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Abstract
Falciform ligament abscess (FLA) is a rare occurrence as a consequence of local inflammation. This report presents a case of FLA on a background of recent cholangitis and laparoscopic cholecystectomy complicated by superficial umbilical wound infection. Diagnosis was by clinical examination and CT imaging. Management was by laparoscopic drainage.
- Surgery
- Gastrointestinal surgery
- General surgery
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Background
The falciform ligament is derived from the ventral mesogastrium and connects the liver to the anterior abdominal wall and umbilicus.1 Along its inferior edge, from the umbilicus to the umbilical fissure of the liver, lies the ligamentum teres (obliterated left umbilical vein) and small paraumbilical veins.2 As its leaves are continuous with the umbilical fissure, there is a potential pathway for the spread of disease from the porta hepatis to the falciform ligament.3 Between its two layers lies a potential space for the development of a falciform ligament abscess (FLA).3
FLA is associated with local, vascular or lymphatic spread of infection from surrounding structures.4 In paediatric patients, it is commonly caused by infection of the umbilicus (omphalitis).4 In adults, it is often attributed to inflammation or infection of the gallbladder, bile duct, liver or pancreas.4
FLA may present with abdominal pain, nausea, vomiting and postprandial fullness.5 Examination may reveal fever, an abdominal mass and tenderness.5 Blood tests would be expected to demonstrate leucocytosis.5 These features may not always be present. Diagnosis of an FLA can be confirmed radiologically through ultrasound, CT or MRI. Ultrasound may demonstrate a hypoechoic lesion.6 7 CT and MRI would be expected to demonstrate a peripherally enhancing mass with internal fluid and air content, with potential thickening of the ligament.8 9 However, it may not exhibit typical imaging features of an abscess.8
Due to its rarity and non-specific presentation, the diagnosis of FLA is often missed, leading to delays in management. Management options include antibiotics, surgical drainage and percutaneous drainage.
Case presentation
A women in her 70s presented to the emergency department with epigastric and right upper quadrant pain, 2 months following interval laparoscopic cholecystectomy for cholangitis. There was no history of fever or vomiting. Examination revealed epigastric tenderness with no signs of peritonism and unremarkable vital signs.
Seven months prior, the patient had an episode of acute cholangitis, which was managed through endoscopic retrograde cholangiopancreatography, stone retrieval, sphincterotomy and plastic pancreatic and biliary stent insertion. Three months later, she had an elective interval laparoscopic cholecystectomy. At the conclusion of the laparoscopic cholecystectomy, the gallbladder specimen retrieval pouch split at the umbilical port site on removal. There was no evidence of contamination of the wound on inspection and the gallbladder was removed intact. The umbilical port site was washed out with one litre of normal saline to prevent infection. Histopathological examination of the gallbladder revealed cholelithiasis and chronic cholecystitis. Two weeks postoperatively, the patient developed a superficial umbilical wound infection with Streptococcus anginosus, which was managed with oral antibiotics (amoxicillin-clavulanate).
During her presentation with abdominal pain, blood tests revealed a white cell count of 8.2 (normal range 3.5–11.0), C reactive protein (CRP) of 17 (normal range <5.0) and unremarkable liver function tests. CT abdomen demonstrated a 20×26×17 mm circumscribed hyperdense structure with associated fat stranding in the vicinity of the falciform ligament (figure 1). The patient was admitted in hospital and observed overnight. Due to resolution of symptoms and clinical stability, the patient was discharged with the provisional diagnosis of falciform ligament infarction. This provisional diagnosis was selected based on the radiological findings and main presenting complaint being umbilical pain in the absence of clinical and biochemical features of infection of the falciform ligament. The infarction was presumed secondary to disturbance of the falciform ligament during insertion of the routine epigastric port during cholecystectomy. An outpatient appointment was made to follow this up in 4 weeks.
Initial CT with arrows indicating a circumscribed structure in the vicinity of falciform ligament: (a) axial section, (b) sagittal section.
Two weeks later, the patient represented to the emergency department with pain in the epigastrium and right upper quadrant, in the absence of fever or vomiting. Vital signs were unremarkable. This time, examination revealed a tender palpable epigastric mass. Her blood test results were unremarkable apart from a mild elevation in CRP to 36. Repeat CT revealed progression of the previously demonstrated lesion anterior to the liver, measuring 30×29×31 mm, with mixed tissue–fluid density appearances now more suggestive of an inflammatory phlegmon with early abscess formation (figure 2).
Interval CT with arrows demonstrating the growth of collection in vicinity of falciform ligament: (a) axial section, (b) sagittal section.
Treatment
Laparoscopy revealed a thick inflamed falciform ligament containing purulent material (figure 3). This was drained laparoscopically, followed by an abdominal washout. There was no evidence of any spilled gallstones or foreign body identified at imaging or laparoscopy.
Falciform ligament abscess, laparoscopically drained and suctioned.
