Round ligament varicosity: a rare but important differential diagnosis of groin lumps during pregnancy.

Round ligament varicosity is rare and mainly reported during pregnancy. A systematic review of the literature identified 48 relevant studies reporting a total of 159 cases of round ligament varicosity, 158 of which were associated with pregnancy. Where reported, the mean age of the patients was 30.65 years, and 60.2% were of Asian ethnicity. The laterality of the condition was almost equally distributed, and nearly 50% presented with a painful groin lump. More than 90% of the patients were diagnosed via Doppler ultrasound scan of the affected groin. Conservative management was successful in more than 90% of the patients. Associated maternal complications are rare, with no mortality reported. No fetal complications or loss were reported. Round ligament varicosity can be misdiagnosed as a groin hernia, which may lead to unnecessary surgery during pregnancy. Therefore, increased awareness of this condition among clinicians is important.

Preoperative sonographic assessment of a leiomyoma of the round ligament.

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Whose surgery is this? Endometriosis of the round ligament.

We report two cases of endometriosis of the round ligament in a 37 and 26 - years old women, with a lump in their right groin and catamenial pain referred to plastic surgery department. MRI showed in both cases nodular lesion in the right inguinal region. The patological examination of the surgical specimen revealed endometriosis of the round ligament. The presence of a groin mass with pain increasing during the menstrual period must raise the suspicion of inguinal endometriosis and a gynecological evaluation is essential to provide a correct management of this rare condition.

Transvaginal ultrasound for diagnosis of deep endometriosis involving uterosacral ligaments, torus uterinus and posterior vaginal fornix: prospective study.

OBJECTIVE: To evaluate the accuracy of transvaginal ultrasound (TVS) in diagnosing deep endometriosis (DE) involving the uterosacral ligaments (USLs), torus uterinus (TU) or posterior vaginal fornix (PVF) in women with suspected endometriosis scheduled for laparoscopic surgery. METHODS: In this prospective study, consecutive women with clinically suspected pelvic endometriosis who were scheduled for laparoscopic surgery were invited to participate. TVS was performed before surgery. TVS findings were compared with those obtained at laparoscopy and confirmed histologically. The accuracy of TVS for diagnosing DE involving the USLs, TU or PVF was assessed. Additionally, the association of DE involving the USLs, TU or PVF on TVS with symptoms and with DE affecting other pelvic locations was assessed. RESULTS: In total, 172 patients were included. The global sensitivity and specificity of TVS in diagnosing DE affecting the USLs, TU and/or PVF were 92% and 87%, respectively. For DE involving the USLs, the accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio and negative likelihood ratio of TVS were 89.5%, 96.6%, 82.1%, 85.0%, 95.8%, 5.41 and 0.04, respectively; the respective values for DE involving the TU were 86.6%, 83.9%, 89.4%, 89.0%, 84.4%, 7.92 and 0.18, and the respective values for DE involving the PVF were 93.6%, 87.0%, 94.6%, 71.4%, 97.9%, 16.20 and 0.14. Logistic regression analysis showed a significant association between DE affecting the USLs, TU and/or PVF and DE affecting the rectosigmoid (odds ratio, 5.43; P < 0.001). Dyschezia was associated strongly with DE involving the USLs, TU and PVF, while dysmenorrhea was associated significantly with DE involving the TU. CONCLUSION: TVS has high accuracy, sensitivity, specificity, PPV and NPV for the detection of DE involving the USLs, TU and PVF in women with suspected endometriosis scheduled for laparoscopic surgery. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Imaging in gynecological disease (21): clinical and ultrasound characteristics of accessory cavitated uterine malformations.

