Laparoscopic surgery for endometriosis of the round ligament: A case of a patient with right-sided inguinal pain.

Round ligament endometriosis is a rare phenomenon reported in approximately 0.3% to 0.6% of endometriosis cases. Presurgical diagnosis is carried out for about 50% of the cases. The association of the right-sided inguinal hernia, nonspecific pain in the organs, and no history of surgery or labor make the diagnosis intricate. We report a case of endometriosis of the round ligament in a 39-year-old woman who complained of intense pain in the right groin during the menstrual period for about 4 years, with no complaints of bulging or change in the size of the mentioned area. The clinical suspicion of inguinal endometriosis, supported by sonography and magnetic resonance imaging, was confirmed by histological examination of the surgical specimen after laparoscopic surgery, which included the mass and the extraperitoneal segment of the round ligament. After surgery, the patient's pain disappeared completely. The round ligament endometriosis or endometriosis of the inguinal region could be considered an important differential diagnosis in women of reproductive age without a history of surgery who presented with inguinal region pain during menstruation but no clear mass was palpable in the physical exam.

Ligamentum Teres Augmentation for Hiatus Hernia Repair After Bariatric Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: Hiatal hernia (HH) and symptomatic gastroesophageal reflux disease are common complications after metabolic bariatric surgery. This meta-analysis aims to investigate the safety and efficacy of ligamentum teres augmentation (LTA) for HH repair after metabolic and bariatric surgeries (MBS). MATERIALS AND METHODS: CENTRAL, Embase, PubMed, and Scopus were searched for articles from their inception to September 2023 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system. RESULTS: Five studies met the eligibility criteria, with a total of 165 patients undergoing LTA for HH repair after MBS. The distribution of patients based on surgical procedures included 63% undergoing sleeve gastrectomy, 21% Roux-en-Y gastric bypass, and 16% having one anastomosis gastric bypass. The pooled proportion of reflux symptoms before LTA was 77% (95% CI: 0.580-0.960; I2 = 89%, n = 106). A pooled proportion of overall postoperative symptoms was 25.6% (95% CI: 0.190-0.321; I2 = 0%, n = 44), consisting of reflux at 14.5% (95% CI: 0.078-0.212; I2 = 0%, n = 15). The pooled proportion of unsuccessful LTA outcomes was 12.5% (95% CI: 0.075-0.175; I2 = 0%, n = 21). CONCLUSION: Our meta-analysis demonstrated that LTA appears to be a safe and efficacious procedure in the management of HH after MBS.

Mid-term outcomes of laparoscopic vaginal stump­round (Kakinuma method) and stump­uterosacral (Shull method) ligament fixation for pelvic organ prolapse: A retrospective comparative study

BACKGROUND: Laparoscopic sacrocolpopexy (LSC) and robot-assisted sacrocolpopexy (RSC) using mesh are popular approaches for treating pelvic organ prolapse (POP). However, it is not uncommon that native tissue repair (NTR) should be presented as an option to patients who are expected to have extensive intraperitoneal adhesion or patients for whom LSC or RSC is difficult owing to various risk factors. Laparoscopic vaginal stump-uterosacral ligament fixation (Shull method) has been introduced as a method for NTR in case of POP. However, effective repair using this surgical procedure may not be possible in severe POPs. To solve the problems of the Shull method, we devised the laparoscopic vaginal stump-round ligament fixation (Kakinuma method) in which the vaginal stump is fixed to the uterine round ligament, a histologically strong tissue positioned anatomically higher than the uterosacral ligament. This study aimed to retrospectively and clinically compare the two methods. METHODS: Of the 78 patients who underwent surgery for POP between January 2017 and June 2022 and postoperative follow-up for at least a year, 40 patients who underwent the Shull method (Shull group) and 38 who underwent the Kakinuma method (Kakinuma group) were retrospectively analyzed. RESULTS: No significant differences were observed between the two groups in patient background variables such as mean age, parity, body mass index, and POP-Q stage. The mean operative duration and mean blood loss in the Shull group were 140.5 ± 31.7 min and 91.3 ± 96.3 ml, respectively, whereas the respective values in the Kakinuma group were 112.2 ± 25.3 min and 31.4 ± 47.7 ml, respectively. Thus, compared with the Shull group, the operative duration was significantly shorter (P < 0.001) and blood loss was significantly less (P = 0.003) in the Kakinuma group. Recurrence was observed in six patients (15.0%) in the Shull group and two patients (5.3%) in the Kakinuma group. Hence, compared with the Shull group, recurrence was significantly less in the Kakinuma group (P = 0.015). No patients experienced perioperative complications in either group. CONCLUSIONS: The results suggest that the Kakinuma method can serve as a novel and viable NTR procedure for POP.

