Right-sided Ligamentum Teres Research Articles

Predicting portal venous anomalies by left-sided gallbladder or right-sided ligamentum teres hepatis: A large scale, propensity score-matched study.

Right-sided ligamentum teres (RSLT) is often associated with portal venous anomalies (PVA) and is regarded as a concerning feature for hepatobiliary intervention. Most studies consider RSLT to be one of the causes of left-sided gallbladder (LGB), leading to the hypothesis that LGB must always be present with RSLT. However, some cases have shown that right-sided gallbladder (RGB) can also be present in livers with RSLT. To highlight the rare variation that RSLT may not come with LGB and to determine whether ligamentum teres (LT) or gallbladder location is reliable to predict PVA. This study retrospectively assessed 8552 contrast-enhanced abdominal computed tomography examinations from 2018 to 2021 [4483 men, 4069 women; mean age, 59.5 ± 16.2 (SD) years]. We defined the surrogate outcome as major PVAs. The cases were divided into 4 subgroups according to gallbladder and LT locations. On one hand, we analyzed PVA prevalence by LT locations using gallbladder location as a controlled variable (n = 36). On the other hand, we controlled LT location and computed PVA prevalence by gallbladder locations (n = 34). Finally, we investigated LT location as an independent factor of PVA by using propensity score matching (PSM) and inverse probability of treatment weighting (IPTW). We found 9 cases of RSLT present with RGB. Among the LGB cases, RSLT is associated with significantly higher PVA prevalence than typical LT [80.0% vs 18.2%, P = 0.001; OR = 18, 95% confidence interval (CI): 2.92-110.96]. When RSLT is present, we found no statistically significant difference in PVA prevalence for RGB and LGB cases (88.9 % vs 80.0%, P > 0.99). Both PSM and IPTW yielded balanced cohorts in demographics and gallbladder locations. The RSLT group had a significantly higher PVA prevalence after adjusted by PSM (77.3% vs 4.5%, P < 0.001; OR = 16.27, 95%CI: 2.25-117.53) and IPTW (82.5% vs 4.7%, P < 0.001). RSLT doesn't consistently coexist with LGB. RSLT can predict PVA independently while the gallbladder location does not serve as a sufficient predictor.

Laparoscopic Cholecystectomy in Patients with Left Sided Gallbladder Using an Indocyanine Green (ICG) Fluorescence Cholangiography

Introduction: Left-sided gallbladder is a relatively rare anatomical variation that is frequently associated with a biliary system anomaly. In patients with LSGB, LC is associated with a higher incidence of bile duct injury (4.4%), necessitating the establishment of a safe surgical approach in these patients. Here, we describe a case of left-sided gallbladder with cirrhotic liver treated by using an ICG fluorescence cholangiography during laparoscopic cholecystectomy. Method & Results: 62-year-old man with gallbladder adenomyoma was admitted to our hospital. Computed tomography demonstrated that the gallbladder was centrally dislocated and left-sided gallbladder with right-sided ligamentum teres. A laparoscopic cholecystectomy was performed. The round ligament was attached to the right side of the gallbladder, and the left-sided gallbladder was diagnosed by intraoperative findings (figure 1.). The patient was discharged 2 days after surgery without postoperative complications. Conclusions: ICG fluorescence cholangiography should be used in cases of left-sided gallbladder during laparoscopic cholecystectomy. An assessment of the extra- and intrahepatic biliary system is essential to avoid biliary injury in cases of left-sided gallbladder.

A Case of Ceftriaxone-associated Biliary Pseudolithiasis with Right-sided Ligamentum Teres

A Case of Ceftriaxone-associated Biliary Pseudolithiasis with Right-sided Ligamentum Teres

Analysis of right‐sided ligamentum teres: The novel anatomical findings and classification

The true anatomy of right-sided ligamentum teres (RSLT) has not been fully explained for a century. This study aimed to clarify the exact anatomy of RSLT. The computed tomography data of 17651 surgical patients were observed and 76 patients with RSLT, were classified into the bilateral ligamentum teres (LT) group (type A) and three RSLT groups, (B) bifurcation type, (C) trifurcation type, and (D) independent posterior branch type. Type A had double LT that connected to both the right and left sides of the umbilical portion (UP). Types B-D had a P3+4 rather than a left UP. Type D was anatomically different from types A-C. Upon comparing types A-C and type D, type D had a significantly smaller volume of segments 3+4 (P<.001), and the UP was more often on the left side. The position of the gallbladder fundus in type D was more commonly observed on the right side of the LT compared with that observed in the other types (P=.007). The change in the volume of segments 3+4 and the extent of the RSLT shift create a false perception that the gallbladder changes the position.