OBJECTIVE: To describe the clinical and ultrasound characteristics of accessory cavitated uterine malformations (ACUMs). METHODS: This was a single-center observational study of consecutive patients diagnosed with an ACUM, who had undergone an ultrasound examination by an experienced ultrasound examiner between January 2013 and May 2019, identified retrospectively from medical records. ACUM was diagnosed when a cavitated lesion with a myometrial mantle and echogenic contents was seen within the anterolateral wall of the myometrium beneath the insertion of the round ligament. In all women, presenting symptoms and clinical history were recorded along with detailed descriptions of the lesions and any concomitant pelvic abnormalities. RESULTS: Twenty patients diagnosed with an ACUM were identified. Median age was 29.2 (interquartile range, 25.0-35.8) years. None of the women was premenarchal or postmenopausal. All of the women reported painful periods or pelvic pain and none of them reported subfertility. Twelve of the ACUMs were in the right anterolateral myometrium and eight were in the left anterolateral myometrium. Both a myometrial mantle and a fluid-filled cavity were considered to be defining features on ultrasound. The fluid contained within the cavity was either echogenic with a ground-glass appearance or hyperechoic. All of the lesions were spherical in shape. The Doppler flow seen in the outer rim was not markedly different from that of the surrounding myometrium, and the content of the cavity was avascular on Doppler examination. The mean outer cavity diameter of the ACUMs was 22.8 (95% CI, 20.9-24.8) mm and the mean internal cavity diameter was 14.1 (95% CI, 12.2-16.1) mm. Four women opted for transvaginal ultrasound-guided alcohol sclerotherapy. Surgical excision was carried out in eight cases, and the diagnosis was confirmed on histopathological examination in all of them. CONCLUSIONS: ACUMs are a uterine abnormality with a distinct ultrasound appearance, which are associated with dysmenorrhea and chronic pelvic pain. Knowledge of their typical appearance on ultrasound could facilitate early detection and treatment. There are several treatment options for ACUM, ranging from simple analgesia to complete excision. Further prospective and longitudinal studies are required to study the prevalence and natural history of this condition. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Is round ligament varicosity in pregnancy a common precursor for the later development of inguinal hernias? The prospective analysis of 28 patients over 9 years.

PURPOSE: Short-term effects of round ligament varicosity (RLV) in pregnancy have been investigated in small-scale studies. The long-term effects are unknown. This study aims to evaluate the risk of groin hernia manifestation after RLV in pregnancy, to delineate possible risk factors and to analyze the natural course of pregnancy and post-partum period with regard to RLV. METHODS: In a prospective analysis 28 pregnant women with RLV presented to the hernia clinic over 9 years. After clinical and ultrasound examination during pregnancy and publication of early results in 2013 a second structured follow-up was conducted. Demographic data, hernia-specific risk factors, comorbidities, pregnancy and birth-related data as well as post-partum period were documented without loss of follow-up. In these women, all pregnancies that occurred, including the ones without RLV, were analyzed. RESULTS: Median follow-up was 68 months (11.4-104.9). Only one groin hernia was found. No risk factors could be identified. After uncomplicated childbirth complaints subsided spontaneously in all but one patient within 4 weeks. Recurrence rates in subsequent pregnancies are up to 89%. CONCLUSION: Temporary RLV-induced dilation of the deep inguinal ring in pregnancy is not a common precursor for the development of inguinal hernias later in life. All findings support the theory that the hindrance of venous blood flow caused by the gravid uterus is an important contributing factor for RLV in pregnancy, which is self-limited but has a high risk of recurrence and is not an indication for surgery before or after delivery or for cesarean section.

Mesothelial cyst of the round ligament.

Mesothelial cyst of the round ligament is a rare finding in females, with only a few cases reported so far. A case of a 25 year old female patient presenting with a palpable mass in her right inguinal region is presented. The preoperative investigation through ultrasound (U/S), computed tomography (CT) and magnetic resonance imaging (MRI) revealed the presence of an intraabdominal cystic lobular mass in the inguinal canal, in contact with the femoral vessels. The mass was excised and the diagnosis of a benign mesothelial cyst was made through pathological examination. Even though it is a rare condition, it is advisable that clinicians consider in the differential diagnosis when evaluating a non-reducible mass in the inguinal region of a female patient.

Laparoscopic excision of round ligament endometrioma.

A 14-year-old female patient consulted due to 4 months of recurrent right pelvic pain during her menstrual period. Sonography revealed a 35 mm haemorrhagic right ovarian cyst, initially treated with hormone therapy and oral analgesics with no response. Surgery was indicated due to growth on sonography control and no response to medical treatment. Laparoscopy showed a 7 cm leiomyomatous-like mass arising from the right round ligament that was extracted en bloc without rupture with right salpingectomy and ovarian preservation. The histopathological examination confirmed the diagnosis of round ligament endometrioma with no atypia. The patient presented an uncomplicated postoperative course and was discharged home 48 hours after surgery. Hormonal contraceptives were initiated after the histopathological confirmation; the patient remains asymptomatic at 1-year follow-up.

A Rare Cause of Inguinal Mass: Round Ligament Cyst.

Round ligament mesothelial cyst is a rare cause of inguinal mass. Round ligament cysts are generally diagnosed during operation in cases who are operated with a pre-diagnosis of inguinal hernia. In this study, we aim to present two cases, who have applied to our clinic with the complaint of a mass in inguinal region and who are diagnosed as round ligament cyst, together with their ultrasound, magnetic resonance images and operation images.

