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Al-Judi and Safarini: Peritoneal cyst arising from falciform ligament of the liver

Introduction

The first case of a cyst of the falciform ligament of the liver was reported by Henderson in 1909,1 and there have been a total of 12 reported cases (Table 1), including this one.2

TABLE 1

Cases reported in the literature

Author(s) and year of publication Age and sex of patient Presenting symptoms Description of falciform cyst
Henderson, 1909 41 years, male 8-year history of abdominal mass Straw-coloured, thin-walled cystic tumour the size of an infant’s head; unilocular cyst, 8 cm in length, containing clear liquid
Chifoliau, 1926 49 years, male 4-year history of abdominal mass
Wakeley and MacMyn, 1937 54 years, female Dyspepsia for many years and a 4-month history of abdominal mass Fibrous-walled cyst, 2 inches in diameter
Herrou, 1937 32 years, male 2-year history of abdominal mass and dyspepsia Unilocular cyst the size of an infant’s head
Herrou, 1937 31 years, female 8-year history of right lumbar pain Multilocular cyst the size of an infant’s head, with pedicle attached to the liver and umbilicus
Lightwood and Campbell, 1939 4 months, male Abdominal mass from birth Mass similar in size to liver
Brown, 1948 26 years, male Acute abdominal pain and abdominal mass 10 × 12 cm cyst with partial torsion around a fibrous band anchored to the anterior abdominal wall
Karabin, 1951 24 years, female Dull abdominal pain for 6 weeks after blunt trauma to the abdomen; repair of partial eventration of the intestine through the umbilicus at birth Fusiform cyst 6 inches in length, 2 inches in width and 7 inches in depth, filled with sero-sanguinous fluid
Gondring, 1964 27 years, female 6-year history of progressive colicky epigastric pain; abdominal mass Pear-shaped cyst 9 cm in width, 11 cm in length and 7 cm in depth, reddish brown, containing blood clot and bile-coloured fluid
Entenime, 1984 27 years, female 11-month history of intermittent abdominal pain; physical examination clear Abdominal/pelvic CT showed 5-cm cystic lesion of the falciform ligament; excised surgically
Patel, 2009 61 years, female 12-month history of abdominal pain and bloating CT showed large cystic structure in right side of the epigastrium; excised during open surgery
Al-Judi and Safarini, 2017 30 years, female Upper abdominal pain and epigastric mass Sonography, CT, magnetic resonance imaging and exploratory laparoscopy revealed 8 × 6 cm cyst

CT, computerized tomography.

Anatomically, the falciform ligament contains the ligamentum teres hepatis (the round ligament of the liver), which is the obliterated fetal left umbilical vein. This lies in the free edge of the falciform ligament and extends from the umbilicus to the porta hepatis, where it attaches to the ligamentum venosum between the two lobes of the liver (Figure 1). The falciform ligament represents a portion of the persistent ventral mesentery consisting of the round ligament, paraumbilical veins, adipose tissue, and a small collection of both smooth and striated muscle fibres.3

FIGURE 1

The falciform ligament in relation to the parietal peritoneum, round ligament and liver lobes.

HMJ-665-fig1.jpg

Case report

A 30-year-old woman with a history of abdominal pain (lasting a few months) presented with a well-defined epigastric mass in the right upper quadrant. The palpated mass was tense but not tender, extended laterally from the midline of the abdomen, occupied the whole epigastrium and measured 8 × 6 cm. Abdominal ultrasound, computerized tomography (CT) and magnetic resonance imaging (MRI) revealed a large, fluid-filled, well-circumscribed cystic mass (Figures 24). During laparoscopy, the lesion was seen to be unilocular, occupied the suprahepatic space, extended to the umbilicus and was attached to the teres ligament (Figure 5). It had a thick fibrous wall and was filled with serous fluid (Figure 6). Histology revealed a benign fibrous lesion lined with one layer of cuboidal epithelial cells (Figure 7). Cytology of the aspirated fluid revealed a proteinaceous background, a few foamy cells and no inflammatory or malignant cells.4

FIGURE 2

Abdominal ultrasound scan showing the cyst occupying the epigastric region on both sides (left/right) and the central attachment to the linea alba (arrow).

