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Falciform ligament

The falciform ligament is a thin, sickle-shaped fold of parietal peritoneum that extends from the anterior abdominal wall and diaphragm to the liver, serving as a key anatomical landmark that divides the liver into its right and left lobes.^[1] This double-layered structure attaches superiorly to the undersurface of the diaphragm and the posterior surface of the anterior abdominal wall just to the right of the midline, while its inferior free border connects to the ventral surface of the liver near its inferior border.^[2] It lies in an oblique plane, with one surface facing anteriorly toward the peritoneum behind the right rectus abdominis muscle and diaphragm, and the other facing posteriorly toward the left lobe of the liver.^[2] The ligament's free inferior edge contains the ligamentum teres hepatis (also known as the round ligament of the liver), a fibrous remnant of the fetal left umbilical vein, along with paraumbilical veins that typically remain obliterated in adults but can recanalize under pathological conditions.^[1] Embryologically, the falciform ligament derives from the ventral mesentery of the liver, with the round ligament forming by the degeneration of the left umbilical vein after birth.^[1] Its blood supply includes branches from the superior thoracic, inferior phrenic, and internal thoracic arteries superiorly, and the middle or left hepatic artery inferiorly, with venous drainage primarily via the internal thoracic and inferior phrenic veins, as well as the portal venous system through the paraumbilical veins.^[1] Functionally, while it provides passive support and stabilization to the liver, its primary clinical relevance stems from its vascular contents, which can dilate in portal hypertension to form visible periumbilical collaterals known as caput medusae.^[1] In surgical contexts, the falciform ligament is invaluable as a landmark for hepatic procedures and can be mobilized as a pedicled flap for reconstructions, such as repairing duodenal perforations, managing hiatal hernias, or controlling hemorrhage after pancreatectomy.^[1] Rare pathologies include torsion leading to infarction, cystic formations, and involvement in malignancies or infections, though these are uncommon and often discovered incidentally during imaging or laparotomy.^[1] Overall, its anatomical position and contents make it a critical structure in abdominal surgery and the evaluation of hepatobiliary disorders.^[1]

Anatomy

Gross anatomy

The falciform ligament is a broad, thin, sickle-shaped fold of parietal peritoneum that connects the liver to the anterior abdominal wall, specifically the posterior surface of the rectus sheath, and the inferior surface of the diaphragm. It lies in an oblique anteroposterior plane, with one surface facing the peritoneum overlying the right rectus abdominis muscle and diaphragm, and the opposite surface in contact with the anterosuperior aspect of the left hepatic lobe. This structure serves as a key peritoneal attachment, anchoring the liver within the abdominal cavity.^[1]^[3] The ligament extends superiorly from its attachment along the coronal plane of the liver's diaphragmatic surface, between the right and left lobes, and descends inferiorly to the level of the umbilicus, effectively dividing the liver into its larger anatomical right lobe and smaller left lobe. Superiorly, it is continuous with the anterior layer of the coronary ligament at the liver's superior margin. Its free inferior border is rounded and contains the ligamentum teres hepatis, a fibrous cord representing the obliterated left umbilical vein, along with potential paraumbilical veins and variable adipose tissue enclosed within the double-layered peritoneum.^[1]^[4]^[3] In typical adult anatomy, the falciform ligament measures approximately 8 cm in length, with a maximum width of about 5 cm at its base near the liver, tapering to 1 cm distally toward the umbilicus. Anatomical variations are uncommon but include complete absence or partial defects, such as nonfixation or perforations, which are typically incidental findings during surgery or imaging. These variations may involve altered attachments or accessory peritoneal folds but do not usually impact function.^[5]^[6]

