Internal Herniation Through the Falciform Ligament of the Liver: A Systematic Review of Diagnosis and Operative Strategies

Abstract

Internal herniation through a defect in the falciform ligament of the liver is an exceptionally rare occurrence with a risk of small-bowel obstruction that can result in strangulation and bowel necrosis if diagnosis is delayed. Because of its infrequency, available evidence is limited to isolated case reports and small descriptive studies, and optimal diagnostic and operative strategies remain poorly defined. A systematic search of PubMed/MEDLINE, Embase and Cochrane Library was performed to identify English-language articles published over the past 10 years reporting cases of internal herniation through the falciform ligament. Titles and abstracts were screened using predefined inclusion and exclusion criteria, followed by full-text review. Data were extracted regarding patient demographics, presentation, imaging findings, operative management and outcomes. A qualitative synthesis was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Seven studies met the inclusion criteria, all of which were single-patient case reports or imaging-focused descriptions. Patients typically presentations varied but included acute abdominal pain and symptoms of small-bowel obstruction, and both congenital and iatrogenic falciform ligament defects were implicated. Computed tomography frequently demonstrated closed-loop bowel positioned anterior to the liver, beak-like tapering at the site of constriction and abnormal displacement of the round ligament. All patients underwent urgent surgical intervention. Management consisted of reduction of the herniated viscus with division or closure of the falciform ligament defect, with bowel resection required when ischemia was present. Both open and laparoscopic approaches were reported, and short-term postoperative outcomes were generally favourable. Internal herniation through the falciform ligament is a rare but potentially serious surgical emergency that should be considered in cases of unexplained proximal small-bowel obstruction. Recognition of characteristic computed tomography findings may facilitate earlier diagnosis and intervention. Prompt operative exploration remains the cornerstone of management, with ligament division or closure and selective bowel resection based on intraoperative viability.