Cyst of the left triangular ligament of the liver.

Abstract

Cysts of the hepatic ligaments are relatively rare as shown by the fact that only 7 cases could be found in the literature. Four of these were in the falciform ligament (1, 6) and 3 in the ligamentum teres (2, 8, 4). No cases were described in the triangular ligaments. The falciform ligament is a double layer of peritoneum that goes from the upper and anterior surfaces of the liver to the lower surface of the diaphragm and the back of the linea alba. Its line of attachment divides the liver into left and right lobes. The ligamentum teres is a fibrous cord running in the falciform ligament down to the umbilicus; it is the remnant of the umbilical vein. At the posterior portion of the upper surface of the liver, the left layer of the falciform ligament turns to the left and forms the anterior layer of a triangular fold called the left triangular ligament. This passes from the upper surface of the left lobe to the diaphragm (8). Brown (1), in reviewing the reported cases of cysts of the hepatic ligaments in 1948, classified them as primary or secondary. The primary cysts can be of lymphatic origin, a developmental defect, or the result of peritoneal inclusion. Geist (5), discussing solitary nonparasitic cysts of the liver, included some cases in the hepatic ligaments. Various classifications of hepatic cysts have been devised, but that of Jones (7) is probably the most widely accepted. In most of the cases described the cysts were large, some reaching the size of a child's head, and were usually palpable. The diagnosis was not made prior to surgery. In a few cases, roentgen studies of the gastrointestinal and renal systems were done, and in some instances showed extrinsic pressure on the gastrointestinal tract. The symptoms varied somewhat, but a number of the patients had pain in the epigastrium, indigestion, or a full feeling most marked after meals. One patient presented with acute symptoms as result of torsion. Pathologically the cysts were essentially the same except for the case to be reported here, which contained hepatic tissue. There was a thin fibrous connective tissue wall in which muscle fibers were occasionally present. The cysts were in most cases unilocular with a smooth endothelial lining and contained a serous fluid that was clear or slightly cloudy. Case History G. B., a 55-year-old white female, complained of heaviness in the epigastrium and burning epigastric pain. The history and physical examination were otherwise not contributory. Roentgen examination of the upper gastrointestinal tract showed an indentation in the fundus of the stomach. The examination was repeated with air contrast and a defect measuring 2 to 3 cm. was demonstrated, with indentation of the fundus, and also a localized elevation of the diaphragm (Fig. 1).