Pedicled falciformopexy as an alternative surgical technique in peptic ulcer perforation: a case report and review of the literature

Abstract

Introduction and importance:

Peptic ulcer disease has a lifetime prevalence of 5%–10%, with perforation occurring in 0.004%–0.014% of cases. Omental patch repair is the standard surgical technique for the management of perforated peptic ulcers. This case describes a rare case of duodenal perforation successfully managed using the falciform ligament as an alternative flap. It underscores the value of the pedicled falciformopexy when omentopexy cannot be performed, and highlights the importance of adaptability in operative strategy for rare and challenging surgical scenarios.

Case presentation:

A 60-year-old male presented with 48 hours of worsening abdominal pain, peritonitis, and hemodynamic instability, with imaging confirming pneumoperitoneum. Exploratory laparotomy revealed a 1 × 1 cm² perforation on the first part of the duodenum with thinned-out, short and atrophied omentum, for which a pedicled falciform ligament flap repair was done. The patient recovered uneventfully without any complications.

Discussion:

Perforated peptic ulcer carries high morbidity and mortality (10%–40%), requiring aggressive resuscitation and immediate surgical intervention. The falciform ligament, being well-vascularized and positioned anterior to the duodenum, offers a tension-free and reliable alternative for perforation coverage when the omentum cannot be used. Although infrequently reported, available literature supports its safety and effectiveness, with outcomes similar to traditional omental patch repair, even in large perforations of size 2–3 cm.

Conclusion:

Pedicled falciformopexy is a valuable alternative to traditional omentopexy when omental tissue is inadequate. This case contributes to the limited evidence supporting its use, and emphasizes the need for individualized surgical decision-making in challenging cases.

Introduction and importance

The lifetime prevalence of peptic ulcer disease (PUD) is 5%–10% with an incidence of 0.1%–0.3% per year. It occurs due to acid-peptic injury to the stomach or duodenal mucosa, leading to mucosal erosion and exposing deeper tissues to digestive secretions[1]. The annual incidence of peptic ulcer perforation ranges from 0.004% to 0.014%, with mortality ranging from 10%–40%^[1,2^]. The omental patch repair is the preferred surgical technique for closure of the perforation as it provides a more effective seal, reduces postoperative complications, and supports better healing[3]. The falciform ligament can be used as an alternative flap for closure when the omentum is inadequate, unhealthy (in cases of severe peritonitis), thin, or has been previously resected[4].

HIGHLIGHTS

• Perforated peptic ulcer occurs in 0.004%–0.014% of cases, with significantly high mortality up to 40%.

• Pneumoperitoneum on imaging strongly suggests hollow viscus perforation.

• Aggressive resuscitation followed by immediate surgical intervention decreases morbidity and mortality.

• Pedicled falciformopexy is a valuable alternative to traditional omentopexy when omental tissue is inadequate.

• This case highlights the importance of adaptability in operative strategy for rare and challenging surgical scenarios.

We report a similar case of a 60-year-old gentleman with a duodenal ulcer perforation, who was successfully operated on and managed with falciformopexy. This case is important as it highlights the successful use of the falciform ligament as an effective alternative flap for duodenal perforation when the omentum cannot be used. Such scenarios are uncommon, and there is limited evidence supporting alternative repair methods. It also provides valuable guidance for surgeons encountering similar intraoperative constraints and underscores the importance of flexibility and innovation in surgical decision-making.

This work has been reported in line with the revised SCARE criteria, 2025[5].

Case presentation

A 60-year-old male, a smoker and occasional alcohol consumer, presented to our emergency department with chief complaints of abdominal pain and vomiting for 2 days. The pain was sudden in onset, piercing in character, non-radiating, and initially confined to the epigastric region, which later became generalized. It was associated with two episodes of vomiting, which were non-bilious, non-blood stained, non-foul smelling, and non-projectile. There was no history of previous abdominal surgery, any medical comorbidities, recurrent acid peptic disease, or use of non-steroid anti-inflammatory drugs (NSAIDs). On examination, the patient was hypotensive (BP 80/60 mm Hg) and tachycardic (pulse rate 120 bpm). The abdomen was distended with generalized tenderness, rebound tenderness, and rigidity. Laboratory findings revealed a leukocytosis with a total count of 18,400/mm³, while all other hematological and biochemical parameters were within normal limits. An erect chest X-ray demonstrated free air under both domes of the diaphragm (Fig. 1), and abdominal ultrasound showed moderate ascites with mobile debris.

