Peritoneal Folds Research Articles

Small bowel occlusion due to congenital peritoneal encapsulation treated with laparoscopic resection of the hernia sac: A diagnostic and therapeutic challenge

Congenital peritoneal encapsulation (CPE) is an extraordinarily rare condition characterized by an additional peritoneal membrane encasing part or whole of the small intestine. The etiology of CPE, believed to originate from atypical adhesions during fetal mid-gut development, remains uncertain. Clinical presentations involving intestinal obstruction are extremely rare. We report a case of a 39-year-old male of Egyptian origin who presented to our emergency department with abdominal pain and vomiting. Initial abdominal computed tomography scan showed no mechanical obstruction. However, worsening symptoms necessitated laparoscopic exploration, which revealed a mechanical obstruction in the jejunum due to a peritoneal-vessel band and CPE involving the initial segment of the small bowel. The peritoneal fold, encircling the first jejunal loops, was resected up to the Treitz ligament, releasing the jejunum. The patient had an uncomplicated postoperative recovery and was discharged on the fourth postoperative day.

Intestinal Obstruction Due to a Congenital Band: Two Cases of Congenital Bands in Adults

Small bowel obstruction is the most common surgical disorder of the small intestine. Adhesions are by far the most frequent causes followed by hernias, tumors, intussusception, foreign bodies, gallstones, and inflammatory bowel disease. During embryogenesis, abnormal adhesion of the peritoneal folds induces a congenital band which can cause small bowel obstruction. It is extremely rare and usually observed in childhood. We report two cases of small bowel obstructions in adults due to congenital bands. The first patient is a woman of 47 years-old admitted for chronic abdominal pain, and the second one is a 20 years-old man admitted for the etiological assessment of chronic constipation. Surgical exploration was performed revealing a small bowel obstruction due to congenital band with complete resolution of the symptoms after surgery.

Step-by-step Peritoneal Bladder Flap Bunching (PBFB) technique: an innovative approach following lymph node dissection in robotic radical prostatectomy.

Robot-assisted radical prostatectomy (RARP) has become a popular surgical approach for localized prostate cancer due to its favorable oncological and functional outcomes, as well as lower morbidity. In cases of intermediate- and high-risk prostate cancer, bilateral pelvic lymphadenectomy (PLND) is recommended as an adjunct to RARP (1-3). Despite its benefits, PLND can lead to surgical complications, with postoperative lymphocele formation being the most common. Most postoperative lymphoceles are clinically insignificant with variable incidence, reaching up to 60% of cases 4. However, a small percentage of patients 2-8% may experience symptomatic lymphoceles (SL), which can cause significant morbidity (4, 5). We perform our RARP technique with our standard approach in all patients (6). After vesicourethral anastomosis a modified PF created to prevent symptomatic lymphocele. We start by suturing the peritoneal fold on the right side, medially to the vas deferens, followed by a similar stitch on the left side to approximate the edges in the midline. A running suture bunches the bladder peritoneum from both sides, passing through the pubic bone periosteum to secure it in place (7). This approach keeps the lateral pelvic gutters open for lymphatic drainage, while allowing fluid drainage from the true pelvis into the abdomen. A pelvic ultrasound was done for all patients at 6 weeks post operative, and additional clinical follow-up was carried out at 3 months following surgery. We have demonstrated a modified technique of peritoneal flap (PBFB) with an initial decrease in postoperative symptomatic lymphoceles, the technique is feasible, safe, does not add significant morbidity, and does not require a learning curve.

VNOTES hysterectomy using the lateral window technique in case of a ventrofixed uterus following previous cesarean sections: A video article

vNOTES uses the vagina as the surgical channel for endoscopy and achieves improved cosmesis compared to conventional laparoscopy as there are no abdominal incisions. Ventrofixation of the uterus to the abdominal wall following previous cesarean sections further adds to the surgeon's concern of bladder injury. In such cases, a modification of the technique is proposed: introducing the vNOTES port first, before the opening of the vesico-uterine peritoneal folds, thus carried out under endoscopic view. Medial anterior vesico-uterine adhesions are identified and circumscribed by creating a lateral window in the broad ligament on both sides. This allows the cutting of adhesions under endoscopic view to minimize the risk of bladder injuries. The aim of this technical note is to present this modification of the surgical technique for vNOTES hysterectomy in case of ventrofixed uterus.

