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

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 cm 2 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.