Lipoma of round ligament on the intraperitoneal portion (abdominal site): a case report.

OBJECTIVE: Primary tumors of round ligament are rare, and when found are typically leiomyomas. Endometrioma, and mesothelial cysts are the benign lesions recognized as involving the round ligament. We report a case of lipoma of the round ligament in a 48-year-old premenopausal woman. Round ligament lipoma on the intraperitoneal portion (abdominal site) is very rare and it should be kept in the differential diagnosis of ovarian and abdominal masses.

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.

Round ligament leiomyoma: a rare manifestation of a common entity.

A 68-year-old woman with a history of multifocal uterine leiomyomas presented with left groin pain and was referred for cross-sectional imaging to assess for the presence of an inguinal hernia. In this patient, MRI demonstrated a round ligament leiomyoma encased in the proximal left inguinal canal. Leiomyomas are the most common benign gynecologic tumors, however round ligament leiomyomas are very rare. The purpose of this case report is to highlight a rare manifestation of a common entity.

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.

CT of inguinal canal lipomas and fat-containing inguinal hernias.

Inguinal canal lipomas are a frequent, often unrecognised finding on abdominopelvic CT. Commonly referred to as spermatic cord or round ligament lipomas, they are not true tumours of fat but are extrusions of extraperitoneal fat into the inguinal canal. Their fat content and shared location in the inguinal canal result in confusion with fat-containing inguinal hernias with which they often coexist. As laparoscopic herniorrhaphies proliferate, greater awareness of the condition by radiologists is needed to provide accurate preoperative information. This pictorial essay highlights the differentiating diagnostic features of inguinal canal lipomas and fat-containing inguinal hernias.

Bilateral round ligament varicosities mimicking an inguinal hernia in pregnancy: case report.

A 22-year-old pregnant woman presented with a painful swelling in the right groin. Sonography was performed to confirm a presumptive diagnosis of inguinal hernia based on physical examination. Gray-scale sonography examination revealed bilateral inguinal cystic lesion expanding with the Valsalva maneuver. Color Doppler imaging demonstrated multiple prominent vessels with retrograde venous flow during Valsalva maneuver. Bilateral round ligament varicosities were diagnosed and inguinal hernia was excluded by sonographic findings. Round ligament varicosities should be considered in the differential diagnosis of groin swelling during pregnancy.

Varices of the round ligament mimicking an inguinal hernia--an important differential diagnosis during pregnancy.

Pregnancy is a recognised risk factor for the development of inguinal hernias due to an increase in intra-abdominal pressure. Whilst often managed conservatively until after the pregnancy, if the hernia presents acutely as a painful or tender groin lump, urgent or emergency repair may be required. Many clinicians rely heavily on clinical examination alone in order to diagnose the presence of such a hernia. In pregnancy, however, in order to prevent unnecessary surgery, the use of ultrasound has a more important role to play in reaching this diagnosis. We report a cautionary case that highlights the need for ultrasound evaluation of all painful groin lumps in pregnant women prior to considering surgery.

Mesothelial cyst of the round ligament mimicking a metastasis: a case report.

A mesothelial cyst of the round ligament is a rare cause of an inguinal mass. Clinically, it is frequently misdiagnosed as one of commoner diseases such as an inguinal hernia, femoral hernia, lipoma, and lymphadenopathy upon physical examination. Some previous reports elaborated the sonographic features of a mesothelial cyst of the round ligament. However, to our knowledge, few reports have described the CT features of a mesothelial cyst. We illustrated here the sonographic and multidetector CT features of a case of a mesothelial cyst of the round ligament that presented as an inguinal palpable mass and mimicked a metastasis in a patient with a Sertoli-Leydig cell tumor of the ovary.

[Round ligament varicosities mimicking inguinal hernia during pregnancy]. / Een reponibele zwelling in de lies bij een zwangere: varicositas van het ligamentum teres uteri.

3 pregnant women, aged 34, 28, and 39 years respectively, presented with an inguinal swelling. In one patient the swelling was bilateral and painful. Reposition was possible and ultrasound examination revealed round ligament varicosities, the most common cause of an inguinal swelling during pregnancy. Expectative treatment is advised as the condition usually disappears after parturition. It is concluded that in every pregnant woman with an inguinal swelling, sonography with doppler imaging must be performed to confirm the diagnosis of round ligament varicosities to avoid unnecessary surgery.