An interlobar ligament connecting the right and left lobes of the liver – A cadaveric case report

Several ligaments and peritoneal folds attach the liver to other organs and to the abdominal wall. These are the falciform ligament, ligamentum teres hepatis or round ligament, right triangular ligament, left triangular ligament, lessor omentum, and ligamentum venosum. We report a unique ligament connecting the right and left lobes of the liver, on its visceral surface near its inferior border. This ligament is seen forming a tunnel through which the ligamentum teres is seen to travel.The knowledge can be used by the radiologists and clinicians in image interpretation and subsequent clinical diagnosis and by anatomists and embryologists for academic interests. Further, this ligament and the tunnel formed by it maybe a potential site for strangulation of abdominal content.

A marginal branch of the left hepatic artery running along the umbilical vein and supplying the anterior surface of the liver left lobe: a report of 5 cases in 12 Japanese human fetuses.

In human fetuses, the left hepatic artery (LHA) issues the marginal artery that runs along the umbilical vein and, sometimes, reaches the umbilicus. The further observation demonstrated that, in 5 of 12 Japanese midterm fetuses (crown-rump length mm: 46, 50, 54, 59, 102), the marginal artery issued not only a thin umbilical branch but also a liver parenchymal branch that took a posterosuperior recurrent course in a peritoneal fold and supplied the anterior surface of the liver left lobe (segment III). However, in 22 Spanish fetuses of which gestational ages corresponded to the Japanese ones, we did not find the parenchymal branch. Therefore, between human populations, there seemed to be a considerable difference in the incidence as to whether or not the marginal artery issues the liver parenchymal branch. The parenchymal branch might be degenerated at the later stages due to friction between the liver free surface and growing diaphragm.

Agenesis of gallbladder-series of four cases - why it is difficult to diagnose preoperatively?

Agenesis of gallbladder (AGB) is a rare clinical entity first reported by Bergman in 1702. The incidence is about in 10–65 cases/1,00,000 population. It is seen in 1/6th cases of biliary atresia. It is of unknown etiology and is believed to be due to abnormal embryonic development. Nearly 70% cases are sporadic. AGB may be associated with other congenital abnormalities including the biliary system. The majority (nearly 50%) of the patients are symptomatic with misinterpreted signs and symptoms of cholecystitis and lands up to unnecessary surgery. Our series of four cases have male: female ratio of 3:1. Two of the cases underwent laparoscopic surgery. Among the other two, one had biliary pancreatitis due to primary calculous in the common bile duct (CBD) with upstream dilation. Other cases had chronic pancreatitis with dilated pancreatic duct and a proximal calculous close to ampulla causing proximal dilation of CBD. Two operated cases were postoperatively diagnosed by magnetic resonance cholangiopancreatography (MRCP) and the non-operated patients were also diagnosed by MRCP. Symptomatic AGB is often wrongly interpreted as cholecystitis with cystic duct obstruction or as sclero-atrophic gallbladder, therefore leading to pointless surgical interventions. In case of false-positive ultrasonography (USG) of AGB, it has been suggested that either a loop of gas-containing bowel located in the gallbladder fossa or periportal tissue and subhepatic peritoneal folds impersonate a contracted gallbladder containing gallstones. When USG reveals such reports or in cases of non-visualization in other imaging modalities, the need of additional preoperative imaging investigation must be in the surgeon’s mind such as MRCP to avoid surgery which is not at all required.

