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.

Primary spontaneous inguinal endometriosis: Two cases with emphasis on the diagnostic approach.

OBJECTIVE: While endometriosis is common, inguinal endometriosis with hernia is rarely observed, making its preoperative diagnosis challenging. CASE REPORT: We report two cases of inguinal endometriosis with different presentations and focus on tailored surgical treatment. The two patients in our series presented with painful swelling in the right groin area. Surgery and pathological examination confirmed the diagnosis of endometriosis in both cases. Herniorrhaphy and excision of the extraperitoneal round ligament were performed in one patient with concomitant inguinal endometriosis and indirect inguinal hernia. CONCLUSION: We highlight the importance of the preoperative evaluation of concomitant pelvic endometriosis, round ligament involvement, and endometriosis within the inguinal hernia sac. Inguinal endometriosis with or without hernia should be considered even in reproductive-aged women without a previous medical and surgical history. Postoperative hormonal therapy, including dienogest, can be considered to prevent disease recurrence.

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.

Round Ligament Varicocele Masquerading as an Inguinal Hernia During Pregnancy.

Hernia is an exceedingly common pathology, to which inguinal hernias are frequently diagnosed. Though this entity is regularly seen, in pregnancy a different diagnosis must be excluded: round ligament varicocele (RLV). Round ligament varicocele has a similar presentation to inguinal hernia, and therefore is often misdiagnosed. Though misdiagnosis potentially occurs from a lack of knowledge of the disease, RLV has shown that it's at least as common as inguinal hernia in pregnancy. The issue with misdiagnosis occurs as there is significant difference in management; hernia may require operative intervention, while RLV follows a conservative course. Therefore, an accurate diagnosis is essential, and an incorrect diagnosis can be associated with an unnecessary operation and consequence. We present the case of a patient in her second trimester who was referred for surgery due to suspicion of an inguinal hernia, and review the literature for evaluation recommendations, appropriate diagnostic strategies, and management tactics for RLV.

Preoperative sonographic assessment of a leiomyoma of the round ligament.

NA.

Myolipoma of the round ligament of the liver: a diagnosis to be considered.

A 39-year-old patient consulted for an incidental finding of a mesenteric-epiploic mass measuring 11x6x9.5 cm. Laparoscopic excision of the lesion and cholecystectomy were indicated, revealing a myolipomatous mesenchymal neoplasm in the hepatic round ligament.

Inguinal endometriosis: A systematic review.

Inguinal endometriosis is a very rare entity with uncertain pathophysiology, that poses several diagnostic and therapeutic challenges. This study aimed to summarize published literature on the diagnosis and treatment of this condition. Thus, a systematic literature search was conducted in PubMed/MEDLINE, Scopus and the Cochrane Library. An effort was made to numerically analyze all parameters included in case reports and retrospective analyses, as well. The typical and atypical features of this condition, investigations used, type of treatment and histopathology were recorded. More specifications about the surgical treatment, such as operations previously performed, type of surgery and treatment after surgery have been acknowledged. Other sites of endometriosis, the presence of pelvic endometriosis and the follow-up and recurrence have been also documented. Overall, the search yielded 61 eligible studies including 133 cases of inguinal endometriosis. The typical clinical presentation includes a unilateral inguinal mass, with or without catamenial pain. Transabdominal or transvaginal ultrasound was typically used as the first line method of diagnosis. Groin incision and exploratory surgery was the treatment indicated by the majority of the authors, while excision of part of the round ligament was reported in about half of the cases. Chemotherapy and radiotherapy were initiated in cases of coexisting endometriosis-related neoplasia. Inguinal recurrence or malignant transformation was rarely reported. The treatment of inguinal endometriosis is surgical and a long-term follow-up is needed. More research is needed on the effectiveness of suppressive hormonal therapy, recurrence rate and its relationship with endometriosis-associated malignancies.

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.

A Rare but Noteworthy Diagnosis for "Lumps in the Groin" During Pregnancy: Round Ligament Varices.

BACKGROUND Round ligament varices (RLVs) are a rare entity that occurs almost only in pregnancy. Given its rarity and perhaps the lack of its awareness, it is not surprising that RLVs are often an overlooked differential diagnosis for inguinal swelling. Furthermore, this is aggravated by the fact that the clinical findings of RLVs on physical examination are usually non-specific and indistinguishable from the other more common causes of groin swelling. CASE REPORT A 35-year-old Asian woman, gravidity 1 parity 0 presented at 26 weeks of gestation with a painless right inguinal lump. She was given a provisional diagnosis of "inguinal hernia." Ultrasonography and color Doppler of the right inguinal lump showed echo-free tubular structures within the right inguinal canal, which became more prominent with Valsalva maneuver and demonstrated vascularity on color Doppler with a venous flow pattern, compatible with RLV. The patient was therefore reassured and treated conservatively. The symptoms spontaneously resolved after a few weeks postpartum. CONCLUSIONS With this case, we hope to increase the awareness of round ligament varices as an important differential diagnosis for an inguinal lump in pregnancy, and highlight the potential difficulty in making the diagnosis clinically. Ultrasonography can serve as a crucial investigation for the prompt and precise diagnosis of RLV, but more importantly, can be a safer alternative to invasive surgical exploration.