Microscopic anatomy

The falciform ligament consists primarily of acellular connective tissue composed of dense irregular collagen fibers, forming a supportive stroma between its two peritoneal layers.^[7] This connective tissue is largely avascular and aneural in its core but includes sparse fibroblasts responsible for maintaining the extracellular matrix. Elastic fibers are present within the stroma, contributing to the ligament's flexibility.^[8] The ligament is enveloped by two layers of simple squamous mesothelium, representing an extension of the parietal peritoneum, which provides a smooth, low-friction surface interfacing with the peritoneal cavity.^[1] This mesothelial lining lacks significant glandular or other epithelial structures beyond its basic squamous composition, emphasizing the ligament's role as a passive peritoneal fold.^[9] Within the connective tissue stroma, vascular components include small arteries and veins derived from branches of the internal thoracic and hepatic arteries, along with a network of lymphatics that facilitate fluid drainage. Paraumbilical veins are embedded along the ligament's length, running parallel to the ligamentum teres and serving as potential portosystemic collaterals.^[1] The nerve supply comprises sympathetic and parasympathetic fibers originating from the hepatic plexus, which travel primarily along vascular structures to provide vasomotor innervation without forming distinct neural networks in the ligament itself.^[1]

Development

Embryonic origin

The falciform ligament originates as a double-layered peritoneal fold derived from the ventral mesogastrium, the embryonic mesentery suspending the foregut derivatives—including the developing stomach and liver—to the anterior abdominal wall. This structure begins to form during weeks 4 to 6 of gestation, coinciding with the initial differentiation of the digestive tube.^[1]^[10] The liver bud, or hepatic diverticulum, emerges as an endodermal outgrowth from the caudal foregut at the end of week 3 or early week 4, invading the ventral mesogastrium and progressively splitting it into two components: the falciform ligament, which connects the liver to the ventral body wall, and the lesser omentum, linking the liver to the stomach and duodenum. The septum transversum, a mesodermal mass located anterior to the pericardial cavity, contributes to the superior attachment of this fold by providing mesenchymal support and facilitating the liver's rapid expansion into the mesentery during this period.^[1]^[11]^[10] Concurrently, the fetal left umbilical vein develops and traverses the free inferior margin of this emerging fold, delivering oxygenated blood from the placenta to the growing liver and establishing the pathway that will later become the ligamentum teres hepatis. By week 8 of gestation, the fold has fully attached the enlarging liver to the anterior body wall, adopting its characteristic sickle shape as the liver occupies a significant portion of the abdominal cavity.^[12]^[1] The patterning of the ventral mesogastrium and falciform ligament involves key signaling pathways, notably fibroblast growth factor (FGF) signaling from the adjacent cardiac mesoderm and septum transversum, which is essential for hepatic specification and outgrowth into the mesentery. Hox genes contribute to the broader anterior-posterior patterning of the gut and mesenteries, ensuring proper regional identity during early organogenesis.^[13]^[14]

Postnatal changes

Following birth, the falciform ligament's free inferior border undergoes fibrosis as the umbilical vein obliterates into the ligamentum teres hepatis due to abrupt hemodynamic pressure changes. This occlusion typically begins between the second and fifth postnatal days, with complete fibrous remodeling occurring over the subsequent several weeks to months.^[15]^[16]^[17] As the body grows during childhood and adolescence, the falciform ligament elongates proportionally to accommodate abdominal expansion, while its double-layered peritoneal covering remains patent. The embedded connective tissue progressively densifies with advancing age, contributing to overall structural maturation.^[1] In healthy adults, the paraumbilical veins within the falciform ligament exhibit minimal recanalization under normal physiological conditions, often manifesting as thin, patent remnants (0.6–1.9 mm in diameter) visible on imaging in up to 97% of individuals without clinical significance. Fat deposition may accumulate in the ligament in cases of obesity, resulting in focal fatty changes adjacent to its attachment sites.^[18]^[19]^[20]