A ligament to identify the inferior limit of dissection in minimally invasive surgery for inguinal hernia

Background: Minimally invasive surgery has recently become the approach of choice for surgeons for inguinal hernia repair. Subsequent to excellent visualisation of the preperitoneal space by high definition and 4K systems during laparoscopy and robotic surgery, as well as increasing use of multi detector CT scans to visualise abdomen, our knowledge of the anatomy of the posterior view of inguinal region has been enhanced. However, recurrence after surgery for groin hernia continues to be an issue during its learning curve especially for laparoscopic repair. One cause for recurrence is the infolding of the mesh after its placement in the preperitoneal space. A reason for this is inadequate dissection of the peritoneal fold especially inferomedially. The peritoneum has to be dissected inferomedially till the point where the vas deferens turns medially. During the course of a randomised study done to compare Transabdominal preperitoneal mesh repair with Totally extraperitoneal mesh repair for Inguinal hernia, a structure was seen passing from the medial aspect of the vas deferens where it turned medially Methods: Prospective analysis of 106 consecutive patients who underwent laparoscopic inguinal hernia was done to identify the presence of such a ligament. Results: This study demonstrates the existence of a ligamentous structure from the vas deferens to the posterior lamina of subparietal layer of peritoneal space at the site where the vas turns medially. Conclusions: Identification and division of this ligament will help to ensure complete dissection of the peritoneum inferiorly as well as creaseless placement of mesh thus preventing recurrence.

Computed tomography of suppurative and neoplastic diseases involving the canine omenta and omental bursa.

The greater and lesser omenta are fused peritoneal folds that largely delimit the omental bursa (lesser peritoneal cavity). The omental bursa is a potential space within the abdominal cavity that communicates with the greater peritoneal cavity via the omental (epiploic) foramen: it is subdivided into the omental vestibule, caudal omental recess, and splenic recess. Aims of this retrospective case series study were to describe the frequencies of CT findings of dogs with confirmed inflammatory or neoplastic disease of the omenta, omental bursa, or both. The sample included seven adult, medium-to-large breed dogs. All had fluid in the greater peritoneal cavity and 5/7 (71%) dogs also had fluid in the omental bursa. Primary suppurative inflammatory disease was present in three dogs, each dog had a large abscess with central gas in either the omental vestibule (two dogs) or caudal omental recess (one dog). Both abscesses in the omental vestibule arose from the papillary process of the caudate liver lobe and were surgically removed without complication. Neoplasia was present in four dogs and either arose from omentum (hemangiosarcoma, carcinoma) or infiltrated the omentum from an adjacent organ (splenic leiomyosarcoma, gastric adenocarcinoma). Neoplasms created mass-like tumors, infiltrative tumors, or both and had variable distribution (focal, multifocal, or locally extensive). All dogs with neoplasia were euthanized. CT signs of inflammatory and neoplastic disease overlapped, but the presence of gas might prioritize abscessation. CT signs helped decide feasibility of surgery based on extent of local invasion, especially involvement of structures passing through the porta hepatis.

Unusual case of falciform ligament internal hernia in pregnancy

Acute abdomen in pregnancy poses various diagnostic challenges due to limitations in imaging modalities. It can be due to an obstetric or non-obstetric cause. Internal hernia through congenital defects is rare. Although internal hernia is not prevalent in pregnancy, it is increasing nowadays due to previous surgical defects in the mesentery and peritoneal folds. We report an unusual case of an internal hernia through a defect in the falciform ligament in a pregnant female where imaging findings helped in timely surgical intervention.

Surgical principles of vaginal hysterectomy with cervical elongation

A review of strategies and key surgical principles for approaching the difficult anterior and posterior peritoneal entry encountered during vaginal hysterectomy with cervical elongation. Cervical elongation is a known entity among pelvic surgeons, however it lacks a universal quantitative definition. In the literature, it has been variably defined by pathologic measurements, POP-Q exam, or surgeon’s perception. One study found that cervical elongation was present in 16-40% of patients undergoing vaginal hysterectomy for pelvic organ prolapse and was associated with increased operative time. Unfortunately, cervical elongation is often discovered for the first time intraoperatively, at which time it can make anterior and posterior entry difficult due to altered anatomy.1–6 When cervical elongation is discovered, patience is key. This video highlights four surgical principles we have adopted from the laparoscopic approach to assist in safe completion of the procedure. First, continue to completely excise the vaginal attachments to the cervix. This will allow the uterus to begin to descend into the operative field and improve exposure/visualization. Two, as the cardinal ligament is reached, separate the leaves of the broad ligament to visualize the uterine vessels. Isolate the descending uterine branches at the 3 and 9 o’clock position. Three, continue to secure the uterine vessels laterally until the lower uterine segment is reached. Four, once the ascending branches of the uterine artery are isolated, the vesicouterine peritoneal fold can be approached from lateral to medial and anterior entry accomplished. Cervical elongation is difficult to predict. When encountered, we've found it helpful to adopt strategies from laparoscopy. These techniques may be applied in other scenarios where anterior or posterior entry is difficult.

