Incidental Laparoscopic Discovery of a Falciform Ligament Hernia Containing the Round Ligament

A 48-year-old woman presented with a 3-month history of recurrent right upper quadrant pain consistent with biliary colic. The pain was intermittent, typically triggered by fatty meals, and had become more frequent over time. There was no history of jaundice, vomiting, or previous abdominal surgery. Physical examination was unremarkable, with no palpable masses or tenderness. Abdominal ultrasonography demonstrated a normal-caliber bile duct and a mildly distended gallbladder with wall thickening and multiple stones, consistent with chronic calculous cholecystitis. Routine laboratory investigations were within normal limits. A laparoscopic cholecystectomy was scheduled. Intraoperatively, the gallbladder appeared fibrotic and thick-walled. Incidentally, a small herniation of the round ligament was noted through an oval defect in the falciform ligament (Figure 1). The round ligament was gently reduced using atraumatic graspers (Figure 2A), revealing a 1.5 cm defect in the falciform ligament. The linea alba and rectus sheath were intact, and no fascial or peritoneal defect communicating with the anterior abdominal wall was observed, confirming that the defect was limited to the falciform ligament. The defect was closed with interrupted 0-Vicryl sutures (Figure 2B). The cholecystectomy was then completed in the standard manner. The recurrent right upper-quadrant pain was attributed to chronic calculous cholecystitis, confirmed intra-operatively by a fibrotic, thick-walled gallbladder containing multiple stones. The falciform ligament hernia was an incidental intra-operative finding, with no evidence of bowel entrapment or vascular compromise. No preoperative CT was performed, as ultrasonography had already confirmed uncomplicated calculous cholecystitis. The falciform ligament hernia was therefore discovered incidentally during laparoscopy. The patient's postoperative recovery was uneventful, and she was discharged on the first postoperative day. At 6-month follow-up, she remained asymptomatic. Internal herniation through the falciform ligament is a rare surgical finding, representing less than 1% of all internal hernias 1. It was first described by Beardsley in 1929 2 and is typically associated with herniation of small bowel loops. In contrast, herniation of the round ligament of the liver through a defect in the falciform ligament is exceedingly uncommon and usually discovered incidentally during abdominal surgery or imaging 3. The falciform ligament is a double layer of peritoneum that connects the anterior abdominal wall and diaphragm to the anterior surface of the liver, enclosing the ligamentum teres (round ligament) in its free inferior border 4. Congenital or acquired defects in this structure may create a potential site for internal herniation. Acquired causes include trauma, inflammation, or iatrogenic thinning of the falciform ligament during laparoscopic procedures 5. Characteristic CT findings of falciform ligament hernia, when present, include a cluster of small bowel loops or omentum located anterior to the left hepatic lobe and a defect contiguous with the falciform ligament on coronal or sagittal reconstructions 4. In our case, the round ligament was partially trapped within a well-defined 1.5 cm oval opening surrounded by fibrotic edges, requiring reduction before repair. These characteristics are consistent with a true hernial defect rather than a congenital fenestration, which typically presents as a thin, slit-like gap without incarceration. Similar small but clinically relevant falciform defects have been reported to cause internal herniation 1, 4. Differential diagnosis includes epigastric or linea alba hernias, in which the fascial defect lies within the anterior abdominal wall and the hernial sac communicates with subcutaneous tissues. In our case, the defect was located posterior to the anterior abdominal wall and superior to the umbilicus, involving only the falciform ligament and containing the round ligament, without any extension through the rectus sheath. These intraoperative landmarks definitively supported the diagnosis of falciform ligament hernia. Although our case was asymptomatic and discovered incidentally, it highlights an unusual form of falciform ligament hernia involving only the round ligament. Recognition of this entity is valuable for laparoscopic surgeons: unrecognized falciform defects may be misinterpreted as adhesions or cause postoperative internal herniation if left unrepaired. Routine inspection and closure of such defects during laparoscopy are recommended to prevent potential complications 6. Imen Ben Ismail: conceptualization, data curation, and writing – original draft. Marwen Sghaier, Amari Rime, and Hakim Zenaidi: investigation. Saber Rebii: validation and supervision. Written informed consent was obtained from the patient for the publication of this case report and the accompanying images. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.