Function

Structural support

The falciform ligament serves as a key suspensory structure in the liver's anatomy, anchoring the organ to the anterior abdominal wall and the diaphragm to limit excessive mobility during respiratory movements and bodily motion. This attachment occurs via its base on the liver's anterosuperior surface and its extension to the diaphragmatic undersurface, where it integrates with peritoneal reflections, thereby stabilizing the liver within the peritoneal cavity.^[1]^[21] By dividing the liver into its anatomical right and left lobes, the falciform ligament facilitates precise anatomical orientation, particularly in surgical planning, while contributing to the organ's fixed positioning relative to the porta hepatis through its supportive role in the overall ligamentous network. It interacts with adjacent structures such as the coronary and triangular ligaments, forming a cohesive peritoneal framework that collectively secures the liver bed and resists displacement. The ligament's composition as a fibrous, bilayered fold of peritoneum includes extracellular matrix components like collagen types I and IV, which provide tensile resistance to shear forces.^[1]^[22]^[23]

Vascular conduction

The falciform ligament serves as a conduit for venous drainage within the abdominal cavity, primarily housing the paraumbilical veins, which consist of 1 to 3 small tributaries running along its free inferior margin. These veins connect the left branch of the portal vein to the superficial epigastric veins of the anterior abdominal wall, establishing potential portosystemic anastomoses that can function as shunts under pathological conditions such as increased portal pressure.^[1]^[24] At its core, the ligamentum teres hepatis acts as the primary vascular remnant within the falciform ligament, representing the fibrosed obliterated left umbilical vein from fetal circulation. This structure, approximately 10 cm in length and 3 to 6 mm in diameter, extends from the umbilicus to the porta hepatis, where it joins the left portal vein, and possesses the capacity for recanalization when venous pressures elevate.^[1]^[25]^[26] Lymphatic vessels traverse the falciform ligament, facilitating the drainage of lymph from the liver's superficial surfaces toward the hepatic and diaphragmatic lymph nodes, thereby contributing to the clearance of peritoneal fluid. The arterial supply to the ligament derives from branches of the internal thoracic, inferior phrenic, and middle or left hepatic arteries.^[1]^[27] In healthy individuals, blood flow through the paraumbilical veins and ligamentum teres is negligible, with these vessels remaining collapsed due to low pressure gradients, ensuring they do not actively participate in systemic circulation under normal physiological conditions.^[24]^[28]

Clinical significance

Portal hypertension

In portal hypertension, often resulting from cirrhosis or portal vein thrombosis, the paraumbilical veins within the falciform ligament recanalize to form collateral pathways that help decompress the elevated portal pressure.^[1] These veins, located adjacent to the ligamentum teres, become engorged and patent, allowing blood to shunt from the portal system to the systemic circulation via connections with the superficial and inferior epigastric veins.^[29] This recanalization leads to the visible formation of caput medusae, characterized by dilated periumbilical veins radiating across the abdominal wall in a pattern resembling Medusa's head of snakes.^[30] The ligamentum teres, containing the remnant of the umbilical vein, plays a key role in this process by becoming patent and serving as a primary collateral conduit; blood flow reverses direction (hepatofugal) from the liver toward the umbilicus and then to systemic veins, bypassing the high-pressure portal system.^[31] This adaptation occurs as the body attempts to mitigate the hemodynamic stress of portal hypertension, where pressure exceeds 10 mmHg in the portal vein.^[32] The caput medusae sign, first described in the 19th century as a clinical manifestation of portal hypertension, highlights the falciform ligament's involvement in these portosystemic shunts.^[33] The prevalence of patent paraumbilical veins on imaging ranges from 6% to 30% in patients with portal hypertension, though the visible caput medusae sign is rarer (1-5%), particularly in those with decompensated cirrhosis.^[34]^[35] Diagnosis typically involves ultrasound or computed tomography (CT) imaging, which reveals paraumbilical vein dilation greater than 3 mm, often with detectable flow on Doppler.^[19] These dilated veins carry a risk of rupture, contributing to variceal bleeding complications, which can be life-threatening if they occur on the abdominal surface.^[36] The presence of caput medusae indicates decompensated liver disease and advanced portal hypertension, signaling poor prognosis without intervention, as it correlates with increased mortality from complications like ascites and encephalopathy.^[32] Management may involve the transjugular intrahepatic portosystemic shunt (TIPS) procedure to reduce portal pressure, decompress collaterals including those in the falciform ligament, and prevent recurrent bleeding or further decompensation.^[37]

