Falciform Ligament Research Articles

Colonic Large Cell Neuroendocrine Carcinoma with Extensive Carcinomatosis: A Highly Aggressive Tumor

Abstract Introduction/Objective Large cell neuroendocrine carcinoma (LCNEC) of the colon is an exceedingly rare and aggressive neuroendocrine carcinoma. These tumors are associated with a poor prognosis, as they are commonly diagnosed in advanced stages with distant metastases. We present a case of a patient with colonic LCNEC with carcinomatosis peritonei who underwent surgical resection and hyperthermic intraperitoneal chemotherapy. Methods/Case Report The patient is a 49-year-old Caucasian male who presented with several months history of occasional hematochezia, constipation, 40-pound unintentional weight loss, and reflux. An initial diagnosis of adenocarcinoma of colorectal origin was rendered. Subsequently, the patient underwent a low-anterior resection with hyperthermic intraperitoneal chemotherapy (HIPEC). Histological evaluation of the rectosigmoid lesion demonstrated sheets of malignant epithelial cells with scant amphophilic cytoplasm, large pleomorphic vesicular nuclei, prominent nucleoli, and numerous mitotic figures. The tumor invaded the entire colonic wall and extended to the visceral peritoneum with extensive small vessel lymphovascular and perineural invasion with widespread involvement of the diaphragm, spleen, falciform ligament, and omentum. Immunohistochemical stains showed the tumor to be diffusely positive for CK20, CDX2, and synaptophysin; while negative for CK7, PAP, PSA, chromogranin, and p40. These findings are consistent with the diagnosis of a large cell neuroendocrine carcinoma. In addition, CD31 highlighted lymphatic spaces that were extensively filled with tumor cells. One-month post-operative, the patient remains in critical but stable condition with features of acute hypoxic respiratory failure and possible metastatic disease to the lung associated with pleural effusion. Results (if a Case Study enter NA) NA Conclusion Colonic large cell neuroendocrine carcinoma (LCNEC) is a rare, highly aggressive neuroendocrine carcinoma that frequently presents with distant metastases. Clinical awareness of the entity with early diagnosis and surgical resection remains the essential initial step. Utilizing immunohistochemistry stains to further characterize the tumor is critical to reach the correct diagnosis. Accumulating appropriate clinical data will aid in the establishment of future treatment protocols.

EP.TU.439Falciform ligament torsion – a rare cause of the acute abdomen

Abstract The falciform ligament attaches the liver to the anterior abdominal wall and diaphragm. Acute falciform ligament related pathology is rare. In this case report we present a case of acute fat necrosis related to the falciform ligament. A 53 year old women presented with acute upper abdominal pain localised to the right hypochondrium. He was tender to palpation in the same region with a positive Murphy’s sign. A provisional diagnosis of acute cholecystitis was made. Blood work revealed raised inflammatory markers but normal liver function tests. Abdominal ultrasound revealed no gallbladder pathology nor gallstones. Thus computed tomogram (CT) scan of the abdomen was performed, showing hyper-attenuation rim signal present within the inferior aspect of the falciform ligament consistent with local vascular occlusion. The patient was managed with intravenous antibiotics with liberal analgesia and went on to make a successful recovery. Only 10 cases have been reported in the literature related to falciform ligament necrosis. We present this unusual pathology encountered on our acute surgical take, to alert surgeons to this rare diagnosis and provide a review of the literature and provide detail of how such a pathology manifests on CT scan.

Location of liver lacerations resulting from deceleration injuries and a proposal for their classification.

<b>Aim:</b> The aim of the study was to verify during forensic autopsies the occurrence of liver lacerations resulting from deceleration traumas in the locations reported in professional literature, and also to check whether they are located near the left coronary ligament and its extension, i.e. the left triangular liver ligament. </br></br> <b> Methods:</b> The liver injuries were assessed on the base of cases of forensic autopsies, performed at the Department of Forensic Medicine of the Medical University of Lodz from 1<sup>st</sup> September 2011 to 15<sup>th</sup> April 2014. In order to analyze the collected data, descriptive methods and statistical inference methods were used. </br></br> <b>Results:</b> Three types of liver rupture turned out to be characteristic and statistically significant: 1 - on the diaphragmatic surface of the right lobe between its two sectors; 2 - within the left lobe to the right (in segment IV) or to the left (in segment III) of the falciform ligament; 3 - located near the left coronary ligament (in segment II). </br></br><b> Conclusion:</b> Typical location of liver lacerations after deceleration trauma, i.e. the right triangular ligament and falciform ligament, are confirmed in the analysed autopsy material. The place not previously described in the literature, which should be regarded as a characteristic location of a liver rupture after deceleration trauma is the diaphragmatic surface of segment II of the left lobe.

