Hepatic bridge and round ligament of the liver during cytoreductive surgery: a retrospective cohort.

PURPOSE: The hepatic bridge as an anatomical variation may lead to recurrence and treatment failure in cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) by constituting an obscure region during surgery. This report aimed to highlight the relationship between the hepatic bridge and various prognostic factors in peritoneal carcinomatosis. METHODS: Data of 101 patients who underwent CRS/HIPEC for peritoneal carcinomatosis in a single centre were retrospectively reviewed. Demographic characteristics, primary origin of peritoneal carcinomatosis, classification of hepatic bridge, Peritoneal Cancer Index (PCI) score, and completeness of cytoreduction (CC) score were analysed. RESULTS: The tumour was proven histopathologically in 18 (28.6%) of 63 patients who underwent distal round ligament (DRL) resection. The PCI score was found to be significantly higher in patients with tumour in DRL compared to the ones without tumour (p < 0.001). The median PCI score of patients with implant positive DRL was 18 (12-20) and this score was 3 (2-6) for patients with implant negative DRL (p < 0.001). The ROC curve concerning the risk of an implant penetrating the round ligament revealed the optimal cut-off value of PCI at 10 with 88.9% sensitivity and 79.3% specificity. CONCLUSION: The round ligament should be removed, regardless of the PCI score, as a standard in mucinous adenocarcinoma of the appendix and malignant peritoneal mesothelioma. DRL should be removed when PCI is equal or higher than 10 for PC due to colorectal and ovarian cancers.

Round ligament suspension and vaginal purse-string suture: Newly optimized techniques to prevent tumor spillage in laparoscopic radical trachelectomy for cervical cancer.

AIM: The purpose of this study was to investigate the surgical techniques and clinical feasibility of nonuterine manipulator and enclosed colpotomy to avoid cancer cell spillages in laparoscopic radical trachelectomy (LRT) for patients with early-stage cervical cancer. METHODS: We performed the newly optimized surgical techniques of round ligament suspension and vaginal purse-string suture in LRT in 12 patients with early-stage cervical cancer from May 2019 to October 2020. Surgical information and postoperative results were recorded. RESULTS: All 12 patients successfully underwent LRT with round ligament suspension and vaginal purse-string suture, and no conversion to laparotomy was required. The median operation time was 268.5 min (range 200-320 min), including 5 min of round ligament suspension, and the median blood loss was 20 mL (range 5-50 mL). The median number of pelvic lymph nodes removed was 27 (range 19-35), and median amounts of paracervical tissue was 24 mm (range 21-26 mm) and vaginal tissue was 18 mm (range 16-26 mm). No intraoperative complication or serious postoperative complications were reported. CONCLUSION: Round ligament suspension and vaginal purse-string suture techniques are feasible and effective in LRT. They can replace uterine manipulator and unprotected colpotomy with satisfactory perioperative outcomes.

Rupture of perivascular epithelioid cell neoplasm at 34 weeks' gestation: A nonendometriosis case of spontaneous hemoperitoneum in pregnancy.

Spontaneous hemoperitoneum in pregnancy (SHiP) has mainly been discussed in the context of endometriosis. With hormonal changes and enlargement of the uterus during pregnancy, tumors can also increase the chance of rupture and consequent SHiP. We report a case of a 30-year-old primiparous woman presented with sudden-onset intraabdominal hemorrhage at 34 weeks' gestation. The source of bleeding was rupture of a perivascular epithelioid cell neoplasm on the left round ligament of the uterus. The pregnancy ended with an uncomplicated, full-term, vaginal delivery. We performed an additional post-partum surgery to resect the left round ligament and transposition of the right ovary. In cases of SHiP, the possibility of a nonendometriosis origin should be considered. Preoperative imaging and histologic examinations of bleeding lesions are crucial for managing SHiP.

Lesions of Ligamentum Teres: Diagnostic Performance of MRI and MR Arthrography-A Systematic Review and Meta-Analysis.