Figure 1.

X-ray chest showing free gas under both domes of the diaphragm (Red arrow).

A clinical diagnosis of perforation of a hollow viscus was suspected. The patient was adequately resuscitated with intravenous fluids, broad-spectrum antibiotics, and other supportive measures. Emergency exploratory laparotomy was performed via an upper midline incision, revealing approximately 1500 ml of bilious intraperitoneal collection, along with flecks and food materials. A 1 × 1 cm² perforation was identified on the anterior wall of the first part of the duodenum (Fig. 2). Inter-bowel adhesions with flecks were noted, and the omentum appeared thin, translucent, and short, extending only ~ 2–3 cm beyond the greater curvature of the stomach.

Figure 2.

Intraoperative image showing 1 ×1 cm² perforation on the anterior aspect of the first part of the duodenum (Blue arrow).

Thus, the falciform ligament was carefully mobilized from the anterior abdominal wall to ensure it could reach the duodenal perforation site without tension, keeping its attachment to the liver intact to maintain adequate blood supply. The free end of the ligament was then positioned over the perforation, serving as a protective flap. The perforation was repaired using interrupted polyglactin 3–0 sutures, following a technique similar to the classical Graham’s omental patch repair. To prevent compromise of the flap’s vascularity, the sutures were tied in a specific order: the cranial suture was secured first, followed by the caudal suture, and the middle sutures were tied last (Fig. 3). This differs from the classical Graham’s patch, in which the caudal suture is tied first, followed by the cranial suture, and finally the middle sutures. Confirmation of the absence of leakage was done by the methylene blue test from the nasogastric (NG) tube. The wound was closed after thorough peritoneal lavage without any intra-abdominal drain. His postoperative course was uneventful. The NG tube was removed on the second postoperative day, and sips of feeding was started and increased. He was discharged on the 5th postoperative day with triple therapy. At the 2-week and 1-month follow-up, he was doing well with no complications.

Figure 3.

Intraoperative picture showing pedicled falciform ligament flap repair of duodenal perforation, with blue arrow (inferior end of falciform ligament mobilized from anterior andominal wall), white arrow (superior end attached to liver), and green arrow (suture line).

The patient described the sudden, severe abdominal pain as frightening and overwhelming. He expressed deep gratitude for the prompt diagnosis and surgical management. He was pleased with his smooth recovery, and promised to quit smoking and maintain a healthier lifestyle to prevent recurrence.

The sequence of key clinical events is summarized in Table 1 below.

Table 1.

Timeline of events.

Day/Time	Event	Details
2 days before presentation	Symptom onset	Patient developed epigastric pain, which later became generalized with 2 episodes of non-bilious vomiting.
Day 0 (Presentation)	Emergency department visit	Presented with severe generalized abdominal pain, distension, and signs of peritonitis.
	Diagnosed as a case of hollow viscus perforation
		Erect chest X-ray showed free air under the right hemidiaphragm;
Day 0 (Preoperative)	Initial management	Resuscitation and supportive care
Day 0 (Surgery)	Emergency Exploratory Laparotomy	Findings: 1500 ml bilious fluid, 1 × 1 cm anterior duodenal perforation, short omentum. Repair done using falciform ligament flap (modified Graham’s technique). Methylene blue test confirmed no leak.
Post-op Day 1	Postoperative recovery	Patient stable; NG tube in situ; continued monitoring.
Post-op Day 2	Oral intake resumed	NG tube removed; oral sips started.
Post-op Day 3–4	Mobilization and diet advancement	Gradual increase in oral intake; mobilization.
Post-op Day 5	Discharge	Discharged in stable condition on triple therapy.
2-week Follow-up	Early postoperative follow-up	Patient asymptomatic; wound healing well; no postoperative complications.
1-month Follow-up	Final follow-up	Patient resumed normal activities; no complaints.