Excision of Stage IV Endometriosis Extending to the Diaphragm Following Removal of Seven Liters of Peritoneal Fluid

<h3>Study Objective</h3> Educate on procedures for endometriosis removal. <h3>Design</h3> Educational surgical video. <h3>Setting</h3> Patient placed in dorsal lithotomy position, with robot docked initially for excision of lesions in superior abdomen, followed by undocking and repositioning of robot for approach of inferior abdominal cavity and pelvis. <h3>Patients or Participants</h3> Single patient selected following referral from outside hospital system. <h3>Interventions</h3> Robotic-assisted excision of endometriosis throughout abdominal cavity, with complete resection of visible lesions. <h3>Measurements and Main Results</h3> Biopsies of pericardium, right diaphragm, falciform ligament, hepatic lesion, rectum, bladder, right and left pelvic sidewall, and right and left upper abdominal wall positive for endometriosis. <h3>Conclusion</h3> Complete excision of endometriosis has been shown to potentially eradicate disease and should be attempted. Atypical endometriosis can be found throughout the abdominal cavity, which requires proficiency in both anatomy and surgical technique outside of the pelvis.

S2622 Cruveilhier- Baumgarten Syndrome

Introduction: Cruveilhier- Baumgarten syndrome CB) is an uncommon condition, the term is used for cases of liver cirrhosis with portal hypertension in which a recanalization of umbilical and paraumbilical veins causes a loud venous hum that can be heard over the abdomen. Case Description/Methods: A 51 year old male with a past medical history of alcohol abuse, alcoholic liver cirrhosis and esophageal varices presented to the emergency room complaining of coffee ground emesis and dark-colored stools. On a physical exam, a small umbilical venous dilatation with a low-pitched continuous hum was noted on auscultation. Abdominal ultrasound demonstrated hepatofugal flow. CT abdomen and pelvis without contrast showed findings consistent with cirrhotic liver, mild ascites, splenomegaly and umbilical vein recanalization. The patient underwent an EGD, which was negative for any esophageal or gastric varices. Discussion: In 1833 Pegot reported a case of portal hypertension in which a loud venous hum was heard at the umbilicus. In 1883, Sappey described accessory portal veins in the suspensory ligament entering the liver capsule through different locations, such as the vessels located at the falciform ligament through which the anterior parietal veins communicate with the left branch of the portal vein. These vessels play an important role in the origin of transhepatic portosystemic shunts. Paraumbilical vessels may anastomose with the superior epigastric or internal thoracic veins and drain into the superior vena cava or anastomose with the inferior epigastric vein and then drain into the IVC through the external iliac vein. In CB syndrome, the umbilical portion of the left portal vein feeds the paraumbilical vein that then leaves the liver and extends toward the umbilicus. Our case describes a patient with liver cirrhosis who was found to have a continuous umbilical venous hum on a physical exam with imaging findings consistent with a recanalized paraumbilical vein. It is hypothesized that the recanalization of the paraumbilical vein in portal hypertension acts to decrease hepatofugal flow, thus becoming a preventative factor in the formation of esophageal varices. Although uncommon, the presence of recanalization of the paraumbilical vein implies a variation in the prognosis in those with decompensated liver cirrhosis, thus, warrants further investigation. We presented a case of CB syndrome, a condition in which a transhepatic portosystemic shunt can prevent the formation of esophageal varices.