Inguinal Endometriosis in a Nulliparous Woman Mimicking an Inguinal Hernia: A Case Report with Literature Review.

BACKGROUND Endometriosis is a common gynecological disorder occurring in around 10% of women of reproductive age. Inguinal endometriosis is a rare condition; however, it should be considered in the differential for inguinal masses in women of reproductive age. Usually, it occurs after implantation of endometrial tissue during previous surgical procedures. Patients with inguinal endometriosis are often multiparous women with a history of previous gynecological or obstetric surgery. It represents a diagnostic dilemma, as it is often misdiagnosed as other inguinal pathologies. CASE REPORT Herein, we report a case of a 33-year-old nulliparous woman with left groin pain for 2 years increasing in the severity during menstruation. A physical examination revealed a 1.5-cm left inguinal mass. Ultrasound showed an ill-defined speculated solid hypoechoic left inguinal mass measuring 1.6×1.4 cm. Computed tomography (CT) of the pelvis revealed a left inguinal mass measuring 1.7×1.2 cm, demonstrating central hypo-attenuation with thickening of the round ligament. Exploration of the inguinal region revealed an adherent mass to the round ligament and floor of the canal, which was excised completely with a safety margin. The inguinal canal floor was strengthened using proline mesh. Histopathological examination of the mass confirmed the diagnosis of left inguinal endometriosis. CONCLUSIONS Inguinal endometriosis is a rare clinical entity mimicking other common inguinal conditions. A high index of suspicion is crucial for its preoperative diagnosis, especially in the presence of an inguinal mass associated with cyclic changes in size and pain severity. Its standard management is surgical excision.

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.

Long term follow-up of inguinal endometriosis.

BACKGROUND: Inguinal endometriosis (IEM) is a rare extra pelvic endometriosis. Here, we study the clinical characteristics, management strategies, and long-term gynecological outcomes of IEM patients at Beijing Chaoyang Hospital. CASE PRESENTATION: Three patients presented with a total of four lesions (one on the left side, one on the right side, and one bilaterally). The diameters of the four lesions were 2 cm, 2 cm, 3.5 cm and 1.5 cm, respectively. Two patients were admitted with inguinal hernias. Two patients were admitted with endometrioses-one with ovarian endometriosis and one with pelvic endometriosis. The hernia sac was repaired concomitantly via excision of the round ligament in two patients. One patient underwent a concomitant laparoscopy for gynecologic evaluations, including an ablation to the peritoneal endometriosis, and resection of the left uterosacral ligament endometriosis and pelvic adhesiolysis. All lesions were located on the extraperitoneal portion of the round ligament and were diagnosed histologically. No recurrence was observed in the inguinal region. All patients diagnosed with adenomyosis were treated with medication alone without any complaints. CONCLUSIONS: Inguinal endometriosis can occur simultaneously with pelvic endometriosis. In most cases, a concomitant hernia sac appears together with groin endometriosis. Clinical management should be individualized and performed in tandem with general practitioners and obstetrics & gynecology experts. Pelvic disease, in particular, should be followed-up by a gynecologist.

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.

Laparoscopic Total Extraperitoneal Groin Hernia Repair in Females: Comparison of Outcomes Between Preservation or Division of the Uterine Round Ligament.

Background: Laparoscopic repair has been recommended as the method-of-choice of groin hernia repair among women. Whether the round ligament of uterus should be divided to facilitate mesh placement remains controversial. This study aims to review the outcomes of laparoscopic total extraperitoneal (TEP) groin hernia repair in women and to evaluate the impact of division of round ligament. Methods: Consecutive female patients with inguinal or femoral hernias who underwent elective laparoscopic TEP repair at a single institution from 2006 to 2017 were included for retrospective analysis. Primary outcomes were postoperative pain, genital prolapse, and recurrence. Outcomes of patients who had the round ligament divided were further compared with those with round ligament preserved and multivariable adjusted analysis was performed. Results: Sixty-eight patients with a total of 77 TEP repairs were included in the 12-year study period. The mean age was 45 ± 16 years old. Incidental femoral hernia was identified in 4 patients (5.9%). There was 1 (1.3%) recurrence upon mean follow-up of 42.9 ± 37.3 months. The round ligament was divided in 67.5% of patients, and upon multivariable adjusted analysis, there were no statistically significant differences in outcomes in terms of chronic pain (odds ratio [OR] = 2.210, P = .357), paresthesia (OR = 0.241, P = .149), and genital prolapse (OR = 0.327, P = .415) when compared with patients with preserved round ligament. Conclusion: Laparoscopic groin hernia repair in women is associated with low recurrence. Division of round ligament intraoperatively facilitates mesh placement and has minimal impact on clinical outcomes.