Internal hernias through the falciform ligament: a case series and comprehensive literature review of an increasingly common pathology

Abstract

This pathology is a rare, though increasingly frequent, phenomenon that must be considered in the differential diagnosis when a bowel obstruction without other identifiable cause is encountered, particularly in a patient with history of previous laparoscopy. However, preoperative studies have a poor sensitivity for accurately diagnosing a hernia through the falciform ligament. Failure to consider this etiology may result in delayed operative intervention and increased morbidity and mortality.

Small bowel obstruction via herniation through an iatrogenic defect of the falciform ligament following laparoscopic cholecystectomy

“…The herniation of bowel through a congenital defect in the falciform ligament may be provoked by external factors such as the gravid uterus during pregnancy and trauma pushing the bowel up into the upper abdomen. 1 In our case, the patient was a 50-year-old man with a recent history of a laparoscopic cholecystectomy, suggesting the likelihood of an iatrogenic source of the defect. There is one previous case of a patient having herniation of small bowel through a falciform ligament defect following a cholecystectomy.…”

“…A review of case literature from 2013 found preoperative computed tomography (CT) to have 35.7% sensitivity in identifying a falciform hernia while no specific diagnoses were made on abdominal radiography or ultrasonography. 1 However, bearing in mind the clinical symptoms of this patient and the surgical history, it is possible that CT may not have influenced the ultimate intervention of laparoscopy and would only have served to delay treatment.…”

“…Rarely, internal hernias can cause intra-abdominal bowel obstruction, with a reported incidence of up to 5.8% of all cases of intestinal obstruction. 1 The symptoms of an internal hernia can be non-specific, and range from mild abdominal discomfort to severe abdominal pain and obstruction. Consequently, they are frequently diagnosed intraoperatively.…”

“…1 The other two cases of iatrogenic defects both involved prior Nissen fundoplication procedures. 4,5 The laparoscopic method for this procedure involves placement of a 10mm trocar in the right upper quadrant.…”

Chilaiditi's syndrome associated with colonic volvulus and intestinal malrotation—A rare case

“…However, the presence of volvulus necessitated laparotomy during which the herniated colon was found to be trapped beneath the falciform ligament. Falciform ligament hernias have previously been described and may contain small or large bowel though usually through a defect in the ligament 13 . This case was unusual in that the hepatodiaphragmatic interposition contained splenic flexure 15 as opposed to transverse colon 2,3,5,7–12 or sigmoid colon 4 .…”