S1957 Perforated Colonic GIST: A Rare Cause of Acute Abdomen

Introduction: Gastrointestinal stromal tumors (GISTs) are the most common connective tissue neoplasms of the gastrointestinal (GI) tract, usually found in the stomach and small intestine. Approximately 10-30% of patients with this malignancy are asymptomatic. Historically, GISTs have been discovered incidentally as patients often present with nonspecific symptoms such as abdominal pain, nausea, and weight loss. Most patients present with symptoms when the tumor grows >5 cm or with acute complications such as perforation or acute peritonitis. We report a rare case of acute abdomen secondary to a perforated colonic GIST treated by surgical resection and chemotherapy. Case description/methods: A 59-year-old female with hypertension and diabetes mellitus presented with abdominal discomfort for one day, associated with episodes of non-bilious, non-bloody emesis. She denied hematemesis, hematochezia, melena, weight loss, and changes to her bowel habits. Physical examination demonstrated diffuse abdominal tenderness without rigidity or guarding. Initial laboratory investigations revealed a leukocyte count of 17.2 × 103/uL. A computed tomography (CT) scan of the abdomen and pelvis without contrast demonstrated pneumoperitoneum. She was taken to the OR for an emergent exploratory and underwent Hartman’s procedure for a perforated colon. Pathology of the surrounding tissue revealed a high-grade GIST (positive for CD117, KI-67 value of 30%, and mitotic index > 5). Patient was started on Imatinib therapy. A subsequent CT scan five months after discharge revealed several new subcapsular liver masses, the largest measuring 2.6 × 2.2 cm along the falciform ligament and ascites in the left paracolic space. The patient follows with Oncology in outpatient clinic. Discussion: GISTs comprise < 3% of all gastrointestinal tumors and are associated with high rates of malignant transformations. While imagine modalities aid in identification, definitive diagnosis requires histopathological examination. Approximately 95% of GISTs express CD117, a component of the cKIT tyrosine kinase receptor, as in our patient. As majority of GISTs are found in the stomach and small intestine, it is very uncommon for this malignancy to manifest in the colon. Furthermore, it is extremely rare for GISTs to cause perforation and acute peritonitis. Clinical outcome in these cases is dependent on early identification and prompt intervention. While GISTs are rare, providers must consider this diagnosis when visualizing abnormal masses with perforations.

S3196 Diagnosis and Management of Phlegmonous Gastritis in a Young Female Without Predisposing Risk Factors

Introduction: Phlegmonous gastritis (PG) is a rare, but serious, condition characterized by bacterial infection of the gastric wall. Since 1862, less than 500 cases of PG have been reported in the literature, limiting knowledge of its management. We discuss a case of PG in a previously healthy female who was successfully treated with a combination of medical and surgical therapies. Case Description/Methods: A 32-year-old female presented to the emergency department with 10 days of worsening epigastric pain, fever, chills, and nausea. Symptoms onset after consuming a seafood platter containing shrimp, scallops, crab, and crawfish from a local restaurant. She had no significant past medical history. CT demonstrated heterogeneously enhancing wall thickening of the distal stomach and the first portion of the duodenum with adjacent fat stranding. Lab work was significant for leukocytosis and elevated CRP. Following admission, the patient was empirically started on piperacillin-tazobactam with general surgery and gastroenterology consulted. On hospital day 2, an EGD was performed which showed a raised lesion in the antrum with central ulceration and an overlying yellow exudate. Biopsies of the lesion were consistent with active gastritis with cryptitis. No organisms, including H pylori, were visualized on routine stains. MRI revealed a 7.5 x 4.3 cm mass in the gastric antrum with central necrosis and multiple septations. EGD with EUS on hospital day 6 noted a mass in the antrum arising from the muscular layer with areas of necrosis. FNA was performed, showing gastric columnar cells, smooth muscle fragments, and a cluster of bland-appearing spindle cells. The following day, she underwent an open distal gastrectomy with Billroth I reconstruction. Significant adhesions and a desmoid reaction involving the distal stomach to the falciform ligament was present. Tissue pathology showed a perforated ulcer with perigastric abscess and acute serositis. No malignant cells were identified. The post-operative course was uncomplicated, and the patient was discharged home on hospital day 11. Discussion: This case highlights the need to consider PG in the differential diagnosis of persistent abdominal pain, although patients may lack classic risk factors for this condition, such as immunosuppression or recent intervention. Discussion should be prompted regarding the optimal treatment regimen for PG, as there are currently no guidelines regarding standardized therapy.Figure 1.: Fig 1A: An abdominal X-ray showing the faint outline of the trichobezoar impacted within the stomach and leading to the convoluted small intestinal tract. Fig 1B: An abdominal CT scan showing the trichobezoar compacted within the stomach and the small intestines. Fig 1C: Post-operative picture of the removed trichobezoar that shows it took on the form of the stomach shape along with the tapered, elongated end of the form of the small intestine.