Reflux After Sleeve Gastrectomy: Safety and Effectiveness of Laparoscopic Ligamentum Teres Cardiopexy, a Single-Center Experience.

BACKGROUND: Obesity is a well-known risk factor for gastroesophageal reflux disease (GERD). Even though symptoms may be mitigated or resolved with the weight loss caused by sleeve gastrectomy (SG), it may be associated with higher incidences of postoperative GERD. Ligamentum teres cardiopexy (LTC) is an alternative to Roux-en-Y gastric bypass, the gold standard treatment for GERD. METHODS: This study was a retrospective single-center chart review, all patients in this cohort underwent LTC to treat refractory GERD at our institution. The option for LTC was presented after patients' refusal to undergo RYGB conversion. We collected baseline characteristics, standard demographics, pre-operative tests and imaging, and SG information, as well as intraoperative and perioperative data regarding LTC, and postoperative complications. RESULTS: Our cohort included 29 patients; most were Caucasian (44.8%) females (86.2%). The mean weight and BMI before LTC were 216.5 ± 39.3 lb and 36.1 ± 5.4 kg/m2, respectively. Mean total body-weight loss (TBWL) at 12 and 24 months were 28.7% ± 9.5% and 28.4% ± 12.4%, respectively. The mean interval between the index bariatric surgery and LTC was 59.9 ± 34.9 months, mean operative time was 67 ± 18.2 min, and median length of stay (LOS) was 1 day (IQR = 1-2 days). Twelve patients (57.1%) were able to discontinue antisecretory medications, while 9 (42.9%) still required them to remain asymptomatic. Mortality and reoperation rates were 0% and the incidence of complication was 19.4% (n = 6). CONCLUSIONS: LTC is a safe and effective surgical alternative to treat refractory GERD symptoms after SG.

The contribution of the ligamentum teres to the hip fluid seal: A biomechanics study.

BACKGROUND: The suction seal of the hip plays an important role in maintaining hip stability; however, the function of the ligamentum teres in maintaining this seal remains poorly understood. This study aimed to evaluate the effectiveness of the hip suction seal in ligamentum teres deficient hips for joint positions occurring during gait. METHODS: Six fresh-frozen human cadaveric hips were dissected and mounted to an Instron materials test system. Each specimen was analyzed for average peak distraction force, stiffness, and total energy during hip displacement. Testing was performed in the native intact ligamentum teres state and the deficient ligamentum teres state. Specimens were examined in 20° of flexion, neutral, and 10° of extension. FINDINGS: In the neutral position, the ligamentum teres deficient state displayed a significant decrease in peak distraction force (mean difference: 33.2 N, p < 0.001), average stiffness (mean difference: 63.7 N/mm, p = 0.016), and total energy (mean difference: 82.3 mJ, p = 0.022) compared to the intact controls. In extension, the deficient state exhibited a significant decrease in peak distraction force (mean difference: 42.8 N, p < 0.001) and total energy (mean difference: 72.9 mJ, p = 0.007). In flexion, the deficient state displayed a significant decrease in peak distraction force relative to contols (mean difference: 7.1 N, p = 0.003). INTERPRETATION: The ligamentum teres plays a significant role in maintaining the suction seal of the hip, with its effect being most prominent when the hip is in neural alignment or in extension. The findings suggest that ligamentum teres deficiency may be a relevant treatment target in the clinical setting.

Feasibility of venous cuff using an open round ligament or inferior mesenteric vein around the hepatic vein for a left lobe graft in living-donor liver transplantation.