OBJECTIVE: The purpose of this study is to determine the diagnostic performance of MRI and MR arthrography for depicting ligamentum teres lesions. MATERIALS AND METHODS: A literature search was performed. Original studies reporting the diagnostic accuracy of MRI examinations for the depiction of ligamentum teres lesions were included. RESULTS: Eight studies entailing 1456 MRI examinations were included (frequency of median ligamentum teres injury, 25.9%; interquartile range, 14.1-45.3%). Two studies reported the results of unenhanced MRI examinations, and their diagnostic performance could not be estimated. Sensitivity, specificity, and diagnostic odds ratio (DOR) of all MRI examinations were 64.7%, 86.9%, and 12.2, respectively, whereas the sensitivity, specificity, and DOR of MR arthrography examinations were 82.2%, 88.6%, and 35.9, respectively. The heterogeneity (I2) for all MRI and MR arthrography examinations was 92.3% and 88.2%, respectively. Five blinded MR arthrography studies with 643 MR arthrography examinations found an appropriate threshold effect for summary ROC construction (AUC, 0.95). The summary estimate of these studies yielded a sensitivity of 87.8%, a specificity of 91%, and DOR of 73.1. The heterogeneity (I2) for this group was 64.3%. In patients with low pretest probability (25%), MR arthrography enabled the exclusion of ligamentum teres lesion (postprobability for a negative result, 4%; negative likelihood ratio, 0.13). CONCLUSION: MR arthrography can depict ligamentum teres lesions with high accuracy. However, its diagnostic performance for differentiating various types of ligamentum teres lesions (partial, complete ligamentum teres tears, and hypertrophic ligamentum teres), as well as the diagnostic performance of unenhanced MRI for the depiction of ligamentum teres lesions, is yet to be determined because of the paucity of reported data in the literature.

Usefulness of MR arthrography of the hip with leg traction in the evaluation of ligamentum teres injuries.

PURPOSE: To retrospectively evaluate the diagnostic accuracy of magnetic resonance (MR) arthrography of the hip with leg traction in the evaluation of ligamentum teres lesions and to evaluate whether there is increased articular distraction, possibly indicating secondary instability, in hips with ligamentum teres injuries. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained for this retrospective study. MR arthrograms of the hip with leg traction of 184 consecutive patients, including 108 men (mean age, 32.6 years; range, 19-53 years) and 76 women (mean age, 38.5 years; range, 18-56 years), who underwent hip arthroscopy were assessed for the presence of ligamentum teres lesions. The MR arthrographic findings were independently assessed by two radiologists who were blinded to the arthroscopic results. The inclusion criteria stipulated no previous surgery, arthroscopy within 1 month after MR arthrography, and availability of a detailed surgical report with ligamentum teres findings. The arthroscopy findings served as the reference standard. Sensitivity, specificity, accuracy, and K statistics for interobserver and intraobserver agreement were calculated. RESULTS: At arthroscopy, 32 ligamentum teres injuries were found. The ligamentum teres was normal in 152 (82.6%) patients and had suffered low-grade partial tears in 15 (8.1%) patients, high-grade partial tears in 10 (5.4%) patients, and complete ruptures in 7 (3.8%) patients. MR arthrography with axial traction demonstrated moderate sensitivity and high specificity for both low-grade (62/93%) and high-grade (66/96%) partial tears. Grouping low- and high-grade partial tears increased the diagnostic performance of MR arthrography, yielding a sensitivity of 87% and a specificity of 95%. For complete ligamentum teres tears, MR arthrography with leg traction demonstrated high sensitivity (92%) and specificity (98%). Articular distraction was significantly increased in patients with complete ruptures of the ligamentum teres (p = 0.001). CONCLUSION: MR arthrography with leg traction offers accurate diagnosis of ligamentum teres injuries. Patients with complete tears of the ligamentum teres exhibit increased articular distraction that may indicate secondary hip instability.

Arthroscopic Anatomy of the Dislocated Hip in Infants and Obstacles Preventing Reduction.