HMJ-665-fig2.jpg
FIGURE 3

Computerized tomography scan of the epigastrium showing tenting at the midline (arrow) and the cyst extending from right to left.

HMJ-665-fig3.jpg
FIGURE 4

Magnetic resonance image of the epigastrium showing the cyst and tenting at the midline (arrow) of the abdominal wall.

HMJ-665-fig4.jpg
FIGURE 5

Intraoperative photograph showing the falciform ligament cyst, the round ligament and its attachment to the umbilicus and porta hepatis.

HMJ-665-fig5.jpg
FIGURE 6

(a) Fibrous wall of cyst after excision and (b) macroscopic specimen of whole cyst and round ligament after excision.

HMJ-665-fig6a.jpgHMJ-665-fig6b.jpg
FIGURE 7

Histology section (haematoxylin and eosin stain × 50) showing the fibrous membrane and the single-layer cuboidal epithelium.

HMJ-665-fig7.jpg

Clinical features, diagnosis and treatment of falciform ligament cyst

As illustrated by the reported cases, symptoms vary individually and present no specific symptom complex. A mass, if noticed, may be the only complaint. Indigestion, flatulence and a feeling of fullness after meals are often symptoms. The pain, when present, often relates to position and varies from a dull, aching, intermittent pain to a sharp, colicky pain that is poorly localized. There are often no physical signs except the presence of a mass. Typically, the mass is tender, lies to the right of the midline, does not extend below the umbilicus and does not move with breathing.

A striking similarity between the previous 11 cases is the mistaken assumption that a tumour in the right upper quadrant is a renal, hepatic or gall bladder tumour.5 Pertinent history, physical signs and imaging modalities (sonography, CT and MRI) are of value for ruling out the extensive list of differential diagnoses for a lesion in this area of the body.

Treatment is laparotomy, for which the correct procedure is to excise the cyst to obtain the correct pathological diagnosis and to avoid subsequent complications such as haemorrhage, infection, twisting (if the cyst is attached to a pedicle or a fibrous band is present), torsion and strangulation.3 In this case, laparoscopy included the excision of the cyst (see video clip). There were no operative or post-operative complications.

Discussion

The patient was asymptomatic from birth until the cyst grew large enough to be palpable and painful, causing a noticeable increase in abdominal size. MRI can be helpful in revealing the size, content and boundaries of a cyst, but cannot define the nature or origin of the cyst or rule out malignancy. T2 MRI showed the fixed tenting point of the anterior border of the cyst at the umbilicus along the midline of the epigastric area. This may be a newly identified indication that the cyst arises from the falciform ligament of the liver, which could allow preoperative diagnoses in future cases (see Figures 13).

Conclusion

A cyst of the falciform ligament is another entity to consider in the differential diagnosis of a mass in the right upper quadrant that may be attached to the anterior abdominal wall towards the midline and above the umbilicus. Available imaging modalities – sonography, CT and MRI – can aid diagnosis of these rare cysts. Nevertheless, the only currently available option for diagnosis and treatment is laparotomy.

References

1. 

Henderson MS. III. Cyst of the round ligament of the liver. Ann Surg 1909; 50:550–1. https://doi.org/10.1097/00000658-190909000-00003

2. 

Gondring WH. Solitary cyst of the falciform ligament of the liver; report of a case and review of the literature. Am J Surg 1965; 109:526–9. https://doi.org/10.1016/S0002-9610(65)80191-X

3. 

Moore KL, Dalley AF. Chapter 2: Abdomen. In: Clinically Oriented Anatomy, 5th edn. Philadelphia: Lippincott Williams and Wilkins; 2006, p. 214.

4. 

Brown JS. Cysts of the falciform ligament. South Surg 1948; 14:278–82.

5. 

Patel A, Lefemine V, Ramanand BS. A rare case of a peritoneal cyst arising from the falciform ligament. Cases J 2009; 2:134. https://doi.org/10.1186/1757-1626-2-134




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