Hepato-Duodeno-Colic Fold and Sessile Sigmoid Colon – Rare Peritoneal Bands in Abdomen

The presence of aberrant peritoneal folds is one of the differential diagnoses of intestinal obstruction in the pediatric population. Therefore, knowing the variations in the attachment pattern of peritoneum and its folds is essential. In this context, we report a rare peritoneal fold found during the routine human cadaveric dissection of the abdomen, which is attached superiorly to the liver including the gallbladder and inferiorly extended as a bilaminar fold with one attaching to duodenum and other to transverse colon. In addition, the sigmoid colon was completely plastered to the posterior pelvic wall. This variant peritoneal fold is named as hepato-duodeno-colic ligament and is described in detail with its clinical context. The knowledge regarding this abnormal peritoneal fold would be highly useful for surgeons while planning laparoscopic procedures in the upper quadrant of the abdomen.

Different Positions of Vermiform Appendix in Human Cadavers: A Cross-sectional Study

Introduction: The vermiform appendix is a wormlike tube situated in the right iliac fossa. It arises from the posteromedial cecal wall, 2 cm or less below the end of the ileum and suspended by a peritoneal fold known as meso appendix. Position of the appendix influences its mobility. Most common position of appendix has been reported to be retrocecal followed by pelvic position. But there are other variable positions also reported by many. Aim: To study the anatomical variations of the positions of vermiform appendix in human cadavers. Materials and Methods: This was a descriptive cross-sectional study which was carried out in the Department of Anatomy, Assam Medical College, Dibrugarh, Assam, India, from June 2020 to May 2021. Total 14 adult cadavers and 66 new born cadavers were included in the study. All the cadavers were dissected and abdominal cavity was explored. The position of the appendix was then noted in all specimens. Results: In most of the cases the position of vermiform appendix was found in retrocecal position followed by pelvic, pre-ileal and paracolic. In adults, retrocecal positions were more in males (88.9%) than females (40%) in contrast to newborns where retrocaecal positions were more in females (76.7%). As a whole, retrocecal position (66.25%) of appendix was the commonest finding in all cadavers. This was followed by pelvic (30%) position. Paracolic (2.5%) and pre-ilial (1.25%) positions were also noted in newborn cadaver. Conclusion: Knowing the variations in the position of appendix will guide the surgeons during intraoperative procedures. Since the positions of appendix vary considerably signs and symptoms also vary depending upon the different positions. Hence, the knowledge of its diverse anatomical positions is of utmost importance which helps the surgeons in proper management of appendicular pathology.

P-BN28 The Consistency of Operative Safety Markers and the Critical View of Safety During Laparoscopic Cholecystectomy: A Pilot Study

