Background

A nineteen-year-old female was treated for a painful cystic mass that primarily involved the falciform ligament of the liver.

Summary

The patient is a young woman who was seen for umbilical and vague abdominal pain of only several weeks duration. She did not describe any gastrointestinal or genitourinary symptoms. She had not noted any menstrual irregularity. Physical examination was normal with the exception of periumbilical tenderness and slight fullness at the depth of the umbilicus. When seen in the emergency room, CT scan of the abdomen was completed.

Case Report

A  nineteen-year-old woman was seen for vague umbilical pain. She said her pain was of sudden onset and felt like deep pressure at the base of her umbilicus and more deeply in her abdomen. She was seen in the emergency room where a CT scan was obtained that showed a nine-centimeter cystic mass extending from her umbilicus toward her upper abdomen. She had no other subjective complaints. She had CKD1 from glomerulosclerosis and previously had pilonidal sinus operation.

There was mild tenderness deep to her umbilicus.

An operation through an upper midline incision was done. There was a tense cystic mass extending from the underside of her umbilicus well into the falciform ligament of the liver. On freeing the cyst from the underside of the skin of the umbilicus, the cyst was entered and “chocolate” fluid was expressed. The cyst and portion of the falciform ligament completely dissected away from the umbilicus and anterior abdominal wall.

She was discharged one day after operation and went on to recover without problems. She eventually was seen by the gynecology team to consider further treatment options.

Final pathology showed a fibrous-lined cystic endometrioma measuring about 7 cm with both inflammation and hemosiderin laden macrophages.

Picture1

CT images showing large cystic structure at the umbilicus extending into falciform ligament.

Picture2

CT images showing large cystic structure at the umbilicus extending into falciform ligament.

Picture3

Picture4

Opened “chocolate cyst” from the falciform ligament.

Discussion:

The falciform ligament is a remnant of the ventral embryonic mesentery. The obliterated umbilical vein lies at its free edge. It also acts as a supporting structure for the liver and separates the left lateral segment of the liver from the left medial segment.

Although endometriosis is a relatively common cause of pain or “tumor-like mass” at the umbilicus, extension of the endometriotic process into the falciform ligament is not reported in PUBMED.

Bryan reviewed cystic lesions of the falciform ligament and found only a dozen reported cases. (1) Brock and colleagues described surgical diseases of the falciform ligament and reported two additional cases. (2)