Living-donor liver transplantation (LDLT) is an established treatment for patients with end-stage liver disease or acute liver failure, and outflow reconstruction is considered one of the most vital techniques in LDLT. To date, many strategies have been reported to prevent outflow obstruction, which can be refractory to liver dysfunction and can cause life-threatening graft loss or mortality. In addition, in this era of laparoscopic hepatectomy in donor surgery, especially LDLT using a left liver graft, it has been predicted that cutting the hepatic vein with automatic linear staplers will lead to more outflow-related problems than with conventional open hepatectomy because of the short neck of the anastomosis orifice. We herein review 10 cases of venoplasty performed with a novel venous cuff system using a donor's round ligament around the hepatic vein in LDLT with a left lobe graft, which makes anastomosis of the hepatic vein sterically easy for postoperative venous patency.

Editorial Commentary: Borderline Hip Dysplasia Combined With Increased Anteversion and Ligamentum Teres Disruption Is a Recipe for Hip Microinstability.

The ligamentum teres (LT) is known to play a role as a secondary stabilizer of the hip joint. LT tears can be associated with hip instability. In patients with borderline developmental dysplasia of the hip (BDDH), the correlation between LT tears and microinstability is even more pronounced because of the increased mechanical stress placed on the ligament. This relationship may lead certain surgeons to consider new indications for LT reconstructions. However, caution is warranted regarding the potential role of LT reconstruction in these patients, particularly since the primary deficiency in BDDH is bony undercoverage. Addressing this bony undercoverage should be a primary consideration that may be supplemented with other procedures, which may include addressing soft-tissue injuries around the hip such as LT tears. This is especially the case in those patients with persistent symptoms after management of labral tears or LT disruption.

Ligamentum Teres Tears and Increased Combined Anteversion Are Associated With Hip Microinstability in Patients With Borderline Dysplasia.

PURPOSE: To investigate the differences in the prevalence of ligamentum teres (LT) tears and other radiographic measurements in borderline dysplasia of the hip (BDDH) with/without microinstability and to evaluate the associations between these imaging findings and the prevalence of microinstability in patients with BDDH. METHODS: This was a retrospective study of symptomatic patients with BDDH (18° ≤ lateral center-edge angle <25°) treated with arthroscopy in our hospital between January 2016 and December 2021. These patients were divided into the BDDH with microinstability (mBDDH) group and the stable BDDH (nBDDH) group. The radiographic parameters associated with hip joint stability, such as the state of LT, acetabular versions, femoral neck version, Tönnis angle, combined anteversions, and anterior/posterior acetabular coverage, were reviewed and analyzed. RESULTS: There were 54 patients (49 female/5 male, 26.7 ± 6.9 years) in the mBDDH group and 81 patients (74 female/7 male, 27.2 ± 7.7 years) in the nBDDH group. The mBDDH group had greater LT tear (43/54 vs 5/81) and general laxity rates, increased femoral neck version, acetabular version and combined anteversion (52.4 ± 5.9 vs 41.5 ± 7.1 at 3-o'clock level) than the nBDDH group. Binary logistic regression showed that LT tears (odds ratio 6.32, 95% confidence interval 1.38-28.8; P = .02; R2 = .458) and combined anteversion at the 3-o'clock level (odds ratio 1.42, 95% confidence interval 1.09-1.84; P < .01; R2 = .458) were independent predictors of microinstability in patients with BDDH. The cutoff value of combined anteversion at 3-o'clock level was 49.5°. In addition, LT tear was correlated with increased combined anteversion at 3-o'clock level in patients with BDDH (P < .01, η2 = 0.29). CONCLUSIONS: LT tears and increased combined anteversion at the 3-o'clock level on the acetabular clockface were associated with hip microinstability in patients with BDDH, suggesting that patients with BDDH and LT tears might have a greater prevalence of anterior microinstability. LEVEL OF EVIDENCE: Level III, case‒control study.

Ligamentum teres cardiopexy for post vertical sleeve gastrectomy gastroesophageal reflux.

