Liver ligaments are double-layered folds of peritoneum that attach the liver to surrounding organs, or to the abdominal wall. The majority of ligaments associated with the liver are remnants of embryological blood vessels that regressed as the fetus developed. The nomenclature of some of the ligaments is based on the structures that they connect, so it’s quite easy to remember them. For example, the hepatoduodenal ligament connects the liver to part of the duodenum.
The liver has several ligamentous attachments that anchor it in the right upper quadrant (RUQ) of the abdominal cavity. These include the coronary, triangular, falciform, round, hepatogastric and hepatoduodenal ligaments, together with ligamentum venosum.
Attaches the liver to the diaphragm, and the right kidney and adrenal gland
Right and left components
Covers left lobe of the liver
Anchors the liver the anterior abdominal wall and the diaphragm
|Ligamentum teres (hepatis)
|Round ligament of the liver
A remnant of the left umbilical vein
|A remnant of the ductus venosum
Occupies the fissure of the ligamentum venosum
Two parts: hepatogastric ligament, hepatoduodenal ligament
In addition to securing the liver in its intraabdominal position, they also help to separate the abdominal cavity into partially isolated spaces and become very important during surgical procedures in the RUQ. This article will discuss the different liver ligaments and their clinical significance.
- Coronary ligament
- Triangular ligaments
- Falciform ligament
- Ligamentum teres
- Ligamentum venosum
- Lesser omentum: Hepatogastric and hepatoduodenal ligaments
- Clinical significance
The liver has crucial homeostatic functions and it is the largest accessory digestive organ within the peritoneal space. It consists of four lobes and two major surfaces. Because it is such a large organ, it requires seven ligaments to keep it relatively immobile in its anatomical location. The largest of the seven hepatic ligaments is the coronary (coronal) ligament. This structure is a reflection of the diaphragmatic peritoneum that attaches to the superior and posterior aspects of the right lobe of the liver.
The coronary ligament is divided into anterior and posterior layers. The anterior (upper) layers further divide to anchor the superior surface of the liver to the inferior surface of the diaphragm on the right-hand side. Also on the right-hand side, the posterior (lower) layers of the coronary ligament attach the posterior surface of the liver to the posterior abdominal wall, right kidney and its associated adrenal (suprarenal) gland. The attachment of the coronal ligament to the liver and its division into the two layers creates a triangular area that is devoid of peritoneum. This is referred to as the bare area of the liver, which is located on its diaphragmatic surface.
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On the right lobe of the liver, the anterior and posterior layers of the coronary ligament of the liver join to form the right triangular ligament. However, there is no true coronary ligament on the left-hand side. Instead, the layers of the coronary ligament approximate to form the left triangular ligament.
Before diving into further details, revise the location of the liver using the following resources:
The triangular ligaments are asymmetrical bilateral structures that help to hold the liver in place. There are two in total, right and left, both of which are continuations of the coronary ligament. The right triangular ligament is a relatively short structure. It begins at the apex of the bare area of the liver and is formed by the right part of both layers of the coronary ligament. In contrast to its predecessor, the left triangular ligament is much longer. It is formed from the left halves of the two layers of the coronary ligament. Consequently, the left triangular ligament projects over the superior surface of the left lobe of the liver. The ligament lies anterior to the abdominal esophagus, the medial part of the gastric fundus and the cranial segment of the lesser omentum.
As the left triangular ligament is longer and travels along the liver for a greater distance, it becomes continuous with both the falciform ligament and the lesser omentum along its course. The arrangement is such that the posterior layer of the left triangular ligament is continuous with the lesser omentum inferolaterally. In turn, the anterior layer of the left triangular ligament is continuous with the falciform ligament superomedially.
Now that the main ligaments attached to the superior and posterior aspects of the liver have been examined, it’s time to learn about the ones anchoring the anterior surface. The second-largest hepatic ligament is the falciform ligament. The sickle-shaped ligament (as suggested by its name) takes a craniocaudally course along the anterior surface of the liver. Superiorly, the falciform ligament is attached to the visceral aspect of the anterior abdominal wall (just an inch to the right of the median plane) and the inferior surface of the diaphragm. It is also continuous with the superior surface of the liver between the left and right lobes.
