial variations or different observation methods: the observations were made with the naked eye,3 laparoscopically without removing the peritoneum in patients with Cruveilhier-Baumgarten syndrome,4 and under a surgical microscope (present study) - only our observation method is sufficient to allow the slender terminal branches deriving from the ligament to be traced.…”

“…The morphologic relationship between the UR and the ligamentum teres hepatis (LTH) has been described, 3,4 and a protective function of the ligament against umbilical hernia has also been proposed 3. However, dissections frequently revealed that the relationship between the 2 structures doest support previous descriptions3,4; the LTH terminated in the inferior border of the UR, fused with both sides of the ring, the 2 medial umbilical ligaments (MdU) after bifurcation,3 or had an insertion site at the umbilicus or supra-umbilical region 4. Moreover, the umbilical fascia (UF) does not always cover the UR, and variations of the UR, the median umbilical ligament (MnU), and MdU were found, which have rarely been reported in anatomy textbooks.…”

Diagnostic value of mini-laparoscopy in patients with abdominal neoplasm

“…In this review, bleeding from the abdominal wall and umbilical veins caused by the trocar (8 deaths) and complications following liver biopsy, with bleeding, bile leakage and bile peritonitis (17 deaths), posed the highest risk [15] . Catastrophic bleeding from large caliber vessels in the abdominal wall may be avoided by pre-laparoscopic US with high-frequency and high-resolution linear scanners and with the aid of duplex sonography; laparoscopists can use these methods to reduce potential injury to these vessels by selecting the trocar as the point of entry [16] . A 5 mm caliber mini-laparoscope is used in our clinical practice.…”

Unusual hepatic‐portal‐systemic shunting demonstrated by Doppler sonography in children with congenital hepatic vein ostial occlusion

“…23,24 However, this is the first report in which sonography has documented such a long and unusual course for a PUV, down to its communication with the right EIV, in a case of hepatic venous outflow obstruction (as described for patient 1). Identifying such an extension is very important to avoid causing hemorrhage, which could be fatal, during any invasive investigative technique (eg, laparoscopy 25 ) or surgical procedure (eg, appendectomy) in this area. Generally, the hemodynamic role of a patent PUV varies from being a hepatofugal pathway in cases of intrahepatic portal hypertension to a hepatopetal pathway in cases of extrahepatic PV obstruction.…”