Marginal ulcers are a known complication following Roux-en-Y gastric bypass (RYGB) or other gastrointestinal reconstructive surgeries involving gastrojejunostomy. Although rare, a perforated marginal ulcer is a life-threatening emergency that demands rapid surgical intervention. Traditional repair often involves Graham patch omentoplasty. However, in select cases where the omentum is unavailable or unsuitable, alternative methods such as the falciform ligament patch may be considered.
This article presents a case report of a marginal ulcer perforation successfully repaired using the falciform ligament, highlighting its viability as an alternative surgical technique in acute care settings.
What Is a Marginal Ulcer?
A marginal ulcer typically develops at the gastrojejunal anastomosis—the site where the stomach is joined to the small intestine in procedures like RYGB. These ulcers can occur weeks to years after surgery and may be caused by:
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Gastric acid exposure
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Ischemia at the anastomotic site
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Smoking or NSAID use
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Helicobacter pylori infection
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Technical issues during surgery
While many marginal ulcers are asymptomatic or cause mild discomfort, in rare instances they can perforate, leading to peritonitis and requiring emergent surgical repair.
Case Presentation
Patient Profile
A 47-year-old female with a history of Roux-en-Y gastric bypass performed 5 years prior presented to the emergency department with sudden onset severe upper abdominal pain, nausea, and mild fever. She reported a history of smoking and irregular use of NSAIDs.
Clinical Findings
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Vital signs: HR 115 bpm, BP 100/60 mmHg, Temp 38.2°C
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Abdominal exam: Diffuse tenderness with guarding and rebound in the upper abdomen
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Lab results: Elevated WBC count (16,000/µL), CRP elevated
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Imaging: Upright chest X-ray and CT scan showed free intraperitoneal air, consistent with viscus perforation.
The patient was taken for emergency exploratory laparotomy with a working diagnosis of perforated ulcer.
Intraoperative Findings
Upon exploration:
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A 0.8 cm perforation was identified on the jejunal side of the gastrojejunostomy, consistent with a perforated marginal ulcer.
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The omentum was scarred and retracted, likely due to previous surgeries, rendering it unsuitable for a traditional omental (Graham) patch.
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The falciform ligament was found to be intact, well-vascularized, and easily mobilized.
A decision was made to use the falciform ligament to repair the perforation.
Surgical Technique: Falciform Ligament Patch
Step-by-Step Summary:
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Mobilization of the falciform ligament from the anterior abdominal wall, preserving its vascular supply.
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The perforation edges were refreshed and irrigated.
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The falciform ligament was positioned over the perforation site, and sutured using interrupted absorbable sutures to anchor it securely.
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A drain was placed near the repair site.
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Abdominal cavity was irrigated and closed in layers.
The patient was transferred to the intensive care unit postoperatively for monitoring.
Postoperative Course
The patient recovered well post-surgery:
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Enteral nutrition resumed by day 4.
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Drains removed on day 5 after no signs of leak.
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Discharged home on postoperative day 7, with recommendations to avoid NSAIDs and resume proton pump inhibitors.
At 3-month follow-up, the patient remained asymptomatic with no signs of recurrence.
Discussion
Why Use the Falciform Ligament?
The falciform ligament, a thin fold of peritoneum containing the ligamentum teres, is rarely utilized in modern abdominal surgery. However, it provides several advantages when traditional options are not feasible:
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Readily available and accessible through midline incisions
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Rich vascular supply from the left inferior phrenic and middle hepatic arteries
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Can be mobilized without additional incisions
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Acts as a biologic patch that promotes healing and tissue integration
This technique is particularly valuable in patients with prior surgeries, dense adhesions, or compromised omentum—common in post-bariatric surgery cases.
Literature Review
While reports on falciform ligament use in marginal ulcer repair are scarce, its use in duodenal and gastric perforations has been documented in both trauma and elective surgeries. Our case supports extending this application to marginal ulcers in the post-gastric bypass population.
Conclusion
This case highlights the successful repair of a marginal ulcer perforation using the falciform ligament, an effective alternative when omental tissue is not viable. Surgeons should be aware of this underutilized but valuable technique in complex abdominal cases, particularly those involving prior bariatric procedures. Early recognition, timely intervention, and flexible surgical strategies are key to reducing morbidity and improving outcomes in ulcer perforation cases.