Letter to the Editor: Round ligament fixation: A promising alternative for the prevention of hepatic cyst recurrence

Abstract

We commend on the retrospective study published in the World Journal of Gastrointestinal Surgery by Wu et al for describing laparoscopic fenestration reinforced by suturing the round ligament of the liver to the cyst wall, leveraging autologous tissue to maintain patency and potentially reduce recurrence. The reported series demonstrated technical feasibility, minimal morbidity, and encouraging early radiological responses. We highlight the practical advantages over omental transposition - ready availability, the ability to reach high-dome lesions, and avoidance of omental traction. However, several points require clarification. These include patient selection (solitary vs polycystic disease), management of biliary communication, cyst location and size thresholds, suture choice and tension to avoid ischemic necrosis, and criteria for drain removal and imaging follow-up. To define durability, we advocate for prospective comparative studies against standard fenestration with or without omentoplasty, based on standardized endpoints. Key outcomes should include symptom relief, recurrence-free survival, reintervention, quality of life, and follow-up beyond 12 months. Additionally, we provide practical considerations to guide broader adoption.

Key Words: Hepatic cysts; Liver round ligament; Laparoscopic fenestration; Cyst recurrence; Omental transposition; Autologous tissue barrier; Minimally invasive surgery; Surgical technique modification

Core Tip: Wu et al introduced a novel technique that uses the round ligament of the liver to prevent hepatic cyst recurrence after laparoscopic fenestration. This approach offers distinct advantages, including consistent anatomical availability, superior reach to high-dome lesions, and avoidance of omental mobilization. Critical gaps remain regarding optimal patient selection, technical standardization of suture placement, and long-term recurrence rates beyond 12 months. Prospective comparative trials with patient-reported outcomes and extended surveillance are essential to validate this autologous solution and to establish its role in contemporary surgical practice.

TO THE EDITOR

We read with great interest the retrospective study published in the World Journal of Gastrointestinal Surgery by Wu et al[1] describing their modified laparoscopic fenestration technique for hepatic cysts that uses the round ligament of the liver as a biological barrier. The authors present an innovative approach that addresses a persistent challenge in hepatic cyst surgery that helps with the prevention of postoperative recurrence while preserving the minimally invasive benefits of laparoscopy. The reported technique offers several theoretical advantages. First, the round ligament is a readily available autologous tissue that eliminates concerns regarding foreign body reactions or mesh-related complications[2]. Second, unlike omental transposition, which may be technically challenging or impossible in patients with previous upper abdominal surgery, obesity, or a shortened omentum[3], the round ligament has consistent anatomy and reliable accessibility. Third, the authors demonstrated that an adequate length (> 12 cm) can be achieved to reach high-dome lesions near the diaphragm, a location where traditional omentoplasty often fails due to insufficient reach or excessive tension[4].

Several critical points warrant further clarification to ensure reproducibility and to guide appropriate patient selection. The manuscript lacks detailed inclusion and exclusion criteria. Were patients with polycystic liver disease included, or was the cohort limited to solitary simple cysts? This distinction is crucial, as polycystic disease carries different recurrence risks and may require alternative management strategies[5]. Additionally, the authors should specify how they excluded cysts with biliary communication preoperatively, as inadvertent fenestration of cystadenomas or communicating cysts can result in biliary peritonitis or persistent bile leakage[6].

The description of the operative technique, although innovative, would benefit from additional technical details. What suture material was employed for ligament fixation? Absorbable sutures may lose their integrity before adequate adhesion formation[7], while permanent sutures carry a risk of long-term foreign body reactions[8]. How many fixation points were used, and how was suture tension calibrated to avoid ligament ischemia and necrosis while maintaining adequate apposition? Were anatomical variations in the round ligament thickness or vascularity considered, and did they influence technical success or preclude the technique in any patient?

Our primary concern is the limited follow-up duration (3 months to 12 months). Hepatic cyst recurrence typically manifests over years rather than months, with some series reporting recurrence rates exceeding 30% at 5 years after simple fenestration[9]. While a 3-12-month follow-up is reasonable for an initial case series, long-term surveillance is essential to determine true efficacy[10]. We recommend follow-up with standardized imaging protocols at 6, 12, 24, and 60 months to establish accurate recurrence-free survival curves. Additionally, the outcome classification requires refinement. The authors categorize results as “cured” (complete disappearance), “markedly effective” (> 50% reduction), “effective” (25%-50% reduction), and “ineffective” (< 25% reduction). However, radiological size reduction does not necessarily correlate with symptom relief, which is the primary indication for intervention[11]. Did all patients achieve sustained symptom resolution? Were any patients with substantial size reduction still symptomatic due to residual mass effect? Incorporating patient-reported outcome measures and quality of life assessments would strengthen future studies.

From a practical implementation perspective, we pose several questions regarding the adoption of this technique. How does the round ligament function in patients with hepatic fibrosis or cirrhosis, where altered tissue compliance might affect adhesion formation? Does tissue quality compromise suture integrity in patients with obesity and fatty infiltration of the ligament? For cysts located in the posterior segments or caudate lobe, does the limited ligament reach become a constraint despite the reported 12-cm length?

We suggest that future investigations employ a comparative study design, ideally prospective and randomized, comparing round ligament fixation with standard fenestration with or without omental transposition. Standardized endpoints should include recurrence defined by both size criteria and symptom recurrence, reintervention rates, perioperative complications graded by the Clavien-Dindo classification, hospital costs, and validated quality-of-life instruments. Subset analyses based on cyst size, location, and patient characteristics would help define optimal indications. Despite these questions, we applaud the authors for introducing a technically feasible modification that leverages an anatomic structure often overlooked in hepatobiliary surgery. The round ligament represents an ideal biological solution that requires further validation. We encourage the authors to continue following their cohort and collaborate in multicenter studies that define the role of this technique in the surgical armamentarium for hepatic cysts.

CONCLUSION

The round ligament fixation technique represents an innovation that leverages readily available autologous tissue to prevent hepatic cyst recurrence. Early results demonstrate technical feasibility and safety, with practical advantages over omental transposition. Prospective comparative studies with standardized endpoints, patient-reported outcomes, and extended follow-up beyond 12 months are essential to establish long-term durability and define optimal patient selection criteria.