Hepatic volume profiles in potential living liver donors with anomalous right-sided ligamentum teres.

In living liver donors with rare anatomical anomaly of right-sided ligamentum teres (RSLT), right or left hemiliver procurement is commonly contraindicated. The purpose of this study was to evaluate the hepatic volume profiles in potential donors with RSLT using semi-automated CT volumetry (CTV). Among 5535 potential donor candidates in our institution between April 2003 and May 2019, 23 cases of RSLT (0.4%) were included. Proportional liver volumes were measured using semi-automated CTV and compared with those of manual volumetry and intraoperative graft weights (seven surgical cases). The mean percentage volume of the right posterior section was significantly larger than that of the left hemiliver (38.5 ± 8.4% vs. 23.3 ± 5.7%, P < 0.001). Particularly in independent right lateral type, the mean percentage volume of the right posterior section was about two times larger to that of the left hemiliver (41.5% ± 6.5% vs. 21.9% ± 4.4%, P < 0.001), whereas the volume proportions of these two parts were similar between the two parts in bifurcation and trifurcation types (P = 0.810 and 0.979, respectively). Semi-automated CTV of corresponding whole liver, right posterior section, right anterior section, and left hemiliver showed strong correlations with manual CTV (r = 0.989-0.998; P < 0.001). For the seven surgical cases, the graft weights estimated by semi-automated CTV showed a significant correlation with intraoperative graft weights (r = 0.972; P < 0.001). In independent right lateral type of RSLT, the right posterior section tends to be significantly larger than left hemiliver, and may be an alternative option for graft in potential living liver donors with this rare anatomical anomaly.

A case of perihilar cholangiocarcinoma with bilateral ligamentum teres hepatis treated with hepatopancreatoduodenectomy

BackgroundBilateral ligamentum teres (BLT) hepatis is a very rare anomaly defined as the connection of the bilateral fetal umbilical veins to both sides of the paramedian trunk, and it has never been reported in the English literature.Case presentationA 72-year-old man who presented with obstructive jaundice was referred to our hospital. Contrast-enhanced computed tomography revealed that the patient had right-sided ligamentum teres (RSLT) and left-sided ligamentum teres (LSLT). The umbilical portion of the left portal vein, which the LSLT connected, became relatively atrophic in this patient. The RSLT attached to the tip of the right anterior pedicle and formed the umbilical portion of the right portal vein. The patient was diagnosed with perihilar cholangiocarcinoma which had invaded the root of the posterior branch of the bile duct, LHD, and intrapancreatic bile duct. The central bisectionectomy, in which the liver parenchyma was resected along the RHV on the right side and the LSLT on the left side, and caudate lobectomy combined with pancreatoduodenectomy were performed.The presence of the patient with BLT is important for ascertaining the mechanism of the development of RSLT. Two umbilical veins are present initially during the embryonic stage. In general, the right-sided vein disappears, and the atrophic left-sided vein remains connected to the left portal vein originating from the vitelline vein. Several papers on the mechanism of the development of RSLT have been published. Some authors have mentioned that a residue of the right umbilical vein and the disappearance of the left umbilical vein are the causes of RSLT. On the other hand, some authors have asserted that RSLT is the result of atrophy of the medial liver area. The presence of BLT in patients indicates that the mechanism of the development of RSLT is characterized by a residue of the right umbilical vein and the disappearance of the left umbilical vein.ConclusionsThe mechanism and origin of RSLT can be understood through cases of BLT, and surgeons must pay attention to anomalies of the portal and hepatic veins in patients with abnormal ligamentum teres.

Laparoscopic left lateral sectionectomy for a patient with right-sided ligamentum teres