Peritoneal Metastases: Their Associated Imaging Features

Peritoneal Metastases (PM) detection remains a challenge even with modern imaging. Knowing imaging features of abnormal findings frequently associated with PM is of interest to improve PM detection. Although ascites is a common imaging finding of PM, the presence of ascites alone, even in patients with known cancer, is not enough to diagnose PM. The peritoneum should be read as an own organ with careful analysis of the ligament (e.g. falciform and hepatoduodenal ligament), the mesos and the omenta. Indirect manifestations of visceral peritoneal involvement is a segment of small bowel fixed to the parietal peritoneum, the appearance of blockage of free circulation of ascites, plurisegmental bowel obstruction and clumped bowel that is a strong predictor of diffuse involvement of the visceral peritoneum by a high grade tumor. Ovarian and umbilical metastases are frequently associated with PM in particular in digestive cancers. Moreover, ovarian metastases has been shown to be less responsive to chemotherapy than other metastases and should not be chosen as a target lesion for RECIST assessment. The presence of cardiophrenic angle lymph nodes also increases the possibility of metastatic spread in peritoneum. Finally, the most common PM mimickers include colonic diverticulum, mesenteric lymph nodes, splenosis implants, fat necrosis and postoperative changes after cytoreductive surgery and HIPEC.

Avoiding the Falciform Ligament Sign during the Intraoperative Cholangiogram

Avoiding the Falciform Ligament Sign during the Intraoperative Cholangiogram

Successful endoscopic surgical treatment of pleuroperitoneal communication in two infant cases

BackgroundPleuroperitoneal communication (PPC) is an uncommon, but potentially life-threatening complication of peritoneal dialysis (PD). If a fistula does not close with conservative treatment, surgical repair is required. However, approximately half of these patients are forced to shift from PD to hemodialysis. Although it is important to confirm the site of the fistula to achieve a successful surgical treatment, this identification is more difficult in pediatric patients than in adults.Case presentationWe report two infantile cases of severe PPC associated with PD. In both cases, the age at onset was less than 2 years, and right-sided pleural effusion with dyspnea was observed. PPC was diagnosed by the change in color of the pleural fluid after the injection of a dye into the peritoneal cavity. Peritoneal scintigraphy and single-photon emission computed tomography and computed tomography (SPECT/CT) were performed, and these were effective in locating the fistula site. Endoscopic surgery (video-assisted thoracic surgery (VATS) and laparoscopic surgery) was performed. Indocyanine green (ICG), which was injected into the abdominal cavity, showed the exact site of the fistula. The fistula was successfully closed by attaching an absorbable sheet to it from the thoracic side and an autograft (the falciform ligament) to it from the abdominal side in one patient. In the other patient, the fistula site was resected and sutured, and reinforced with an absorbable sheet. In both cases, PD was resumed without any complication.ConclusionWe successfully treated two infants of PPC by endoscopic surgery. To identify the fistula site, the ICG navigation method was useful. Even in small infants, PPC can be treated successfully by endoscopic surgical repair if the site of the fistula is identified.

Laparoscopic cholecystectomy for left-sided gallbladder.