Discussion and review of the literature

PUD results from an imbalance between stomach acid-pepsin and mucosal defense barriers, such as mucous and bicarbonate. This imbalance causes mucosal erosion and subsequent penetration through the entire thickness, leading to perforation[6]. Helicobacter pylori (50–80%), chronic NSAIDs use (25%), smoking (23%), physiological stress, and genetic factors are risk factors for PUD[2]. Around 10%–20% of cases of PUD develop major complications in the form of upper gastrointestinal bleeding, obstruction, and perforation (2–14%) requiring immediate intervention[7]. In our case, active smoking and a history of occasional alcohol consumption were the only significant risk factors for peptic ulcer disease.

Peptic ulcer perforation usually presents with acute onset of severe abdominal pain in the epigastrium, later becoming generalized. Sudden onset of abdominal pain, tachycardia, and abdominal rigidity constitute the triad of a hallmark of a perforated peptic ulcer[2]. Typical features of peritonitis, in the form of tenderness, rebound tenderness, guarding, or rigidity, are present in 67% of the patients (similar to our case). In patients with contained or sealed perforation, the findings may be subtle or minimal, requiring a high index of suspicion[1]. Radiological evaluation with chest X-ray erect view showing both domes of the diaphragm is the first investigation of choice to detect free gas under the right hemidiaphragm, with a sensitivity of 30%–85% (as in our case)^[1,8^]. CT of the abdomen has a higher sensitivity up to 88% in detecting free air, site, and size of perforation. Contrast-enhanced CT with oral water-soluble contrast and triple contrast CT further improve sensitivity and specificity in the remaining 12% of cases^[1,9^].

Since patients of perforated peptic ulcer present in a state of systemic hypoperfusion, initial management consists of prompt resuscitation, broad-spectrum antibiotics, and other supportive therapy to decrease morbidity and mortality[2]. Definitive treatment consists of emergency surgical repair of the perforation by open or laparoscopic approaches. Laparoscopic surgery offers the advantages of less postoperative pain and wound infections, and less overall mortality with similar postoperative leak, intra-abdominal abscesses, and reoperation rate compared to open surgery[10]. They are used in cases of small perforation (size < 2 cm) and in individuals with hemodynamic stability whenever expertise is available^[4,11^].

The most commonly used technique for the repair of duodenal ulcer perforation is omental patch repair, performed using either the classical or the modified method. In the classical Graham’s patch repair, three to four sutures are placed at the edges of the perforation. A tongue of adjacent healthy omentum is then positioned over the perforation, after which the sutures are tied (Fig. 4B). The omentum is used as an external patch and does not need to be pushed into the defect like an obturator. To preserve the vascularity of the omental patch, the knots are tied sequentially: the caudal suture is tied first and kept slightly loose, followed by the cranial sutures tied tightly, with the middle sutures tied tightly at the end. In the modified Graham’s patch repair, the perforation is first closed using an initial set of three to four sutures. Subsequently, a tongue of healthy omentum is placed over the closed perforation and secured with an additional set of sutures. This technique may leave a potential space between the duodenal serosa and the omentum due to the knots, which may increase the risk of post-operative leakage (Fig. 4A)^[12,13^]. However, in cases where the omentum is inadequate, non-viable, unhealthy, thin, or has been resected in a previous surgery, the falciform ligament can be used as an alternative flap for closure.

Figure 4.

(A) Modified Graham’s patch repair showing a potential space between the duodenal serosa and the omentum; (B) classical Graham’s patch repair showing the omentum completely plugging the perforation.

Fry et al first reported the technique of closure of perforation using a pedicled falciform flap in 1987[14]. Only a few studies are available regarding its use in perforated peptic ulcer. The falciform ligament is a well-vascularized, sickle-shaped peritoneal fold stretching from the umbilicus to the liver, positioned across the duodenum, offering a tension-free flap for suturing to a perforated ulcer^[7,15^]. It can even be used to repair perforations of size 2–3 cm during both open and laparoscopic surgery without significantly increased morbidity and mortality compared to omental patch repair[4].

Post-operative complications like surgical site infection, pneumonia, leaks at closure site, intra-abdominal abscess, wound dehiscence, and ileus have been reported in 30% of cases[16]. Advanced age (>60 years), delayed presentation (>24 hours after onset of symptoms), hemodynamic instability (SBP < 100 mmHg), and the presence of significant comorbidities are the major factors associated with poor outcomes, with mortality ranging from 10% to 40%^[1,2^]. Our patient underwent emergency open midline laparotomy due to hemodynamic instability and delayed presentation (after 48 hours of symptoms onset), and the pedicled falciform ligament was used to successfully repair the perforation site, as the omentum was thin, atrophied, and short in length. He had a smooth perioperative and postoperative recovery without a significant increase in morbidity.