BackgroundA right-sided ligamentum teres (RSLT) is a rare congenital anomaly in which the fetal umbilical vein is connected to the right paramedian trunk. RSLT creates difficulty in liver resection with respect to decision-making regarding the resection line, deviation of the vasculobiliary architecture. We report a case in which laparoscopic left lateral sectionectomy (LLLS) was performed to treat colorectal liver metastasis (CRLM) in a patient with RSLT.Case presentationA 63-year-old man with a past history of rectal cancer presented to our institution due to liver metastasis in the left lateral section from rectal cancer. In this patient, an RSLT was diagnosed and LLLS was planned. The lateral superior branch of the portal vein (P2) branched off behind the bifurcation of the portal vein and running separately from the common branch of the lateral inferior branch (P3) and left paramedian branch (P4) so that stapling could not be performed for liver resection. Frequent intraoperative ultrasonography (IOUS) was necessary to identify the root of P2 and P3. The resection line was distant from the falciform ligament and was carefully decided. The lateral superior branch of Glisson (G2) and lateral inferior branch of Glisson (G3) were separately resected. The patient had a favorable clinical course without any complications.ConclusionsThe resection line of LLLS, which is distant from the falciform ligament, should be carefully identified using IOUS due to the deviation of the umbilical portion and falciform ligament. The recognition of portal vein and hepatic vein anomalies and clear identification of the lateral sectional branches are important to complete LLLS in patients with an RSLT.

Implications of Left-sided Gallbladder in the Emergency Setting: Retrospective Review and Top Tips for Safe Laparoscopic Cholecystectomy.

Left-sided gallbladder without situs viscerum inversus (LSG-woSVI) is a rare congenital anomaly. Clinical features and routine presurgical imaging could miss the anomalous position, thereby producing complications during surgery. Laparoscopic cholecystectomy can be performed safely, but the risk of bile duct injury (BDI) is greater than in cholecystectomy of the orthotopic gallbladder. We present a retrospective review of all scientific literature for diagnosed cases of LSG-woSVI undergoing cholecystectomy from 1996 to 2014. Our objectives were to outline empirical top tips for a safe cholecystectomy in incidentally diagnosed LSG-woSVI. We carried a comprehensive search of PubMed using medical subject headings "left-sided gallbladder," "right-sided ligamentum teres" "situs viscerun inversus," "preoperative diagnoses," "cholecystectomy," and "bile duct injury." We considered a classification of the LSG-woSVI in 2 groups: True LSG-woSVI and LSG-woSVI in patients with right-sided ligamentum teres. Our retrospective review revealed 55 cases of LSG-woSVI. The mean age was 51 years ±17 SD, male/female ratio was 2:1, clinical presentation was pain in the right upper abdominal quadrant in 75.5%, preoperative diagnosis was reached in 16.3%, True LSG was diagnosed in 83%, acute cholecystitis was found in 50%, laparoscopic cholecystectomy was performed in 79.6%, fundus-first dissection technique was used in 16.7%, intraoperative cholangiography was performed in 39.1%, and BDI occurred in 7.3% of the reported cases. Increased awareness of the anatomic aberrations in LSG-woSVI associated with improved preoperative diagnosis and a good knowledge about safe surgical techniques for cholecystectomy could indubitably reduce the incidence of BDI.

Biliary architecture of livers exhibiting right-sided ligamentum teres: an indication for preoperative cholangiography prior to major hepatectomy

ObjectiveTo obtain information about the basic biliary anatomy of livers with right-sided ligamentum teres (RSLT). Summary of background dataRSLT is a relatively rare anomaly with a reported incidence of 0.2–1.2%. Although the portal/hepatic venous and arterial anatomy of livers with RSLT has already been established, the biliary architecture of such livers remains unclear. MethodsRSLT was detected in 48 patients during 12,071 consecutive image readings (0.4%). Of these patients, the cholangiograms of 46 patients were analyzed, and their intrahepatic biliary tree confluence patterns were classified. ResultsThe following four unique biliary confluence patterns were identified in livers with RSLT: the symmetrical type (23/46), independent right lateral type (13/46), total left type (6/46), and total right type (1/46). Analyses of the portal and arterial branching patterns of these livers showed that there were no correlations between their biliary confluence patterns and their portal or arterial ramification patterns. ConclusionThe basic biliary architecture of livers with RSLT was clarified. As the RSLT patients' anomalous biliary confluences differed from those seen in normal livers and were difficult to predict, preoperative cholangiography should be performed prior to complex hepatobiliary surgery involving livers with RSLT to ensure patient safety.