Left-sided gallbladder (LSGB) is a rare congenital anomaly in the gallbladder, which is defined as a gallbladder located on the left side of the falciform ligament without situs inversus. We retrospectively analyzed 13 patients diagnosed with LSGB in a single center to confirm the safety of laparoscopic cholecystectomy (LC) and reviewed the anatomical implications in those patients. Of the 4910 patients who underwent LC for the treatment of gallbladder disease between August 2007 and December 2019, 13 (0.26%) were diagnosed as having LSGB. We retrospectively analyzed these 13 patients for general characteristics, perioperative outcomes, and other variations through the perioperative imaging workups. All patients underwent LC for gallbladder disease. In all cases, the gallbladder was located on the left side of the falciform ligament. The operation was successfully performed with standard four-trocar technique, confirming "critical view of safety (CVS)" as usual without two cases (15.4%). In one case, which had an intraoperative complication and needed choledochojejunostomy because of common bile duct injury, there was an associated variation with early common bile duct bifurcation. The other patient underwent an open conversion technique because of severe fibrosis in the Calot's triangle. Furthermore, on postoperative computed tomography, abnormal intrahepatic portal venous branching was found in all cases. Although LSGB is usually encountered by chance during surgery, it can be successfully managed through LC with CVS. However, surgeons who find LSGB have to make efforts to be aware of the high risk of bile duct injury and possibility of associated anomalies.

Complicated intra-abdominal focal fat infarction: Emphasis on falciform ligament infarction with abscess formation: A case series

The term “Intra-Abdominal Focal Fat Infarction” (IFFI) encompasses a range of conditions where infarction of fatty tissue is the underlying pathological process, including Epiploic appendagitis, omental infarction, fat necrosis related to trauma or pancreatitis as well as rarer entities such as falciform ligament infarction. Uncomplicated IFFI is usually self-limiting and managed conservatively with oral antiinflammatory therapy. Rarely complications such as liquefaction and secondary abscess formation may arise with associated deterioration in symptoms and signs prompting a change in management including Laparoscopic resection or Percutaneous drainage. We present 3 cases of complicated IFFI with emphasis on the rarer Falciform ligament infarction with abscess formation.

Small bowel obstruction due to internal herniation through a defect in the falciform ligament: a rare case report and review of the literature

BackgroundThe falciform ligament hernia is a type of internal herniation, caused by a defect in the falciform ligament of the liver. The etiology for this defect may be congenital or iatrogenic, created after the laparoscopic intervention.Case presentationA 45-year-old male was presented to our hospital, complaining of abdominal pain for 2 days. The physical examination revealed diffuse abdominal tenderness and guarding. The abdominal X-ray was suggestive of intestinal obstruction. On abdominal CT images, dilated proximal ileal loops between the left hepatic lobe and anterior abdominal wall, forming a closed-loop with mesenteric edema and fat stranding, were observed. There were findings of ileus in the jejunal loops proximal to this segment, but the ileal loops and the colon were completely collapsed, consistent with small bowel obstruction due to internal herniation through a defect in the falciform ligament. The patient underwent surgical intervention, reduction of the herniated bowel loops, and repairing the hernia defect. He had an uneventful recovery with a favorable outcome.ConclusionHerniation through a defect in the falciform ligament is extremely rare but should be considered in the differential diagnosis of acute abdomen. The clinical manifestations of falciform ligament hernia are nonspecific and may underestimate the diagnosis, leading to a delayed treatment that affects the management outcome. Computed tomography plays an important role in the timely diagnosis and planning of surgical intervention, precluding intestinal strangulation.

Extradural anterior clinoidectomy in surgical management of clinoidal meningiomas

BackgroundDespite the recent advances in skull base surgery, microsurgical techniques, and neuroimaging, yet surgical resection of clinoidal meningiomas is still a major challenge. In this study, we present our institution experience in the surgical treatment of anterior clinoidal meningiomas highlighting the role of extradural anterior clinoidectomy in improving the visual outcome and the extent of tumor resection. This is a prospective observational study conducted on 33 consecutive patients with clinoidal meningiomas. The surgical approach utilized consisted of extradural anterior clinoidectomy, optic canal deroofing with falciform ligament opening in all patients. The primary outcome assessment was visual improvement and secondary outcomes were extent of tumor resection, recurrence, and postoperative complications.ResultsThe study included 5 males and 28 females with mean age 49.48 ± 11.41 years. Preoperative visual deficit was present in 30 (90.9%) patients. Optic canal involvement was present in 24 (72.7%) patients, ICA encasement was in 16 (48.5%), and cavernous sinus invasion in 8 (24.2%). Vision improved in 21 patients (70%), while 6 patients (20%) had stationary course and 1 patient (3%) suffered postoperative new visual deterioration. Gross total resection was achieved in 24 patients (72.7%). The main factors precluding total removal were cavernous sinus involvement and ICA encasement. Mortality rate was 6.1%; mean follow-up period was 27 ± 13 months.ConclusionsIn this series, the use of extradural anterior clinoidectomy provided a favorable visual outcome and improved the extent of resection in clinoidal meningioma patients.

