A rare cause of bowel obstruction: strangulated internal hernia through a congenital defect in the falciform ligament

Abstract

Introduction: Internal herniation through a defect in the falciform ligament is an exceptionally rare cause of small bowel obstruction. Few cases have been reported in the literature. Case presentation: We report the case of a 24-year-old man with no previous medical or surgical history who presented with acute epigastric pain and vomiting for 12 hours. Physical examination revealed localized tenderness in the epigastric region. Computed tomography (CT) demonstrated clustered and distended small bowel loops in the prehepatic region, with mesenteric vessels converging toward a central point between the right and left hepatic lobes. Laparoscopy revealed an ischemic distal ileal loop strangulated through a 2-cm defect in the falciform ligament. Conversion to laparotomy was performed due to limited visualization. The incarcerated loop was viable, and simple division of the falciform ligament allowed reduction. The postoperative course was uneventful, and the patient was discharged on postoperative day 2. Discussion: Internal hernia is a rare cause of bowel obstruction, accounting for less than 1% of cases in the general population and up to 5.8% of all small bowel obstructions. Herniation through the falciform ligament represents approximately 0.2% of internal hernias and may be congenital or iatrogenic following laparoscopic procedures. The preoperative diagnosis remains challenging because of nonspecific clinical and radiological findings, leading to frequent intraoperative discovery. Conclusion: Falciform ligament hernias are rare and often difficult to diagnose preoperatively. Prompt surgical intervention is essential to prevent bowel ischemia and reduce morbidity.