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Anatomical Variation of Ligamentum Teres of Liver - a Case Report

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Anatomical Variation of Ligamentum Teres of Liver - a Case Report Article ID: WMC003389 ISSN 2046-1690 Anatomical Variation of Ligamentum Teres of Liver - A Case Report Corresponding Author: Mrs. Suni Ebby, Instructor- CCE & CO and Tutor in Anatomy, Department of Anatomy, Gulf Medical University, Ajman, UAE, 4184 - United Arab Emirates Submitting Author: Mrs. Suni Ebby, Instructor- CCE & CO and Tutor in Anatomy, Department of Anatomy, Gulf Medical University, Ajman, UAE, 4184 - United Arab Emirates Article ID: WMC003389 Article Type: Case Report Submitted on:17-May-2012, 02:16:53 PM GMT Published on: 18-May-2012, 05:51:30 PM GMT Article URL: http://www.webmedcentral.com/article_view/3389 Subject Categories:ANATOMY Keywords:Variations, Ligamentum Teres, Quadrate lobe, Liver, Falciform Ligament How to cite the article:Ebby S, Ambike MV. Anatomical Variation of Ligamentum Teres of Liver - A Case Report . WebmedCentral ANATOMY 2012;3(5):WMC003389 Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Source(s) of Funding: None WebmedCentral > Case Report Page 1 of 7 WMC003389 Downloaded from http://www.webmedcentral.com on 18-May-2012, 05:51:30 PM Anatomical Variation of Ligamentum Teres of Liver - A Case Report Author(s): Ebby S, Ambike MV Abstract therapeutic procedures should not be overlooked4. Elmar and Robert stated that after obliteration of umbilical vein over thenext several months after birth, it becomes the ligamentumteres hepatis, which usually Variations related to the liver are frequently measures 10 to 20 cms long5. encountered. This case reports the variant course of ligamentum teres present and its attachment along the Quadrate lobe is distinguished physiologically as the inferior margin of falciform ligament which was medial segment of the left lobe. The fissure for embedded in a tunnel formed by the liver parenchyma. ligamentum teres forms the left boundary of the It also reports a complete absence of the quadrate quadrate lobe and may be partially bridged by a band 3 lobe. This knowledge can be fruitfully utilised by of liver . Aysin et al, Sanli et al and Abdullahi’s et al anatomists, embryologists, radiologists and surgeons reported absence of the fissure for the round ligament respectively for academic interest, to avoid possible on the visceral surface and the anatomic differentiation errors in interpretation and subsequent misdiagnosis, between the left and quadrate lobes could not be 6-8 and to assist in planing an appropriate surgical differentiated . Sanli et al also noted the absence of 7 approach that is crucial for determining the patient fissure for ligamentum teres . Abdullahi’s et al reported 8 outcome. a complete absence of the left lobe of liver . Atkan et al studied cadaveric livers for the lobe and Introduction segmental anomalies; observed complete absence of quadrate lobe and anomalous quadrate lobes among the specimens9. In a study reported by Joshi et al in Study on the variations on the segmental anatomy of cadaveric livers, the quadrate lobe was found to be the liver are extensive, but morphological anatomy absent10. Albrech of Haller described Pons hepatis as concerning the ligaments of liver are not commonly a functionally insignificant, facultative bridge from liver documented. In adults, cannulation of the upper part of fabric over the muzzle section of the ligamentum teres the ligamentum teres has been achieved for a variety hepatis. Onitsuka et al reported metastatic liver of therapeutic and diagnostic procedures, yet the carcinoma that develops from the pons hepatis, 1 indications for this remain limited . The ligamentum presents as an extrahepatic mass on ultrasonography teres also known as “round ligament of liver” is the and computed tomography4. Pathologies related to fibrous remnant of the left umbilical vein that carries ligamentum teres such as stromal tumour and well-oxygenated and nutrient rich blood from the gangrene11 have been reported in few cases. placenta to the fetus in vitro2. The liver is customarily This case reports on the variation asscociated with apportioned by anatomists into a large right lobe and ligamentum teres and the absence of the quadrate small left lobe by the line of attachment of falciform lobe. Precise knowledge on the morphological ligament anteriorly, and the fissure for ligamentum variations of the liver provides valuable information for teres and ligamentum venosum on the inferior surface3. anatomists, embryologists, operating surgeons12 and The ligamentum teres and small paraumbilical veins radiologists in this era of minimal invasive approaches. course in the inferior free margin of falciform ligament, which demarcates the anatomical right lobe from the Case Report(s) left lobe on the diaphragmatic surface2. The fissure for ligamentum teres can be of variable depth and it ascends backwards from its notch on the inferior On regular dissection of the formalin-fixed cadavers as border to the