PURPOSE: The purpose of this study was to describe the anatomy as seen arthroscopically, the role of the labrum and its relevance in luxation and reduction procedures, and secondary changes to the cartilaginous acetabular roof and to determine the main obstacles preventing reduction of dislocated hips in infants and young children. METHODS: A specialized pediatric medial approach to hip arthroscopy was performed on 25 hip joints in 21 patients younger than 4 years of age. The arthroscopic procedure was conducted using a 2.7-mm cannulated instrument. A subadductor portal was used for the 70° arthroscope, and a high anterolateral portal served as a working portal. The anatomic findings of the individual hip joints were recorded. We examined the femoral head, the teres ligament, the transverse ligament, the acetabulum, and the acetabular labrum. The obstacles preventing reduction were successively resected. RESULTS: An arthroscopic investigation of all major structures and arthroscopic reduction was possible in 25 hip joints. A hypertrophic teres ligament was present in 23 of the 25 hips. Capsular constriction prevented reduction in 22 of the 25 hips. The acetabular labrum was not inverted in any of the examined hip joints and was also never an obstacle to reduction. Secondary changes to the cartilaginous preformed acetabular roof were present in 10 hips. CONCLUSIONS: We have shown that arthroscopy of a developmentally dislocated hip can be safely performed using the subadductor portal. Through this arthroscopic approach, we were able to identify the previously described pathologic structures-the limbus, neolimbus, pulvinar, hypertrophic teres ligament, and capsular constriction. The capsule was the most common block to reduction, followed by the teres ligament. Successful reduction can be achieved by removal of intra-articular tissues, the pulvinar, and the teres ligament, and nearly always a capsular release. The limbus and neolimbus were not factors in achieving reduction in our series. LEVEL OF EVIDENCE: Level IV, case series.

Leiomyoma of the round ligament of the liver: report of one case.

Tumoral conditions in the round ligament of the liver are very uncommon and exhibit nonspecific manifestations, hence a high level of suspicion is necessary for their diagnosis. We report the case of a 47-year-old female patient who presented with abdominal pain for several months; imaging studies showed a lesion of indeterminate nature likely connected with the falciform ligament, and only intraoperative findings acknowledged the presence of an apparently benign tumor in the round ligament of the liver, which biopsy confirmed. Following the excision of the round ligament the patient had a favorable course. As this is a pathologically benign lesion we deem its surgical management both advisable and sufficient. However, because of its small prevalence and the scarcity of literature involving this condition, further studies would be needed to provide information on natural history, treatment, and long-term prognosis.

Preliminary Functional Outcome Following Robotic Intracorporeal Orthotopic Ileal Neobladder Suspension with Round Ligaments in Women with Bladder Cancer.

BACKGROUND: Chronic urinary retention (CUR) is a frequent complication after orthotopic neobladder (ONB) reconstruction in women. To decrease CUR, several open surgical modifications to provide back support to the ONB have been established on the basis of pelvic anatomical differences between females and males. OBJECTIVE: To illustrate our technique for robotic intracorporeal reconfiguration of ONB as integrated into our open surgical approach to provide back support to the ONB with round ligaments in women. DESIGN, SETTING, AND PARTICIPANTS: From November 2017 to April 2021, 28 patients underwent robotic intracorporeal ONB with a minimum of 6 mo of follow-up at a single centre. SURGICAL PROCEDURE: We performed robotic radical cystectomy, pelvic lymphadenectomy, and a complete intracorporeal ONB suspended with round ligaments (rONB). Our surgical procedure is demonstrated in the accompanying video. MEASUREMENTS: Demographics and clinical and pathological data were collected. Perioperative and 90-d complications and 6-mo functional outcomes were compared for the rONB group (n = 12) and the patients receiving a traditional ONB (tONB; n = 16). RESULTS AND LIMITATIONS: The median total operative time was 305 min (interquartile range [IQR] 270-370) for tONB and 303 min (IQR 287-330) for rONB. The median estimated blood loss was 325 ml (IQR 200-700) for tONB and 350 ml (IQR 262-600) for rONB. Some 50% of the tONB group and 41.7% of the rONB group experienced low-grade complications. A total of 12.5% tONB and 8.3% rONB patients experienced high-grade complications with neobladder-vaginal fistula. The cumulative risk of CUR was 37.5% in the tONB group and 16.7% in the rONB group. This study is limited by the small sample size and the short follow-up period. CONCLUSIONS: We established a feasible surgical technique for a robotic intracorporeal ONB configuration suspended with round ligaments. This may prevent the occurrence of emptying dysfunction in women. PATIENT SUMMARY: We describe our stepwise technique for creating a new bladder within the body that is suspended with round ligaments. Patients undergoing removal of the bladder for bladder cancer may benefit from this technique in terms of better urinary function and the advantages of a robotic surgical approach.

Laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament without a uterine manipulator.

OBJECTIVE: To demonstrate the experience of laparoscopic radical hysterectomy for cervical cancer without the use of a uterine manipulator and investigate the feasibility and treatment effectiveness of this surgical approach. MATERIALS AND METHODS: The laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament without a uterine manipulator prevented the oppression of the uterine manipulator on the tumour. Vaginal ligation was performed below the lesion of cervical cancer, and the vagina was cut off below the ligation line. Consequently, the exposure of cancer tissues in the abdominal cavity was prevented, enabling a tumour-free operation. We reviewed the medical records of the 22 patients with stage IB1-IIA2 cervical squamous cell carcinoma who were treated at our hospital between May 2019 and February 2020. All the patients underwent the laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament. All the patients were informed about the different therapeutic schemes and surgical approaches as well as their advantages and disadvantages. Information about operative time, intraoperative blood loss, hospitalisation duration, postoperative complications, postoperative adjuvant therapy, prognosis and other data were recorded. RESULTS: All the surgical procedures were successfully completed without perioperative complications, such as vascular injury, pelvic injury and abdominal organ injury. The mean operative duration was 204 min, and the mean operative blood loss was 102 mL. The mean duration of postoperative hospital stay was 13 days. Nineteen patients received postoperative chemotherapy once before hospital discharge. Urinary retention was the major postoperative complication. All the patients were followed up for 14-23 months. The median follow-up time was 18 months. 21 of the 22 patients survived. No recurrence was detected in the patients during follow-up. One patient who had a pelvic lymph node metastasis but refused complete chemoradiotherapy died before the last follow-up. CONCLUSIONS: This surgical approach appears to be safe and feasible for patients with cervical cancer. A larger sample size and longer follow-up period are required to confirm whether this surgical approach can actually and effectively improve the prognosis.

Spontaneous inflammation and necrosis of the falciform and round ligaments: a case report and review of the literature.

BACKGROUND: Necrosis of the falciform and round ligaments is extremely rare, thus making the diagnosis challenging. It is often misdiagnosed as gallbladder pathology due to the presenting symptoms. Due to the rarity of this pathology, there is limited literature available. CASE PRESENTATION: A 53-year-old white man presented to our hospital with signs and symptoms of gallbladder pain but turned out to have the rare entity of necrosis of the falciform and round ligaments. An extensive review of the world literature was performed using PubMed. Manual cross-referencing of reference lists was performed to obtain all available articles. The personal operative log of the senior author was also searched to reveal one additional case. Statistical analysis was descriptive only, given the small number of reported cases. Thirty-nine articles were found, among which forty-three case were identified, and one additional case was extracted from the operative log of the senior author. Unlike previous reports, we found that isolated inflammation and necrosis of the ligaments occurs at nearly the same frequency in both men and women, not predominantly in women as previously reported in smaller series. The mean age at presentation was 59.5 years old, and cases were typically initially diagnosed as gallbladder pathology, most commonly acute cholecystitis. Computed tomography more frequently than ultrasound revealed the falciform and round-ligament pathology. CONCLUSIONS: Isolated falciform and round-ligament inflammation and necrosis is a rare condition that is difficult to diagnose because it can present mimicking a wide variety of intra-abdominal pathologies, particularly gallbladder pathologies. It is often best treated by laparoscopic resection. Unlike prior reports, our review of the literature, which is the largest that we know of to date, shows that males and females are equally affected. Greater awareness of this entity will aid in future diagnosis.

Acetabular Delamination: Epidemiology, Histological Features, and Treatment.