Abstract Background Safe laparoscopic cholecystectomy(LC) depends on surgeon's experience, operative difficulty, utilisation of traditional safety markers, adapting the dissection technique and, where possible, displaying the critical view of safety (CVS) to confirm cystic pedicle structures prior to division. The Safe Cholecystectomy Multi-Society Practice Guidelines and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy identified no direct comparative evidence to support the CVS over other methods of anatomic identification. The aim of this study, therefore, was to examine the consistency of safety markers guiding the dissection and to determine the value of displaying the CVS. Methods A pilot study was conducted, reviewing video recordings of 241 LCs (144 retrospective and 97 prospective). The consistency of the Rouvier Sulcus (RS), the cystic lymph node (CLN), identification of the common bile duct (CBD) and duodenum and a new marker; the “cystic duct fold” (CDF), the peritoneal fold stretching between the retracted Hartman's Pouch and the CBD guiding the dissection at its distal end over the gallbladder neck, was documented. Data on the safety marker used to commence dissection, gallbladder condition, the LC difficulty grade, the selected technique and whether the CVS was achieved was recorded and analysed. Results Although the CBD and duodenum were visualised in 77%, the CDF was identifiable in 56% (CLN in 52.3%, RS in 50.2%) and the most consistently used to commence dissection in 51.4% (CLN 17.4%, CBD in 11.6% and RS in 6.6%). 12.8% required access to the infundibulum using sub-serosal or trans-vesical dissection (41% had acute cholecystitis, empyema or gangrenous gallbladders). Infundibular dissection was used in 88%. CVS was achievable in 56.8%. The CDF dropped form 87% in difficulty grades 1 and 2 to 16.5% in grades 4 and 5 with the CLN used in 21% of these difficult LCs. Conclusions A new safety marker, the CDF is proposed, being more reliable and safer on account of starting the dissection away from the CBD and potentially aberrant ducts, contrary to the line of RS. The CLN is more reliable in difficult LC, especially with acute inflammation. Infundibular dissection remains the default approach to “target identification” required to display the CVS. The true value of the CVS, as an end product of the process of dissection, lies in “target confirmation” before dividing any structures and in clearing the cystic plate to avoid injury to Couinaud Types C, F and hepato-cystic ducts.

P125 MANAGEMENT OF PERICAECAL HERNIA CAUSING SMALL BOWEL OBSTRUCTION IN THE EVOLVING ERA OF LAPAROSCOPY. A CASE REPORT AND LITERATURE REVIEW

Abstract Introduction “Internal hernias are an unusual cause of intestinal obstruction. Pericaecal hernias are an exceptionally rare type of internal hernia. Laparoscopy for small bowel obstruction was previously considered inappropriate. We present a case of Pericaecal hernia causing small bowel obstruction treated successfully with a laparoscopic approach.” Case-Report “64 year old man presented with abdominal pain, vomiting and constipation for 3 days, no previous surgery. Small bowel obstruction confirmed on PFA and CT. He was treated conservatively for 10 days without settling. A an exploratory laparoscopy revealed a Pericaecal hernia. This was reduced with gentle manoeuvre and the peritoneal folds were divided to prevent recurrence. Recovery was uneventful.” Discussion “Perioperative diagnosis of internal hernia is extremely difficult. Pericaecal hernia is an uncommon type of internal hernia. CT diagnosis of internal hernia remains difficult. Laparoscopy is a valuable tool for diagnosis and treatment with the advantage of minimal invasiveness. However, the laparoscopic manipulation of distended bowel loops remain controversial because of high risk of perforation, reduced space to work in the peritoneal cavity and requirement of advanced laparoscopic skills. Laparoscopic treatment of Pericaecal hernia was reported about 17 years ago but has since been reported more frequently and in recent years there is a move towards laparoscopic diagnosis and management of Pericaecal hernias.” Conclusions “CT diagnosis of internal hernia remains difficult. With the advent of minimal access surgery, diagnostic laparoscopy may be a safe and feasible modality to diagnose and deliver definitive treatment of small bowel obstruction secondary to Pericaecal hernia.”

META-ANALYSIS ON ETIOPATHOGENESIS OF SMALL BOWEL OBSTRUCTION IN THE DEPARTMENT OF GEN. SURGERY P.M.C.H. & K.M.C.H., BIHAR

Background:The small intestine is the longest and convoluted portion in the digestive tract. It starts from pylorus and ends at ileocaecal valve. The small bowel consists of three parts measuring about 5 to 6 meters. The rst 25cm is the duodenum. Out of the rest part of small gut, jejunum th th. constitute the proximal 2/5 and ileum distal 3/5 The jejunum and ileum extend from the peritoneal fold that supports the duodeno-jejunal junction (Ligament of Treitz) down to ileocaecal valve. Material and Methods:All the patients admitted to PMCH, Patna and KMC, Katihar as intestinal obstruction was included for the study. The time period of study was from October 2014 to November 2016 in PMCH and December 2016 to January 2019 in KMC, Katihar. Out of all Intestinal obstruction 59 cases only of adult small gut obstruction were recorded for comparison and conclusive study.Conclusion: Small bowel obstruction remains a frequently encountered problem in abdominal surgery. Although modern day surgical management continues to focus appropriately on avoiding delayed operation, whatever surgery is indicated, not every patient is always best served by immediate operation

What is the precaecocolic fascia?

