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REVIEW ARTICLE
Avoiding the Falciform Ligament Sign during the

Intraoperative Cholangiogram

1
Saksham Gupta , Simon Whitcher 2

AbstrAct
We have observed that the falciform ligament can appear prominently as a vertical lucent artifact making cholangiography difficult during
laparoscopic cholecystectomy. Our suspicion is that this is due to the pneumoperitoneum, and once the pneumoperitoneum is released, this
artifact disappears. We have presented images displaying this phenomenon that we feel would be useful for general surgeons operating on
the gallbladder.
Keywords: Cholangiography, Falciform ligament, Laparoscopic cholecystectomy.
World Journal of Laparoscopic Surgery (2021): 10.5005/jp-journals-10033-1461

With the advent of laparoscopic cholecystectomy as the choice
for surgery on the gallbladder, the intraoperative cholangiogram 1,2 John Hunter Hospital, New Lambton Heights, New South Wales,
has been an adjunct to assess the biliary anatomy to reduce the Australia
1
risk of bile duct injuries. Furthermore, this cholangiogram allows Corresponding Author: Saksham Gupta, John Hunter Hospital, New
the operating surgeon to evaluate for filling defects within the Lambton Heights, New South Wales, Australia, Phone: +61249213000,
distal bile duct and confirm flow into the duodenum and becomes e-mail: saksham_gupta@live.com.au
necessary for any common bile duct exploration. The surgeon How to cite this article: Gupta S, Whitcher S. Avoiding the Falciform
needs to be equipped with strategies on how to achieve the Ligament Sign during the Intraoperative Cholangiogram. World J Lap
best cholangiography images. We would like to report a simple Surg 2021;14(2):136–137.

technique on improving intraoperative cholangiography images Source of support: Nil
during laparoscopic cholecystectomy, which to our knowledge Conflict of interest: None
has not yet been described.
The “falciform ligament sign” has been described as a
vertical lucent artifact in situations where the patient has a more of the X-ray beam. We have observed a similar sign during
pneumoperitoneum on a plain abdominal radiograph in the the artificial creation of pneumoperitoneum during laparoscopic
2,3
setting of hollow viscous perforation. With pneumoperitoneum, cholecystectomy. Surgeons need to be weary not to mistake this
the falciform ligament becomes taut and lies in the axis of the as a contrast leak or a biliary structure during the intraoperative
sagittal plane and in this orientation, would potentially obscure cholangiogram. Even if this sign is correctly recognized, it can

Figs 1A to C: Sequential cholangiogram images taken during an elective laparoscopic cholecystectomy. (A) Scout film taken before the introduction
of contrast dye through the cholangiogram catheter. A radiolucent artifact (red arrow) is seen below the epigastric port. This is the falciform ligament
sign; (B) Attempt made to achieve cholangiogram image; however, this artifact completely overlies the common bile duct. (C) On removal of the
pneumoperitoneum, the shadow disappears, and the common bile duct is better visualized, including the entry of the cystic duct.

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