Cysts of the canal of Nuck: A rare sonographic diagnosis.

The canal of Nuck is a remnant of a peritoneal evagination associated with the round ligament in women. Rarely, the canal of Nuck can remain patent allowing for development of cysts. These cysts are difficult to diagnose due to their rare incidence and because they are often mistaken for other causes of inguinal pain in women. This case series of three women presenting with groin or labial masses highlights the role of sonography as the primary imaging modality in the diagnosis of canal of Nuck cysts. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:175-178, 2017.

[A female patient with an unusual swelling in the groin]. / Een patiënte met een ongewone zwelling in de lies.

A swelling in the groin is a highly prevalent complaint. However, surgical exploration can sometimes reveal an unexpected finding, such as in our case of a postmenopausal 52-year-old female patient. After surgical excision, a left groin mass appeared to be a leiomyoma of the round ligament of the uterus.

Ventrally dislocated attachment of the ovarian suspensory ligament, a risk factor for tubal occlusion as a postoperative complication of inguinal hernia repair: efficacy of laparoscopic inguinal hernia repair for preventing tubal damage.

PURPOSE: Although the traditional cutdown inguinal hernia repair in children is well established, tubal occlusion has been reported as a complication in girls. The purpose was to investigate the mechanism of this complication and the efficacy of laparoscopic repair for preventing tubal occlusion. METHODS: Between October 2006 and May 2010, we performed laparoscopic hernia repair in 100 girls (54 with a right hernia, including 2 with an inguinal ovarian hernia, 40 with a left hernia, including 3 with an inguinal ovarian hernias, and 6 with bilateral hernias). During laparoscopic repair we examined the anatomical relationship between the ovary, ovarian suspensory ligament, internal inguinal ring, and round ligament on both sides. RESULTS: In 17 cases, 5 with an inguinal ovarian hernia and 12 without, the suspensory ligaments were ventrally dislocated and attached around the internal inguinal ring, and the ovary and fallopian tube were positioned near the internal inguinal ring and above the pelvic brim on the side of the original hernia. CONCLUSION: This ventrally dislocated attachment may facilitate sliding of the ovaries and tubes into the hernial sac and induce tubal occlusion as a postoperative complication of inguinal hernia repair. The laparoscopic procedure makes it easy to prevent this complication.

True left-sided gallbladder with a portal anomaly: report of a case.

A 65-year-old female who presented with back pain was diagnosed to have the presence of biliary sludge in the gallbladder. Computed tomography showed that the round ligament connected to the left portal umbilical portion was in the normal anatomical position. However, the gallbladder was located to the left of the middle hepatic vein and the round ligament, attached to the left lateral segment of the liver. The right posterior portal vein diverged alone from the main portal vein, and there was a long stem from the right anterior and left portal veins. Laparoscopic cholecystectomy confirmed the abnormal location of the gallbladder. Most reported cases of left-sided gallbladder are caused by a right-sided round ligament, which is called a "false" left-sided gallbladder. A case of left-sided gallbladder with a normal left-sided round ligament, which is designated as a case of "true" left-sided gallbladder, is extremely rare.

The female gubernaculum: role in the embryology and development of the genital tract and in the possible genesis of malformations.

The female gubernaculum is an embryonic structure that gives rise to the uterine round ligament and seems to be important in Müllerian development. In the absence of androgens and anti-Müllerian hormone, the paramesonephric or Müllerian ducts complete their invagination and development, interfering with the connection of the tissue column that begins at the inguinal cone (the gubernaculum) and targets the mesonephric duct and caudal ligament of the gonad. The gubernaculum then grows over the Müllerian ducts, incorporating its muscular fibres. Outside and above this point, the Müllerian ducts give rise to the Fallopian tubes, whereas medially to the point of insertion of the gubernaculum, the Müllerian ducts develop into the normal uterus, the adequate formation of which is also induced by the mesonephric ducts. Diverse human anatomical and physiological characteristics such as the simplex uterus, as well as pathological conditions and certain female genital malformations, could be related to gubernaculum dysfunction. The main conclusions in this article are: (1) The female gubernaculum is the origin of the uterine round ligament but probably not of the uteroovarian ligament. Gubernacula are composed of muscular fibres that probably derive from the abdominal wall and that, when fixed and fused with the Müllerian ducts, allow or induce, together with the mesonephric ducts, the adequate development and formation of the uterus. (2) The female gubernaculum seems to be responsible for many of the specific human characteristics of Müllerian development, including the uterus simplex, the anteflexion and low intra-abdominal position of the uterus, and the disposition of uterine muscular fibres. (3) The female gubernaculum seems to be related to pathologies arising from the round ligaments and inguinal hernia. Likewise, certain uterine malformations (e.g., didelphys uterus, Rokitansky syndrome) and accessory and cavitated uterine masses might be related to gubernaculum dysfunction.