Outcomes of surgical management of peptic ulcer perforation using the falciform ligament: A cross-sectional study at a single centre in Vietnam

IntroductionPeptic ulcer perforation (PUP) is one of the most common critical surgical emergencies. The omentum flap is commonly used to cover a PUP. However, the omentum cannot be used in cases of severe peritonitis or previous surgical removal. This is the first study conducted in Vietnam that was designed to analyse the outcomes of patients with PUPs who were treated using the falciform ligament. MethodIn this study, we retrospectively identified 40 consecutive patients who were treated for PUP at a single high-volume centre in Vietnam from February 2018 to February 2021. Peptic ulcer perforation was measured during diagnostic evaluation based on preoperative imaging, such as X-ray, and CT scan. Patients who had malignancy, laparoscopic surgery, omentopexy and nonoperative treatment were excluded from this research. ResultsForty patients were included; the mean age of the patients was 66.3 years (range 33–99 years), and some patients had comorbid disease (57.5%), hypertension (30%), diabetes (10%), cirrhosis (7.5%), and chronic renal failure (7.5%). The PUPs were located in the duodenum (80%), or the pyloric (15%) and prepyloric (5%) regions. The procedures used to treat the patients included duodenostomy (32.5%), gastrojejunostomy (37.5%), and antrum resection (2.5%). The average operative time was 88.6 min (45–180 min), hospital stay was 9.6 days (2–35 days), and oral intake was started at 4.1 days (3–8 days); additionally, the 30-day mortality (17.5%) and incidences of pneumonia (25%), multiorgan failure (15%), acute liver failure (5%), wound infection (7.5%), and ulcer peptic fistula (0%) were assessed. Univariate tests showed that an ASA ≥ III and comorbidities, such as pulmonary complications, liver failure and multiorgan failure, were associated with mortality. The multivariate test showed that multiorgan failure was the only factor related to mortality. ConclusionThe falciform ligament can be efficiently used for the closure of a PUP. Although there were no instances of complication with a reperforated peptic ulcer, the mortality rate was slightly highly related to severe comorbidities and postoperative multiorgan failure.

Optic Nerve Mobilization as an Alternative to Anterior Clinoidectomy for Superior Carotid–Ophthalmic Aneurysms: Operative Technique

Carotid-ophthalmic aneurysms arise from the internal carotid artery between the distal dural ring and the origin of the posterior communicating artery. The surgical treatment of these aneurysms usually requires anterior clinoidectomy. However, this procedure is not without complications. In the present report, we have described optic nerve mobilization after optic foraminotomy as an alternative to anterior clinoidectomy to clip superior carotid-ophthalmic aneurysms. We have reported the cases of 3 patients with superior carotid-ophthalmic aneurysms who had undergone surgical clipping. Instead of an anterior clinoidectomy, the optic nerve was mobilized after performing optic foraminotomy. The optic canal was carefully unroofed with a 3-mm, high-speed, diamond drill under constant cold saline irrigation to avoid thermal damage to the optic nerve. After incision of the falciform ligament and optic sheath, the optic nerve was gently mobilized with a No. 6 Penfield dissector, facilitating aneurysmal neck exposure and clipping through a widened opticocarotid triangle. The postoperative course was uneventful for all 3 patients, without any added visual defect. Optic nerve mobilization allowed us to safely widen the opticocarotid triangle and dissect the aneurysm off the optic nerve, without the need for clinoidectomy. This alternative technique permitted, not only early decompression of the optic nerve, but also dissection of the arachnoid between the inferior surface of the optic nerve and the superior surface of the ophthalmic-carotid artery and aneurysm dome. Optic nerve mobilization after optic foraminotomy proved to be a safe and relatively easy technique for exposing and treating superior carotid-ophthalmic aneurysms.