OBJECTIVE: The International Cartilage Repair Society classification is the one mainly used to define chondral defects. However, this classification does not include delamination. The objective of the study is to describe the characteristics of this lesion to better explain its classification in the context of chondral lesions of the hip. DESIGN: We performed a retrospective analysis of 613 patients who underwent hip arthroscopy. In this group, the incidence, localization, histological characteristics, and association to femoroacetabular impingement as well as to other intraarticular lesions of acetabular delamination (AD) were analyzed. Preoperative magnetic resonance imaging accuracy and the different treatment options were also evaluated. RESULTS: In our series, the incidence of the AD was 37% (226 patients over 613). The average age of this group was significantly lower (39.3 years) than the entire group of patients. Isolated cam (P < 0.01) and pincer morphologies (P < 0.05) had a significant statistical association with the AD. This lesion was primarily localized at the acetabular chondrolabral junction, mainly on the anterosuperior quadrant. The intraarticular lesions more frequently associated to AD were labral lesions (94.25%, P < 0.01), ligamentum teres lesions (28.32%, P < 0.05), and femoral head chondral lesions (19.9%, P < 0.01). The histological examination of the AD was characterized by hypocellularity and structural disorder of the matrix, with fissures. Treatment remains controversial. CONCLUSION: AD represents an intermediate stage in chondral damage and can be classified as a "2a" grade lesion. Histological examination confirms the intermediate and progressive character of this injury.

Effect of ligamentum teres tear on the development of joint instability and articular cartilage damage: an in vivo rabbit study.

The contribution of the ligamentum teres to the stabilization of the hip joint and the clinical influence of a compromised ligamentum teres are not well known. This study aimed to investigate joint stability and cartilage damage in a rabbit model by surgically inducing a complete ligamentum teres tear. Twenty adult New Zealand rabbits were used in this study. Rabbits were divided into complete ligamentum teres tear with capsulotomy (n = 9, group I) and capsulotomy only (n = 10, group II) groups. Unilateral surgery was performed on the left hip. Joint instability was assessed by measuring the preoperative and postoperative acetabulofemoral (A-F) distances. Rabbits were euthanized to assess cartilage damage at 24 weeks postoperatively. The median postoperative A-F distance of the operated side in group I [0.68 cm (0.37-1.04 cm)] was larger than that in group II [0.50 cm (0.30-0.65 cm)] (p = 0.041). The median postoperative A-F distance was larger in the operated side [0.68 cm (0.37-1.04 cm)] compared to the nonoperated side [0.45 cm (0.30-0.75 cm)] in group I; it also was larger in the operated side [0.50 cm (0.30-0.65 cm)] compared to the nonoperated side [0.44 cm (0.32-0.67 cm)] in group II, but only group I showed a significant difference (p = 0.016 and 0.395, respectively). Articular cartilage damage was detected at the apex of the femoral head in two rabbits (22.2%) in group I only. Rabbits with a complete ligamentum teres tear showed significant instability at the hip joint and articular cartilage damage in our rabbit model, supporting the potential clinical importance of ligamentum teres as a hip joint stabilizer.

MR arthrography of the hip with and without leg traction: Assessing the diagnostic performance in detection of ligamentum teres lesions with arthroscopic correlation.

OBJECTIVES: To retrospectively assess the diagnostic performance of hip MR arthrography with and without traction in detecting ligamentum teres (LT) lesions with arthroscopic correlation and to evaluate the effect of traction on the imaging appearance of the LT. METHODS: 73 MR arthrograms (73 consecutive patients, mean age, 34.5 years; range, 14-55 years) obtained without and with leg traction (application of 15-23 kg, use of a supporting plate for the contralateral leg) were included. Two blinded readers independently evaluated LT lesions on MR arthrograms on separate occasions: coronal images without traction; coronal images with traction; a multiplanar traction protocol. MR findings were correlated with arthroscopic records. Sensitivity/specificity of traction and non-traction imaging was compared on coronal images with the exact McNemar test. Imaging appearance of the LT with and without traction was assessed in consensus and compared on coronal images using McNemar and McNemar-Bowker tests. (p<0.05, * corrected for type I error). RESULTS: With arthroscopy 29 (40%) LT lesions were identified in 73 patients. Sensitivity was 72%/90% (without traction/with traction; p=0.25*), specificity was 89%/77% (p=0.25*) for reader 1 in assessing coronal images and for reader 2 sensitivity was 59%/86% (p=0.044*) and specificity was 93%/82% (p=0.25*). Alterations in fiber orientation, signal intensity, surface, dimension, fiber continuity after application of traction were observed in 33/73 (45%, p=0.002*), 6/73 (8%, p=0.223), 9/73 (12%, p=0.36*), 6/73 (8%, p=0.031) respectively 9/73 (12%, p=0.003) cases. Traction-related alterations in at least one criterion were observed in 41/73 (56%) cases. CONCLUSION: Application of traction can considerably alter the imaging appearance of the LT and resulted in higher rates of true-positive and false-positive findings compared to conventional MR arthrography.