PURPOSE: Vertical sleeve gastrectomy (VSG) evolved in the early 2000s into the standalone weight loss procedure we see today. While numerous studies highlight VSG's durability for weight loss, and improvements co-morbidities such as type 2 diabetes mellitus and cardiovascular disease, patients with gastroesophageal reflux disease (GERD) have been counseled against VSG due to the concern for worsening reflux symptoms. When considering anti-reflux procedures, VSG patients are unable to undergo traditional fundoplication due to lack of gastric cardia redundancy. Magnetic sphincter augmentation lacks long-term safety data and endoscopic approaches have undetermined longitudinal benefits. Until recently, the only option for patients with a history of VSG with medically refractory GERD has been conversion to roux en Y gastric bypass (RNYGB), however, this poses other risks including marginal ulcers, internal hernias, hypoglycemia, dumping syndrome, and nutritional deficiencies. Given the risks associated with conversion to RNYGB, we have adopted the ligamentum teres cardiopexy as an option for patients with intractable GERD following VSG. METHODS: A retrospective chart review was conducted of patients who had prior laparoscopic or robotic VSG and subsequently GERD symptoms refectory to pharmacological management who underwent ligamentum teres cardiopexy between 2017 and 2022. Pre-operative GERD disease burden, intraoperative cardiopexy characteristics, post-operative GERD symptomatology and changes in H2 blocker or PPI requirements were reviewed. RESULTS: Of the study's 60 patients the median age was 50 years old, and 86% were female. All patients had a diagnosis of GERD through pre-operative assessments and were taking antisecretory medication. Of the 36 patients who have completed their one year follow up, 81% of patients had either a decrease in dosage or cessation of the antisecretory medication at one year following ligamentum teres cardiopexy. CONCLUSION: Ligamentum teres cardiopexy is a viable alternative to RNYGB in patients with a prior vertical sleeve gastrectomy with medical refractory GERD.

Combined Utero-Ovarian and Round Ligament Oophoropexy for Recurrent Torsion of Normal Adnexa: A Case Series.

STUDY OBJECTIVE: Recurrent torsion of otherwise normal adnexa (not involving adnexal cysts) has been reported in young girls and adolescents. Previous ovarian fixation techniques (oophoropexy), such as plication of the utero-ovarian ligament, appear to have limited efficacy in preventing recurrent torsion. A novel technique combining plication of the utero-ovarian ligament and suturing of the ovary to the round ligament has recently been described. In this study, we describe our short-term experience with the combined utero-ovarian and round ligament oophoropexy technique. METHODS: Patients who underwent combined oophoropexy as a primary fixation technique or as a secondary fixation technique (ie, after failure of a previous fixation) due to recurrent torsion of otherwise normal adnexa between January 2020 and December 2022 were included in this retrospective cohort study. Follow-up to assess for further torsion events was conducted by telephone interview. RESULTS: Ten patients underwent combined utero-ovarian and round ligament oophoropexy during the study period. In all cases, at least 2 episodes of torsion of otherwise normal adnexa were surgically diagnosed before oophoropexy (range 2-4). The median patient age at the time of combined oophoropexy was 21.8 years (range 9.1-35.7 years); 3 were premenarchal, and 7 were postmenarchal. After a median follow-up of 19.1 months (range 3.0-29.3 months), only 1 case of recurrent torsion occurred. CONCLUSION: Combined utero-ovarian and round ligament oophoropexy is novel oophoropexy procedure that may reduce the risk of recurrent torsion. However, longer follow-up is needed to determine its efficacy.

The falciform/round ligament "flooring," an effective method to reduce life-threatening post-pancreatectomy hemorrhage occurrence.