Surgical relevance

The falciform ligament serves as a vital anatomical landmark in abdominal surgeries, particularly during laparoscopy and open hepatectomy, where it delineates the boundary between the left hepatic lobe and segment IV, facilitating precise access while helping surgeons avoid injury to underlying hepatic veins that are not visible from the liver's bare area. Its sickle-shaped structure, extending from the anterior abdominal wall just to the right of the midline to the liver's diaphragmatic surface, provides reliable orientation for dissection planes in hepatobiliary procedures.^[1]^[38]^[39] Division of the falciform ligament is a standard step in liver transplantation and gastric surgeries to enable full mobilization of the liver and improve exposure of adjacent structures. During these procedures, the ligament is carefully ligated to minimize bleeding risks from the paraumbilical veins coursing along its free edge.^[1]^[40]^[41] Laceration of the falciform ligament represents a rare intraoperative complication, often occurring in blunt abdominal trauma or during trocar insertion in minimally invasive surgery, which can result in hemoperitoneum due to disruption of its vascular contents. Such injuries have a low incidence, reported at less than 1% in laparoscopic cases overall, though anatomic variants may increase vulnerability.^[42]^[43]^[44] In 20th-century anatomy texts, the falciform ligament was highlighted as a key consideration for midline incisions, where its midline position necessitated paramedian adjustments to prevent inadvertent division and bleeding. In contemporary robotic surgery, it retains importance as an orientation guide, aiding in port placement and flap mobilization for enhanced precision in minimally invasive hepatobiliary interventions.^[45]^[46]^[1] Anomalous insertions or absences of the falciform ligament can hinder liver mobilization and increase procedural risks, such as unexpected bleeding or misorientation, thereby underscoring the value of preoperative imaging like CT or MRI for detection and surgical planning.^[47]^[48]^[49]

Imaging and pathology

On computed tomography (CT) and magnetic resonance imaging (MRI), the falciform ligament typically appears as a thin, avascular band of soft-tissue density, often obscured unless highlighted by adjacent fluid or pathology.^[50] A frequent benign finding is a pseudolesion at its hepatic attachment site, caused by focal fat deposition, which manifests as a hypoattenuating region on non-contrast CT (typically -20 to -100 Hounsfield units) and hyperintense signal on T1-weighted MRI, mimicking a mass but confirmed by its characteristic location and lack of enhancement.^[51]^[52] The falciform ligament sign, visible on supine abdominal CT, is characterized by a triangular soft-tissue density structure outlined by free intraperitoneal air, serving as a reliable indicator of pneumoperitoneum, particularly in cases of gastrointestinal perforation.^[53]^[54] Pathological involvement of the falciform ligament is rare and includes neoplasms such as metastatic deposits, which commonly seed this site due to its peritoneal location, as seen in cases of ovarian, colorectal, gastric, and appendiceal cancers.^[55] Internal hernias through congenital or acquired defects in the ligament can entrap bowel loops, appearing as clustered small-bowel segments with possible ischemia on CT, necessitating prompt surgical evaluation.^[56] Infectious processes may extend from adjacent structures, such as liver abscesses propagating into the falciform ligament, resulting in a peripherally enhancing fluid collection with internal gas on contrast-enhanced CT.^[57]^[58] In systemic amyloidosis, amyloid protein deposition can involve the falciform ligament as part of hepatic amyloidosis, leading to ligament thickening and heterogeneous enhancement on MRI, often in conjunction with diffuse liver involvement.^[59] Ultrasound elastography can reveal increased stiffness in areas of hepatic fibrosis, correlating with chronic liver disease progression. As of 2025, multiparametric ultrasound techniques, including elastography, continue to evolve for assessing liver fibrosis and portal hypertension, potentially aiding detection of falciform ligament alterations. Focal fatty infiltration near the ligamentum teres hepatis (within the falciform ligament) appears as a known pseudolesion, manifesting as echogenic foci on ultrasound and low-attenuation bands on CT.^[60]^[38]^[61]^[62]

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