left end of the fissure for the ligamentum part of medical training in the Department of Anatomy, venosum3. Gulf Medical University, a variant course of the Onitsuka et al reported that the falciform ligament and ligamentum teres with a complete absence of the the ligamentum teres were considered as insignificant quadrate lobe was found. No scar or any evidence of embryological remnants; however, the involvement in previous surgical operation nor any adhesions were disease and significance in radiological imaging and noticed. On piecemeal dissection; ‘on going into the WebmedCentral > Case Report Page 2 of 7 WMC003389 Downloaded from http://www.webmedcentral.com on 18-May-2012, 05:51:30 PM liver parenchyma’, of the specimen preserving the Sato’s et al finding for the absence of quadrate lobe15. relevant structures, tributaries of portal vein and Quadrate lobe is physiologically considered as the hepatic vein, branches of hepatic artery; we observed medial segment of the left lobe, and the quadrate lobe that the ligamentum teres joins with the left portal vein. was undistinguished anatomically in the present case3. Ligamentum teres (LT) was present on the inferior free Atkan et al reported 3.7% and 29.63% of livers studied margin of the falciform ligament, coursed deep through had complete absence and anomalous quadrate lobe a tunnel within the liver substance and completely respectively; quadrate lobe could not be differentiated9. obscured the normal fissure for ligamentum teres Joshi et al found notable variations: 66% rectangular, present on the visceral surface of the liver (Figures 1 6% narrow, 20% had fissured quadrate lobe; another and 2). Complete absence of the quadrate lobe was 20% showed anomalous shapes viz: pear-shaped, noticed (Figure 3). The length of the LT was measured triangular with the apex up, and presence of as 18.5 cm using a thread segment against a standard tongue-like processes in the quadrate lobe. Joshi et al scale. also reported presence of pons hepatis bridging the fissure of ligamentum teres among 30%10; in the Discussion present case, it was a tunnel within the liver substance with complete absence of quadrate lobe. Variation of the anatomy of the ligamentum teres and Conclusion the quadrate lobe is an uncommon anomaly of the liver development, usually noted during autopsies, surgeries13,14 and cadaveric dissections for routine In this case, we have noticed the complete absence of medical training. The fissure for ligamentum teres can the fissure for ligamentum teres and instead it be of variable depth and ascends backwards from its tunnelled deeply through the liver parenchyma thus notch on the inferior border to the left end of the completely obscuring the quadrate lobe. These fissure for the ligamentum venosum3. In this case the findings may be utilised by anatomists, embryologists ligamentum teres was attached along the inferior for academic interest, pathologists to identify a stromal margin of falciform ligament passing deep through a tumor (15) and gangrene of ligamentum teres and by tunnel within the liver tissue reaching the left branch of clinicians, radiologists and surgeons to avoid possible the portal vein. Elma and Robert measured the mean errors in interpretations and subsequent misdiagnosis, length of the ligamentum teres to fall in the range of 10 and to assist in planning appropriate surgical to 20 cm and in our case the length was measured to approaches related to liver pathology. be 18.5 cm5. Aysin et al reported an unsual ligamentum teres within the rectus sheath with the Acknowledgement(s) ventral component of the left sagittal fissure absent, and where the anatomic differentiation between the left and quadrate lobes could not be identified6. In our We wish to convey our sincere thanks to Mr. Kamal case the ligamentum teres was present within the liver Hassan and Mr. Babu Panicker for their techinical parenchyma inside a tunnel and the ventral assistance and for photographing the specimens component of left sagittal fissure was absent. Sanli et al described the fissure for the round ligament on the References visceral surface was absent, and was embedded inside the parenchyma on the diaphragmatic surface7 and also the findings go in favour with us and in our 1. Li XP, Xu DC, Tan HY, et al. Anatomical study on report there is a complete absence of quadrate lobe as the morphology and blood supply of the falciform well. Abdullahi et al reported the absence of the left ligament and its clinical significance. Surg. Radiol. lobe liver, with absence of fissure for ligamentum teres8. Anat 2003;26:106-9. In our case we have noticed absence of fissure for 2. Keith LM, Arthur FD. Clincally Oriented Anatomy, ligamentum teres and quadrate lobe contrary to the Lippincott Williams & Wilkins 5th Ed; 2006:291. classical observation of the lobation of the liver. The 3. Williams PL. Gray's anatomy, New York: Churchill liver is separated into the left and right lobes by the Livingstone, 38thEd 1995:1796-1801 falciform and round ligaments in the second month of 4.
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