PURPOSE: Late post-pancreatectomy hemorrhage (PPH) represents the most severe complication after pancreatic surgery. We have measured the efficacy of major vessels "flooring" with falciform/round ligament to prevent life-threatening grade C late PPH after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). METHODS: All consecutive patients who underwent PD and DP between 2013 and 2021 were retrospectively reviewed on a prospectively maintained database. The cohort was divided in two groups: "flooring" vs. "no flooring" method group. The "no flooring" group had omental flap interposition. Patient characteristics and operative and postoperative data including clinically relevant postoperative pancreatic fistula (CR-POPF), late PPH (grade B and C), and 90-day mortality were compared between the two groups. RESULTS: Two hundred and forty patients underwent pancreatic resections, including 143 PD and 97 DP. The "flooring" method was performed in 61 patients (39 PD and 22 DP). No difference was found between the two groups concerning severe morbidity, CR-POPF, delayed PPH, and mortality rate. The rate of patients requiring postoperative intensive care unit was lower in the "flooring" than in the "no flooring" method group (11.5% vs. 25.1%, p = 0.030). Among patients with grade B/C late PPH (n = 30), the rate of life-threatening grade C late PPH was lower in the "flooring" than in the "no flooring" method group (28.6% (n = 2/7) vs. 82.6% (n = 19/24), p = 0.014). Risk factor analysis showed that the "flooring" method was the only protective factor against grade C late PPH occurrence (p = 0.013). CONCLUSION: The "flooring" method using the falciform/round ligament should be considered during pancreatectomies to reduce the occurrence of life-threatening grade C late PPH.

Retrospective study of preservation and transection of the round ligament of uterus during laparoscopic transabdominal preperitoneal inguinal hernia repair in adult women.

PURPOSE: The processing of the round ligament of uterus in laparoscopic transabdominal preperitoneal (TAPP) repair of inguinal hernia in women has contended. This study aimed to explore whether there is any difference in the surgical outcome and postoperative complications between the two processing modalities, preservation, and transection of the round ligament of uterus, in adult female inguinal hernia patients undergoing TAPP. METHODS: Retrospective analysis of 84 female patients (117 sides) who underwent TAPP in XXX Hospital from July 2013 to August 2022. Patient characteristics and technical details of the surgical procedure were collected and divided into two groups according to whether the round ligament of uterus was severed intraoperatively or not. There were 52 cases (77 sides) in the group with preservation of the round ligament of uterus and 32 cases (40 sides) in the group with transection of the round ligament of uterus, comparing the general condition, surgical condition, and the occurrence of postoperative related complications between the 2 groups. RESULTS: The operative time for unilateral primary inguinal hernia was (129.2 ± 35.1) and (89.5 ± 42.6) minutes in the preservation and transection groups, respectively. There were no statistical differences between the two groups in terms of age, length of hospital stay, ASA, BMI, history of lower abdominal surgery, type and side of hernia, intraoperative bleeding, and time to surgery for primary bilateral hernia (P > 0.05). In addition, there was likewise no statistical difference in the occurrence of postoperative Clavien-Dindo classification, VAS, seroma, mesh infection, labia majora edema, chronic pain or abnormal sensation in the inguinal region, and hernia recurrence in the two groups as well (P > 0.05). CONCLUSION: There is no evidence that the transection of the round ligament of the uterus during TAPP has an impact on postoperative complications in patients. However, given the important role of the uterine round ligament in the surgical management of patients with uterine prolapse and the high incidence of uterine prolapse in older women, hernia surgeons should also be aware of the need to protect the round ligament of uterus in older women.

Ligamentum teres reconstruction using autogenous semitendinosus tendon with toggle technique in rabbits.