Outcome and follow-up
The fluid culture grew mixed enteric bacteria, without any specific organisms grown. The patient was administered intravenous piperacillin-tazobactam 8 hourly while in hospital. She was discharged 3 days postoperatively with a 5-day course of amoxicillin-clavulanate. At 7 months postoperatively, she remains asymptomatic with no recurrence.
Discussion
It is important to consider FLA as a differential diagnosis for a falciform ligament lesion, particularly in the context of previous gastrointestinal infections. Other differential diagnoses include malignancy, haematoma, falciform ligament infarction or granulomatous reaction.
Risk factors for development of FLA include previous hepatobiliary and umbilical infections, present in this patient. During previous cholecystectomy, the gallbladder specimen retrieval pouch had split at the umbilical port site on removal (followed by extensive washout), and her postoperative course was complicated by a superficial wound infection. The patient had cholangitis prior to the laparoscopic cholecystectomy. There was no evidence of a retained foreign body such as clips, sutures or gallstones contributing to this.
Radiological imaging does not always demonstrate characteristic features of an abscess, particularly in its early phase, as demonstrated in her initial CT. It was initially thought that the patient had falciform ligament infarction, which is managed differently from FLA.
Due to its rarity and non-specific presentation, diagnosis is often missed. It may be misdiagnosed as a simple abdominal wall abscess due to its proximity to the anterior abdominal wall.10 It may also resemble a malignant lesion, the work-up for which can pose high risks, costs and distress to patients.8 11 Earlier diagnosis could minimise representation, readmission and unnecessary investigations.
In this case, the patient’s diagnosis was confirmed after representation for non-resolving symptoms, serial CT imaging and diagnostic laparoscopy. This enabled appropriate management, although delayed.
A literature review was conducted to examine the methods of managing FLA. A search of the databases PubMed, Scopus and Embase using search terms ‘falciform ligament abscess’ produced 136 results. Studies were included if they reported on FLA management and were available in English. Paediatric studies were excluded. Twelve studies were analysed and are summarised in table 1.
Overview of studies reporting on falciform ligament abscess
Across all studies, there was a total of 15 patients. 76.9% cases were managed surgically. Of those managed surgically, 30% were managed through the laparoscopic approach. Non-surgical management options include imaging-guided percutaneous drainage and antibiotics. Recurrence was reported in one case (7.7%), 2 months following laparoscopic drainage.5 There is a lack of reporting on quality-of-life and economical outcomes of FLA treatment.
Of the cases managed by laparoscopic surgery, all patients had uneventful postoperative recovery with an average postoperative length of stay of 4 days.5 9 11 However, there was one recurrence after 2 months.5 There was one complicated postoperative course in a patient following open surgery, reported by Doscher et al.12 The patient’s recovery was complicated by wound dehiscence and cardiopulmonary issues, which eventually led to death.12 This highlights the potential morbidity associated with open surgical management.
There were three reported cases of successful conservative therapy with antibiotics. In these cases, patients were assessed in the outpatient setting after 7 to 10 days for clinical and radiological improvements.4 7 13 Doklestic et al showed reduction in size of the FLA on ultrasound scan.4 Wijaya and Salim arranged follow-up CT imaging, which demonstrated reduction and eventual resolution of the FLA.13 Despite the success of these cases with conservative management, there were two cases that failed conservative management and proceeded to open surgery. In a case reported by Kuribara et al, the patient required readmission for surgery, following clinical and radiological progression of FLA.8 In the case by Maeda et al, the patient’s hospital length of stay was extended by several days for administration of antibiotics, prior to proceeding with surgery due to lack of clinical improvement.14 These cases highlight the increased costs associated with length of stay and readmission for patients trialling conservative management of their FLA with antibiotics only.
There is a paucity in the literature on percutaneous drainage of FLA. Imaging-guided percutaneous drainage may be performed under local anaesthetic, avoiding theatre-related costs and anaesthetic-related risks. However, the efficacy of percutaneous drainage may be limited by abscess size, septations and viscosity of contents, posing risk of incomplete drainage and subsequent recurrence. Furthermore, percutaneous drainage may not address the underlying cause of abscess, such as retained gallstone. In this particular case, the phlegmonous appearance on imaging in addition to the history of split retrieval pouch during the original surgery (increasing the suspicion of retained gallstones), prompted the authors to pursue the laparoscopic over the percutaneous approach.
Learning points
Given the rarity and non-specific presentation of falciform ligament abscess (FLA), diagnosis may be missed or delayed.
Diagnosis should be suspected if there is abdominal pain, palpable mass, fever or leucocytosis with history of abdominal infection. Early suspicion and diagnosis is important to prevent the risks and costs associated with unnecessary investigations, failed therapy and repeated presentations or admissions.
Laparoscopic drainage is a simple, safe and effective treatment for this condition.
The literature recommends surgical drainage over conservative management with antibiotics.
There is a lack of reporting on percutaneous drainage of FLA and long-term outcomes of recurrence, quality-of-life effects and economical burden relating to these management options.
Ethics statements
Patient consent for publication
Footnotes
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Contributors The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: ET, RC. The following author gave final approval of the manuscript: HS.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer-reviewed.