The precaecocolic fascia, previously known as Jackson's membrane, is a variable vascular peritoneal fold between the ascending colon and the right posterolateral abdominal wall. First described in 1913, it was originally thought to be of developmental or inflammatory origin and associated with abdominal pain. This investigation aimed to review its frequency, form and structure and look for evidence of association with malformation of the bowel, or previous inflammation. 26 dissecting room cadavers were studied to identify the precaecocolic fascia, any malrotation of the colon or signs of previous inflammation: adhesions, surgical scars, or absence of the appendix. Its structure was examined histologically and latex injections were used to trace the arteries. Membranes comparable with previous descriptions of the precaecocolic fascia occurred in 12 of 26 abdomens. They varied in form and size from long and translucent to short, thick, and opaque. In structure, the fascia resembled a fold of peritoneum containing a thickened fibrous lamina. Large thin-walled arteries in the fascia crossed the arteries in the wall of the colon at the point of attachment. No significant association with colonic malrotation or markers of previous inflammation were found. Attention should be paid to the definition of the precaecocolic fascia and "membrane" seems a more appropriate term than "fascia". It is one of a recognized group of peritoneal folds/bands, doubtful in origin but unlikely to be post-inflammatory. It may modify colonic mobility or complicate colonic operations.

Broad Ligament Pregnancy: Facing the Battle Unarmed

Abstract Broad ligament pregnancy is defined as gestation that grows in the space formed by anterior and posterior peritoneal folds of the broad ligament. We report a case of 30 years old lady admitted to our hospital with the diagnosis of gravida 2, para 1, live birth 1, with 24 weeks of gestation with low lying placenta with anhydramnios. She was taken up for lower segment cesarian section at 28 weeks gestation in view of low lying placenta with chorioamnionitis. The broad ligament pregnancy was diagnosed peroperatively after identifying the anatomical relationship of the pregnancy. Sac was excised and margins secured after extraction of the baby and placenta. Patient had an uneventful postoperative period. Broad ligament pregnancy may be missed in antenatal period but in cases of displaced cervix, early onset unexplained anhydramnios, and failed induction of labor, it may raise high suspicion. Laparotomy/ laparoscopic management is the mainstay of management of broad ligament pregnancy.

Suspension sutures facilitate single-incision laparoscopic-assisted rectal pull-through for Hirschsprung disease

BackgroundTo present a surgical technique of single-incision laparoscopic-assisted endorectal pull-through (SILEP) with suspension sutures using conventional instruments for Hirschsprung disease (HD) and its long-term follow-up outcomes.MethodsThe procedure began with a 1 cm transumbilical skin incision. Three separate punctures were made in the fascia with a 5 mm scope in the middle and 5 mm and 3 mm ports for working instruments on the left and right, respectively. The first suspension suture was placed to secure the sigmoid colon to the abdominal wall. A window was created through the rectal mesentery, and dissection around the rectum was carried out. The second suspension suture was performed to suspend the rectovesical peritoneal fold or the rectovaginal peritoneal fold to the abdominal wall. Dissection around the rectum was continued downward to approximately 1 cm below the peritoneal fold. Then, the operation was completed by a transanal approach.ResultsForty patients underwent SILEP from March 2013 to April 2015. The median age was 2.7 months (ranging from 1 to 17 months). The mean operative time was 96 ± 23 min. No conversion to an open operation was required. The average hospitalization time was 4.5 ± 2 days. There were no intraoperative or perioperative complications. Long-term follow-up results were obtained from 38 patients. A frequency of defecation from every other day to twice a day was noted for 33 patients (86.8%) and more often for 5 patients (13.2%). Two patients had enterocolitis (5.2%).ConclusionSingle-incision laparoscopic rectal pull-through with suspension sutures using conventional instruments is feasible and safe for HD with good long-term outcomes.

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.