Metástasis poco frecuente del carcinoma renal de células claras / Unusual metastasis of clear cell renal cell carcinoma

El ligamento falciforme es una reflexión peritoneal abdominal relacionada con la superficie anterior del hígado, que en su borde inferior libre contiene el ligamento redondo (LR); las lesiones únicas en este son infrecuentes. Presentamos un caso de metástasis única en el ligamento redondo en un paciente con antecedente de carcinoma renal de células claras. Realizamos una búsqueda bibliográfica para identificar casos similares. Nuestro paciente es un varón de 71 años con antecedente de carcinoma renal de células tratado con nefrectomía radical izquierda laparoscópica (estadio pT3a). En tomografía computarizada (TC) control a los 5 años se evidencia lesión focal en la periferia del segmento IVa, ante la sospecha de malignidad, se realiza laparotomía exploradora revisando toda la cavidad abdominal sin evidenciar otros implantes peritoneales. Se halla un nódulo de 1 cm en el ligamento redondo y se realiza su exéresis completa, con diagnóstico anatomopatológico de metástasis de células claras. El LR generalmente está afectado en casos de carcinomatosis peritoneal y solo existen dos casos publicados de metástasis únicas.

The falciform ligament is a peritoneal reflection that attaches the liver to the anterior abdominal wall; its lower edge contains the round ligament (RL). Single lesions in the RL are rare and usually correspond to perivascular epithelioid cell tumors. We present a case report of a single metastasis in the RL in a patient with clear cell renal cell carcinoma who underwent surgery five years ago. We conducted a literature review to identify similar cases and we found two case reports of single metastasis in the RL. Our patient was a 71-year-old man with a history of renal cell carcinoma who underwent left laparoscopic radical nephrectomy (stage pT3a), laparoscopic right adrenalectomy and total thyroidectomy due to multinodular goiter. The pathological examination revealed metastases of renal cell carcinoma. A computed tomography (CT) scan performed at 5-year follow-up showed a focal lesion in segment IVa with no FDG uptake in the PET scan, but as malignancy was suspected, the patient underwent exploratory laparatomy with no evidence of peritoneal implants. A 1-cm node was found in the round ligament that was completely resected. The pathological examination revealed metastatic clear cell renal cell carcinoma. The RL is involved in cases of peritoneal carcinomatosis and only two cases of single metastasis have been reported: in one patient with papillary renal cell carcinoma pT1aN0 and another one with left breast adenocarcinoma.

Sarcoma no ligamento redondo do fígado / Sarcoma in the ligamentum teres of the liver

Leiomiossarcomas são tumores mesenquimais pouco comuns e tornam-se raros quando sua etiologia é de tecido estromal gastrintestinal ou de outra musculatura lisa. Objetivo - relatar um caso de tumor cístico de ligamento redondo de difícil diagnóstico clínico. Relato de caso - paciente de 31 anos com tumoração em hipocôndrio direito e epigástrio há aproximadamente três anos, sem perda de peso ou / Leiomyosarcomas are uncommon mesenchymal tumors and are even scarcer when they develop from gastrointestinal stromal tissue or some other smooth muscle. Aim - To report a case of cystic tumor from the round ligament, with difficult clinical diagnosis. Case report - 31 year-old patient presents with a lumping at the right hypochondrium and epigastrum for about 3 years, with no weight loss or any other complaints...