Like the other hepatic ligaments, the falciform ligament has two layers. The right leaf takes a lateral course to merge with the coronary ligament on the right, while the left leaf unites with the left triangular ligament medially. The two leaves unite to form the falciform ligament, which descends on the anterior surface of the liver between the two lobes. The inferior border of the falciform ligament has no hepatic attachments. Instead, it is occupied by the ligamentum teres hepatis (round ligament of the liver).
More details about the coronary, triangular and falciform ligaments are included below:
The superior and anterior hepatic ligaments have been explained, so it would be a good idea to see the attachments on the inferior and posterior surfaces. During embryonic development, the left umbilical vein drains blood into the left portal vein.
However, about two months after birth, the vein degenerates and forms the ligamentum teres hepatis (Latin for the round ligament of the liver) also just called the ligamentum teres. The ligamentum teres hepatis continues in the inferior border of the falciform ligament and courses in the fissure of the ligamentum venosum on the inferior surface of the liver.
In utero, the ductus venosum was responsible for shunting blood from the left portal vein to the left hepatic vein, thereby bypassing the hepatic circulation. During the first week of extra-uterine life, the ductus venosum degenerates and becomes the ligamentum venosum. This slender fibrous cord passes from the left branch of the portal vein upwards in the fossa bearing its name to reach the inferior vena cava.
Test your knowledge on the liver in situ with this quiz.
Are you curious to find out more about the ligamenta teres and venosum? Then take a look at the following:
Lesser omentum: Hepatogastric and hepatoduodenal ligaments
The lesser omentum forms an “L” shaped attachment that extends from the distal segment of the abdominal esophagus, along the lesser curvature of the stomach to the superior part (the first part) of the duodenum. It inserts on the inferior surface of the liver, adjacent to the fissure of the ligamentum venosum and the porta hepatis.
The lesser omentum may be subdivided into the larger hepatogastric ligament and the smaller (but thicker) hepatoduodenal ligament. The hepatogastric ligament extends between the liver and stomach. It consists of two layers that are continuous with the posterior leaf of the left triangular ligament and the right coronary ligament. They later go on to enclose the inferior vena cava. The hepatoduodenal ligament extends between the liver and duodenum and encircles the constituents of the porta hepatis (portal vein, bile duct, and hepatic artery). The hepatoduodenal component of the lesser omentum also forms the anterior border of the epiploic foramen of Winslow, which is the opening to the lesser sac of the peritoneum.
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In surgeries that require mobilization of the liver, the right coronary, and triangular ligaments are divided in order to liberate the right lobe. This approach is also critical in gaining access to the retrohepatic portion of the inferior vena cava.
The left triangular ligament is particularly important in right hepatic lobectomies. Failure to repair this ligament following a right hepatic lobectomy will result in marked instability of the left lobe of the liver. Furthermore, this may lead to kinking of the hepatic veins and subsequent hepatic dysfunction.
The fundamental principle of radiological imaging is contrast. In plain radiography, air shows up black, while metal-containing structures are white. There are instances (ruptured diverticula, iatrogenic trauma to the intestines) where air gets trapped in the abdominal cavity. This condition is known as a pneumoperitoneum. If the amount of air within the abdominal cavity is significant enough, it could be possible to observe the falciform ligament sign of pneumoperitoneum. This phenomenon is characterized by free peritoneal air outlining the falciform ligament. It is also known as the Silver sign. However, if there is a falciform ligament sign, then it is also likely that there will be a Rigler’s sign, where air can be appreciated on both the luminal and abluminal (peritoneal) sides of the intestines. Just note that a pneumoperitoneum is more likely to be detected on plain radiography as a double bubble sign (air under both sides of the diaphragm) than it is to manifest as the falciform ligament sign.
In some cases, the ligamentum teres hepatis fails to degenerate and remains patent. The patency may also be exacerbated in conditions that result in portal hypertension (e.g. right ventricular failure). The patency of the ligamentum teres hepatis can be problematic in surgical procedures, where the ligament is often divided to enhance visualization of the field (upper abdominal procedures) or to mobilize the liver (hepatic surgeries). The ligamentum venosum serves primarily as a landmark and source of controlling the left hepatic vein during dissections that require control of the vessel.
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