Four branching patterns of intrahepatic biliary tree in cases with right sided ligamentum teres

Right-sided ligamentum teres (RSLT) is a rare entity whose incidence is reported to be 0.2 – 1.2%. The embryologic origin of this anomaly is the connection of the right fetal umbilical vein to the portal system. Although the vascular architecture has been well studied by Nagai, Shindo and their colleagues, there has been no systematic study of intrahepatic biliary anatomy of RSLT. We conducted a survey on the consecutive 4021 patients who received magnetic resonance cholangiopancreatography (MRCP) in our institute from January 2006 to August 2015, and found 13 cases with RSLT (0.3%). The following four branching patterns were identified. Surgeons should recognize these variations to avoid serious biliary injury in major hepatectomy of livers with RSLT. A) Six out of the 13 RSLT cases had apparently normal right and left hepatic ducts. The ventral branch of the right paramedian sector drained into the left hepatic duct. B) One case had an independent right lateral biliary branch. Bile ducts from the paramedian and left lateral sectors formed a common trunk on the left side of the right umbilical portion (UP). C) Five cases had a single common hepatic duct on the left side of the UP. The right lateral biliary branch formed an inverted C shape. D) One case had a single common hepatic duct on the right side of the UP. [biliary tree in RSLT]

複雑な胆管分岐形態を示した右側肝円索を伴う肝門部胆管癌の1例

右側肝円索は，胎生期における右側臍静脈遺残に起因するとされ，門脈右枝に臍部が存在し，同部に肝円索が付着する解剖学的変異と考えられている．今回，複雑な胆管分岐形態を示した右側肝円索を伴う肝門部胆管癌の切除例を経験した．症例は62歳の男性．皮膚黄染を主訴に当院を受診，造影CTで胆管壁の肥厚と肝内胆管の拡張を認め，さらに胆嚢が肝円索の左側に位置する右側肝円索を認めた．胆汁細胞診からはClass IVが検出され，右側肝円索を伴う肝門部胆管癌と診断した．門脈分岐形態を考慮し後区域枝のみ塞栓術を行い，手術は肝後区域切除・肝外胆管切除・胆管空腸吻合術を行った．本症例では胆管分岐においてB2から後区域枝が分岐する形態を示す他，その他の胆管分岐形態からも，右側肝円索における左右対称性の理論に合致するものと考えられた．右側肝円索には脈管の分岐異常を伴うことが多く，術前の詳細な画像検索と慎重な手術計画が重要と考える．

Standard laparoscopic cholecystectomy for malposition of the gallbladder caused by right-sided ligamentum teres

Atypical localization of the gallbladder associated with right-sided ligamentum teres is a rare anomaly of the biliary system. Although the conventional nomenclature as being a left-sided gallbladder is usually used, this definition may be incomprehensive because of lacking the anatomical detail. This report describes atypical localization of the gallbladder associated with right-sided ligamentum teres and abnormal intrahepatic portal venous branching, surgically removed laparoscopically.

右側肝円索を伴う肝細胞癌に対して肝右傍正中領域背側部切除術を施行した1例

右側肝円索を伴う肝細胞癌に対して肝右傍正中領域背側部切除術を施行した1例

Vascular architecture in anomalous right-sided ligamentum teres: three-dimensional analyses in 35 patients

BackgroundRight-sided ligamentum teres (RSLT) is a congenital anomaly that is sometimes encountered during hepatobiliary surgeries. However, a valid protocol for describing the segmental anatomy of livers with RSLT has not been established, and confusions or anatomic misunderstandings have been a major problem. MethodsThe vascular architecture and morphological characteristics were investigated in 35 livers with RSLT using three-dimensional (3D) simulations. ResultsCouinaud's four sectors and three hepatic veins were clearly distinguished in the liver with RSLT using 3D simulations. The ligamentum teres was connected with the right paramedian portal pedicle, and the long axis of the cystic fossa was always observed on the left of the ligamentum teres in all 35 livers. However, when the main portal scissura was visualized using 3D simulation, the gallbladder was always located on the border of either side of the hemilivers, and the malposition of the gallbladder was not confirmed. ConclusionsAlthough the right-sided components of the livers are well developed as a result of the right-dominant distribution of the feeding vessels in livers with RSLT, the basic segmental structure defined by the four sectors and the three hepatic veins are as well preserved as those in the typical liver anatomy.

Left-sided gallbladder with right-sided ligamentum teres hepatis: rare associated anomaly of exomphalos