Recurrent Sphenocavernous Meningioma.

A case of a recurrent sphenocavernous meningioma is presented. The patient is a 42-year-old male who presented with an episode of transient right-sided numbness. A magnetic resonance imaging (MRI) revealed a large left sphenocavernous meningioma. The patient underwent a frontotemporal craniotomy for tumor resection. Near total resection was achieved with minimal residual in the left cavernous sinus (CS) and orbital apex. The pathology was consistent with meningioma, World Health Organization (WHO) grade I. A follow-up MRI was done 9 months after surgery and showed a growth of the residual tumor, which was treated with intensity modulated radiotherapy. Tumor growth was detected on serial imaging over a 4-year period. Surgical resection was offered. A left frontotemporal craniotomy with pretemporal transcavernous approach was performed. The bone flap was reopened and the dura was opened in a Y-shaped fashion. The roof of the optic canal was drilled off, and the falciform ligament was opened to decompress the optic nerve. The tumor was disconnected from the anterior clinoid region (the anterior clinoid process was eroded by the tumor) and reflected off the wall of the lateral CS. Tumor was adherent to the V2 fascicles (the lateral CS wall was resected in the first surgery) and was sharply dissected off. Gross total resection was achieved. The pathology was consistent with meningioma, WHO grade I. The patient had an unremarkable postoperative course without any new neurological deficits. The link to the video can be found at: https://youtu.be/KVBVw_86JqM .

Novel use of the falciform ligament for reconstruction of the inferior vena cava and its tributary.

Tumor invasion into the inferior vena cava (IVC) and hepatic vein (HV) is challenging in cancer surgery with curative intent. Appropriate techniques for venous reconstruction are essential. We have described in detail a novel technique of fashioning an interposition tube graft using the falciform ligament to reconstruct the IVC and HV. The falciform ligament maintains all the benefits of an autologous tissue graft, with the added advantage of its flexibility in customizing graft dimensions. Its use in IVC and HV reconstruction has rarely been reported. The short-term outcomes with this tube graft are promising.

Laparoscopic surgery of epidermoid cyst of the falciform ligament: A case report.

Introduction and importanceThe falciform ligament is a peritoneal fold that extends from the anterior abdominal wall to the liver, which divides the liver into two lobes. Cysts of the falciform ligament are rare and without an apparent cause. The range of the symptoms can vary from abdominal pain to asymptomatic patients. Cysts are treated surgically, and resection is used to make a definitive diagnosis.Case presentationA 36-year-old female patient was treated at an outpatient facility for epigastric pain that lasted for three months. Abdominal MRI and MSCT were performed to verify a cyst formation in the left liver area of about 12 cm in size. Laparoscopic resection of the cist was performed under general endotracheal anaesthesia.Clinical discussionFalciform ligament tumours can be malignant or benign. Treatment of the cyst includes complete excision and pathohistological diagnosis to rule out malignancy. In most cases reported thus far, excision has been done after laparotomy. In our case, the operation was performed in a less invasive way, laparoscopically.ConclusionLaparoscopy can serve as a diagnostic and therapeutic method for cysts of the falciform ligament, both smaller and more significant, that infiltrate the surrounding structures.

Anterograde intraoperative pancreatic stent placement and round ligament patch to prevent pancreatic fistula after distal pancreatectomy

Postoperative pancreatic fistula in distal pancreatectomy is one of the most important complications in this surgery and it is associated with high morbidity and mortality. Pancreatic fistula after distal pancreatectomy remains an unsolved problem and none preventive procedure has been shown effectively.We present a new technique that combine pancreatic stent placement with round ligament autologous patch over pancreatic edge.A guide is introduced through Wirsung duct prior to stent placement. After stent assessment, Wirsung duct is closed. Finally, falciform ligament autologous patch is placed over pancreatic edge. After 6–8 weeks, the stent is removed by oral endoscopy.This technique introduces a new issue on the pancreatic fistula prevention.