Successful mesenterico-left portal vein bypass in a child with duplicated round ligaments and rex recessi.

A 3-year-old girl with idiopathic extrahepatic portal vein obstruction undergoing mesenterico-left portal vein bypass (MLPVB), or Rex shunt, for recurrent variceal bleeding was intraoperatively discovered to have duplicated round ligaments and Rex recessi. The left and right portal veins connected to their respective round ligaments but had minimal communication within the liver. Intraoperative venography identified a better preserved portal system on the left, and standard MLPVB resulted in excellent shunt flow. The shunt remains patent and the patient asymptomatic 9 months after her operation. Abnormal portal anatomy is not a contraindication to MLPVB.

Case of accessory ovary in the round ligament with associated endometriosis.

The phenomenon of accessory ovary, initially described in 1864, is extremely rare. We report a case of an accessory ovary in a round ligament with endometriosis. At the time of laparoscopy a firm 2- to 3-cm mass was noted within the round ligament with a normal ovary visualized. Dissection and removal of the mass was performed. Histopathology revealed ovarian stroma and dense connective tissue with endometriosis. This case fulfills the criteria established in 1959 for accessory ovary and is the first case of an accessory ovary reported within the round ligament. A unique finding with the accessory ovary in this case is the presence of endometriosis. No reported cases exist of endometriosis within an accessory ovary. This information may be pertinent for evaluation of dysmenorrhea when no endometrial implants are present, or with the persistence or recurrence of endometriosis and pain after a bilateral salpingo-oophorectomy.

Ball-valve gastric tumor associated with anomalous junction of the pancreatico-biliary ductal system and a right-sided round ligament: report of a case.

We report the case of a ball-valve gastric tumor associated with anomalous junction of the pancreatico-biliary ductal system (AJPBDS) and a right-sided round ligament, misdiagnosed preoperatively as advanced gastric cancer with pancreatic head invasion. A 72-year-old woman presented with chest pain, but laboratory data showed only anemia. Gastroscopy revealed a bleeding polypoid gastric tumor in the anterior wall of the stomach, herniating into the duodenum (ball-valve syndrome), and a Bormann type-2 tumor in the posterior wall. Ultrasonography showed gallbladder stones, dilatation of the intrahepatic bile duct and pancreatic duct, and a left-sided gallbladder (attributed to a right-sided round ligament with anomalous branches of the portal veins). Laparotomy revealed that the gastric tumors were not advanced cancer invading the pancreatic head. Intraoperative cholangiography showed an AJPBDS, causing dilatation of the intrahepatic bile duct and pancreatic duct. We performed distal gastrectomy and cholecystectomy without biliary diversion. Microscopy revealed that the polypoid tumor was a hyperplastic polyp.

Use of autogenous saphenous vein as a conduit for mesenterico-left portal vein bypass.

The authors describe a case of extrahepatic portal vein (EHPV) thrombosis and portal hypertension treated with a variant of mesenterico-left portal vein bypass (MLPVB) or Rex shunt. In this case, a segment of autogenous greater saphenous vein was used to bridge the distance between the left gastric vein inflow and the left portal vein. Use of such nontraditional conduit in similar circumstances may expand the application of portal revascularization/decompression procedures in treating these patients.

Left-sided gallbladder on the basis of a right-sided round ligament.

Left-sided gallbladder, a rare congenital anomaly, is defined as a gallbladder located to the left of the round ligament. A 42 year-old female underwent a cholecystectomy for gallstone disease. At laparotomy, we found that the round ligament was located to the right of its normal position and was continuous with the right anterior branch of the portal vein. Though normally situated, the gallbladder was therefore, on the left side of the anomalously right-sided round ligament, fulfilling the definition of a left-sided gallbladder. This case indicates that a third type of left-sided gallbladder may occur in addition to the other forms: one resulting from a right-sided round ligament, in addition to the "true" left-sided gallbladder and the variety seen in situs inversus.