Background: Ligamentum teres (LT) has traditionally been considered a vestigial or redundant structure in humans; however, based on new studies and the evolution of hip arthroscopy, the LT injury has been viewed as a source of hip pain. Therefore, LT reconstruction can be beneficial in some cases. Rabbits have been frequently used as a model for cranial cruciate ligament reconstruction but few studies are available for ligamentum teres reconstruction. Objective: To evaluate the semitendinosus tendon to replace ligamentum teres with the toggle technique, using rabbits as an experimental model. Methods: Twenty-six female Norfolk rabbits with approximately 3 months of age were divided into two equal groups after excision of ligamentum teres (LT) from the right hip joint: G1-no reconstruction of LT and capsulorrhaphy; G2-double-bundle reconstruction of the LT using semitendinosus tendon autograft. In both groups, the LT was removed from the right hip joint. In G2 the autograft was harvested from the left hind limb of the same rabbit. The rabbits were evaluated clinically at different time intervals; before surgery (M1), 48 h (M2), 15 days (M3), 30 days (M4) and 90 days (M5) after surgery. Results: The rabbits supported their limbs on the ground in both the groups. As complications of the procedure, four hip joints showed subluxations in the radiographic evaluation of G1; three at M4 and one at M5. In G2; two luxations of hip joints at M3 and one subluxation at M4 were seen. On ultrasound, irregular articular surface was seen in 30.8% of the rabbits that had subluxation of hip joints. Gross evaluation identified tendon graft integrity in 76.92% of the rabbits. Histological analysis revealed graft adhesion to the bone in the early phase comprised of sharpey-like collagen fibers. Conclusion: The double-bundle reconstruction of the LT using autologous semitendinosus tendon associated with the toggle rod shows an early phase of tendon graft ligamentization at 90 days post-operatively in young rabbits, but biomechanical bias suffered by the tendon during gait must be considered.

Feeding gastrostomy and duodenostomy using the round ligament of the liver versus conventional feeding jejunostomy after esophagectomy: a meta-analysis.

Esophageal cancer patients require enteral nutritional support after esophagectomy. Conventional feeding enterostomy to the jejunum (FJ) is occasionally associated with small bowel obstruction because the jejunum is fixed to the abdominal wall. Feeding through an enteral feeding tube inserted through the reconstructed gastric tube (FG) or the duodenum (FD) using the round ligament of the liver have been suggested as alternatives. This meta-analysis aimed to compare short-term outcomes between FG/FD and FJ. Studies published prior to May 2022 that compared FG or FD with FJ in cancer patients who underwent esophagectomy were identified via electronic literature search. Meta-analysis was performed using the Mantel-Haenszel random-effects model to calculate Odds Ratios (ORs) with 95% confidence intervals (CIs). Five studies met inclusion criteria to yield a total of 1687 patients. Compared with the FJ group, the odds of small bowel obstruction (OR 0.09; 95% CI, 0.02-0.33), catheter site infection (OR 0.18; 95% CI, 0.06-0.51) and anastomotic leakage (OR 0.53; 95% CI, 0.32-0.89) were lower for the FG/FD group. Odds of pneumonia, recurrent laryngeal nerve palsy, chylothorax and hospital mortality did not significantly differ between the groups. The length of hospital stay was shorter for the FG/FD group (median difference, -10.83; 95% CI, -18.55 to -3.11). FG and FD using the round ligament of the liver were associated with lower odds of small bowel obstruction, catheter site infection and anastomotic leakage than FJ in esophageal cancer patients who underwent esophagectomy.

Ligamentum Teres Cardiopexy Might Not Prevent Gastro-esophageal Reflux After Laparoscopic Sleeve Gastrectomy: Case Series.

Roux-en-Y gastric bypass (RYGB) is considered the gold standard procedure in patients with obesity and gastroesophageal reflux (GERD), but in patients with preoperative hiatal hernia (HH) or GERD, who are unfit for RYGB, there are no clear guidelines. Ligamentum teres cardiopexy (LTC) has been proposed as an effective alternative. The purpose of this study was to analyze medium-term results of LTC procedure associated with laparoscopic sleeve gastrectomy (LSG) in patients with GERD or HH, according to the absence of pathologic acid reflux in esophageal 24 h pH monitoring test, symptom release, or PPI reduction. Five patients underwent LSG-LTC between March 2018 and October 2019. In one patient, the effectiveness of LTC as an anti-reflux procedure could not be assessed because of conversion to RYGB was required. After a follow-up period of 30 [24-42] months and excessive BMI loss of 62.74 ± 18.18%, GERD recurrence was observed in 75% of patients. The study was discontinued due to unsatisfactory preliminary results with LTC. Our results suggest that LTC might not prevent GERD after LSG in patients with preoperative GERD or HH.

Laparoscopic ureteroneocystostomy and round ligament bladder hitching for ureteral stenosis in parametrial deep endometriosis: Our tips for a tension-free anastomosis.