Purpose The aim of this investigation was to establish the association of left-sided gallbladder and right-sided ligamentum teres hepatis with exomphalos and to clarify the portal venous anomaly associated with right-sided ligamentum teres. Methods Three male infants with exomphalos major associated with left-sided gallbladder and right-sided ligamentum teres hepatis were identified during a retrospective study of exomphalos cases (n = 35) in which exomphalos major comprised 18 cases over 19 years. Results Three infants with exomphalos major (8.6%) had a left-sided gallbladder and right-sided ligamentum teres hepatis. One male infant survived. Computed tomography showed that there is anomalous intrahepatic portal venous branching associated with right-sided ligamentum teres hepatis. The first branch of the portal vein ran to the right posterior segment, and then the portal vein formed a trunk of the left portal vein and right anterior portal veins. The latter vein formed the umbilical segment of the portal vein and finally joined the ligamentum teres hepatis. The inferior vena cava was on the left side below the kidney and crossed to the right side at the level of the kidney. Conclusions Left-sided gallbladder with right-sided ligamentum teres hepatis may not be such a rare associated anomaly in infants with exomphalos. However, there are no reports describing this anomaly with exomphalos in the English medical literature. We believe this is the first report. As long-term survival after repair of exomphalos is increasing, perhaps some of the survivors may develop liver disease which requires liver resection later in life. Recognition of this anomalous relationship with exomphalos is clinically important because it is associated with abnormal intrahepatic portal venous branching and intraabdominal vascular anomalies.

Left-sided gallbladder: Its clinical significance and imaging presentations

To assess the importance of preoperative diagnosis and presentation of left-sided gallbladder using ultrasound (US), CT and angiography. Retrospective review of 1482 patients who underwent enhanced CT scanning was performed. Left-sided gallbladder was diagnosed if a right-sided ligamentum teres was present. The image presentations on US, CT and angiography were also reviewed. Left-sided gallbladder was diagnosed in nine patients. The associated abnormalities on CT imaging included portal vein anomalies, absence of umbilical portion of the portal vein in the left lobe of the liver, club-shaped portal vein in the right lobe of the liver, and difficulty in identifying segment IV. Angiography in six of nine patients demonstrated abnormal portal venous system (trifurcation type in four of six patients). The main hepatic arteries followed the portal veins in all six patients. The segment IV artery was identified in four of six patients using angiography, although segment IV was difficult to define on CT imaging. Hepatectomy was performed in three patients with concomitant liver tumor and the diagnosis of left-sided gallbladder was confirmed intraoperatively. Left-sided gallbladder is an important clinical entity in hepatectomy due to its associated portal venous and biliary anomalies. It should be considered in US, CT and angiography images that demonstrate no definite segment IV, absence of umbilical portion of the portal vein in the left lobe, and club-shaped right anterior portal vein.

Fusion of the midplane with the left intersectional plane: a liver anatomical variation revisited with multidetector-row CT

This article updates the description of an anatomical variation of the liver, in which the gallbladder is adjacent to the ligamentum teres, that was described until now as "right-sided ligamentum teres and right umbilical portion of the portal vein". A study of eight patients showing this anatomical variation has led to a new archetypal anatomical description of the hepatic and portal veins, using multidetector-row computed tomography (MDCT) with three-dimensional (3D) volume-rendering (VR) reconstructions. While 2D axial imaging gave the same information, MDCT imaging with VR reconstructions provided a clear 3D visualization of this anatomical variation. Typical features can be described as follows: (1) juxtaposition of the ligamentum teres and the gallbladder; (2) typical portal vein branching with a right posterior branch, a left posterior branch and a main medial branch that terminates in the ligamentum teres; (3) two main hepatic veins and a hypotrophied medial hepatic vein. We think, based on the direct comparison of anatomical findings and knowledge of chronological embryological development, that this abnormality results from the defective development of the central part of the liver and not from the persistence of the right rather than the left umbilical vein. Because of the presence of only one medial plane, containing both the gallbladder and the ligamentum teres, we propose renaming it "fusion of hepatic planes".

Intrahepatic Portal Venous Variations: Demonstration by Helical CT During Arterial Portography

We assessed the prevalence and types of intrahepatic portal venous variations by helical computed tomography performed with arterial portography (CTAP). In 192 patients without evidence of vascular invasion or distortion, CTAP images were reviewed retrospectively to identify portal venous variations. Of the 192 patients examined, 10 (5.2%) had trifurcation, 5 (2.6%) had a right posterior segmental branch arising from the main portal vein, 5 (2.6%) had an absence of the horizontal segment of the left portal vein, and 1 (0.5%) had an absence of the left lateral segmental portal branch. Of the patients without a horizontal segment, two had a right-sided ligamentum teres associated with malposition of the gallbladder, while another had complete ramification of intrahepatic portal branches from an umbilical vein-like segment. In the patient missing the left lateral segmental branches, the right portal vein segments were subcapsularly located. Variations of the intrahepatic portal veins can be recognized on CTAP imaging. tomography-Portal vein, computed tomography.