The current body of evidence, including prospective studies, retrospective cohorts, and recent meta-analyses (Table 2), demonstrates that falciformopexy offers safety and efficacy comparable to omentopexy for the repair of perforated peptic ulcers. Although a slightly higher leakage risk has been reported, this has not translated into increased mortality or major morbidity. Falciformopexy is particularly valuable when the omentum is unavailable, and our case further supports its role as a practical and effective alternative. Nevertheless, heterogeneity in existing studies underscores the need for high-quality prospective trials to better define optimal indications and outcomes.

Table 2.

Literature summarizing pedicled falciform ligament flap repair and its outcome.

Literatures	Details	Outcome
Olmez et al (2019)[17]	Omentopexy versus falciformopexy for peptic ulcer perforation	No significant difference in postoperative morbidity and mortality
	Prospective study	Atelectasis more in the omentopexy group
	303 patients	Leak more in the falciformopexy group
	Falciformopexy (n = 46) and omentopexy (n = 243)	Conclusion: Falciformopexy is an alternative but not superior to omentopexy
Son et al (2021)[4]	Outcomes of surgical management of peptic ulcer perforation using the falciform ligament	The falciform ligament can be efficiently used.
	Cross-sectional study	Mortality related to postoperative multiorgan failure and severe comorbidity.
	40 patients
Abosheisha et al (2025)[18]	Falciformopexy as an Alternative to Omentopexy in Perforated Peptic Ulcer Repair: A Systematic Review and Meta-analysis	Falciformopexy has a shorter duration of surgery and hospital stay, with higher postoperative leakage and ileus
	3 retrospective cohorts with 1089 patients (Omentopexy in 960 patients and falciformopexy in 129 patients)	No difference in mortality and other complications
		Heterogeneity in the study
		Conclusion: Both have comparable safety and efficacy, need for further prospective high-quality studies
Cordoso et al (2025)[19]	Safety and Efficacy of the Falciformopexy Technique for Peptic Ulcer Perforation: A Systematic Review and Meta-Analysis	No significant differences between the falciformopexy and omentopexy groups regarding mortality, wound infections, or reoperation rates
	6 studies with 868 patients (148 falciformopexy group)	Conclusion: falciformopexy as a viable alternative to omentopexy when omentum is not available
Terzioglu et.al (2023)[20]	The feasibility of falciformopexy in the repair of peptic ulcer perforation	No statistically significant difference was found between the groups in terms of complications, except for an anastomotic leak.
	Retrospective study with 471 patients (425 patients in modified Graham’s omentopexy group and 46 patients in falciformopexy group)
		Anastomotic leak was observed more frequently in patients who underwent falciformopexy than in patients with modified Graham’s omentopexy

Conclusion

The falciform ligament can be used as a reliable and effective alternative for the repair of duodenal perforation when the omentum is inadequate or unsuitable. Its rich vascularity and anatomical accessibility allow for a secure, tension-free closure without added morbidity and mortality. This case reinforces the importance of early diagnosis and adaptability in surgical decision-making, especially in rare intraoperative scenarios.

Ethical approval

Ethical approval by the ethics committee is not required for a case report in our country.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

None declared.

Author contributions

1. Constructing hypothesis for the manuscript: S.K.G., R.J. 2. Planning methodology to reach the conclusion: S.K.G., R.J., R.P., R.K.G., K.N., M.J. 3. Organizing and supervising the course of the article and taking responsibility: S.K.G., R.J., R.K.G., M.J. 4. Patient follow-up and reporting: S.K.G., R.J., K.N., R.P. 5. Logical interpretation and presentation of the results: S.K.G., R.J., R.P., R.K.G. 6. Construction of the whole or body of the manuscript: S.K.G., R.J. 7. Reviewing the article before submission not only for spelling and grammar but also for its intellectual content: S.K.G., R.J., R.P., R.K.G., K.N., M.J.

Conflict of interest disclosure

The authors declare that there is no conflict of interest regarding the publication of this paper.

Guarantor

Rahul Jha.

Research registration unique identifying number (UIN)

Not applicable.