OBJECTIVE: To investigate the feasibility and the efficacy of laparoscopic ureteroneocystostomy with round ligament bladder hitching. METHODS: This is a monocentric retrospective study. Enrolled patients affected by deep endometriosis underwent laparoscopic nerve-sparing parametrectomy and monolateral ureteroneocystostomy with bladder suspension to the round ligament. Perioperative and postoperative outcomes were collected, as well as urinary and pain symptoms before and after surgery. RESULTS: Laparoscopic ureteroneocystostomy with round ligament bladder hitching was performed in nine women. The most frequent postoperative complication was post-voiding urinary retention (22.2%). No ureteral fistula or stenosis of the anastomosis was reported. CONCLUSION: In selected cases of ureteral resection and reimplantation, performing a round ligament bladder hitching allowed us to overcome the ureteral gap. This is a safe and feasible procedure to ensure stability of the anastomosis and avoid the possible disadvantages of the "standard" psoas hitch procedure.

Successful left hepatic trisectionectomy after portal vein embolization for colon cancer liver metastasis in a patient with right-sided ligamentum teres.

Right-sided ligamentum teres (RSLT) is a rare congenital anomaly in which the fetal umbilical vein is connected to the right paramedian trunk of the portal vein. An 80-year-old woman underwent curative sigmoidectomy for sigmoid cancer 3 years prior to presentation. After 1 year, small solitary liver metastasis was noted in segment 4. Because the patient experienced recurrence of the same lesion after chemotherapy and radiofrequency ablation, she was referred to our hospital. CT revealed an anomaly of the liver with RSLT, classified as an independent posterior branch type. The tumor in the left paramedian section was located in the right umbilical portion (RUP), and BDTT was advanced to the common bile duct. Because the estimated future remnant liver volume was 35.2%, transileocecal portal vein embolization (PVE) for the portal branches from the RUP increased it to 43.5% in 3 weeks. Left trisectionectomy with extrahepatic bile duct resection and hepaticojejunostomy were performed. The patient was discharged on postoperative day 75. We successfully performed a left trisectionectomy after PVE in a patient with RSLT. Understanding the vascular and biliary anomalies of patients with RSLT is essential. When the future remnant liver is small, PVE can be considered for safe hepatectomy.

Round Ligament Management in Female Patients Undergoing Inguinal Hernia Repair: Should We Divide or Preserve?

BACKGROUND: Although inguinal hernia repair in female patients is less common than in male patients, it remains a frequent procedure. The decision to divide or preserve the round ligament has largely been left to surgeon preference, but little data exists about its impact on outcomes. This study aimed to describe current practices for round ligament management and identify the impact of division on surgical and patient-reported outcomes. STUDY DESIGN: The 2013 to 2021 Abdominal Core Health Quality Collaborative database was queried for all female patients undergoing inguinal hernia repair with 30-day patient-reported outcome data available. Comparison groups were created based on round ligament management: round ligament division (RLD) or round ligament preservation (RLP). RESULTS: We identified 1365 female patients who underwent open (36.3%), laparoscopic (34.5%), or robotic (28.2%) repair. Most were non-recurrent (93%) and unilateral (82.6%). The round ligament was divided in 868 (63.6%) and preserved in 497 (36.4%) cases. There were no significant differences in overall complications (RLD 7.1%, RLP 5.2%, p = 0.17), reoperation (RLD 0.5%, RLP 0.2%, p = 0.4), or recurrence (RLD 0.1%, RLP 0.4%, p = 0.28). Mean European Registry for Abdominal Wall Hernias quality of life summary scores were not significantly different at 30 days (RLD 27.2, RLP 27.8) or 6 months (RLD 12.8, RLP 17.1). However, a significant difference was found in terms of mean pain-specific scores at 6 months, with lower pain scores in the RLD group (3 vs 4.7, p < 0.01), which persisted on multivariable analysis (p = 0.02). CONCLUSIONS: RLD is a common practice and is not associated with increased complications or recurrence. Although there is some evidence that RLD may result in decreased pain at 6 months, this must be balanced with potential functional complications of division that are not fully studied in this paper.