Round ligament management during minimally invasive groin hernia repair in women: a systematic review and meta-analysis.

BACKGROUND: Female sex has been associated with worse outcomes after groin hernia repair (GHR), including a higher rate of chronic pain and recurrence. Most of the studies in GHR are performed in males, and the recommendations for females extrapolate from these studies, even though females have anatomy intricacies. The round ligament of the uterus (RLU) is associated with pelvic stabilization and plays a role in sensory function. Transection of the RLU during GHR is controversial as it can allow easier mesh placement but can favor genitourinary complications and chronic pain. As no previous meta-analysis compared preserving versus transecting the RLU during minimally invasive (MIS) GHR, we aim to perform a systematic review and meta-analysis evaluating surgical outcomes comparing the approaches. METHODS: Cochrane Central, Embase, and PubMed databases were systematically searched for studies comparing transection versus preservation of the RLU in MIS groin hernia surgeries. Outcomes assessed were operative time, bleeding, surgical site events, hospital stay, chronic pain, paresthesia, recurrence rates, and genital prolapse rates. Statistical analysis was performed using RevMan 5.4.1. Heterogeneity was assessed with I2 statistics. A review protocol for this meta-analysis was registered at PROSPERO (CRD 42023467146). RESULTS: 1738 studies were screened. A total of six studies, comprising 1131 women, were included, of whom 652 (57.6%) had preservation of the RLU during MIS groin hernia repair. We found no statistical difference regarding chronic pain, paresthesia, recurrence rates, and postoperative complications. We found a longer operative time for the preservation group (MD 6.84 min; 95% CI 3.0-10.68; P = 0.0005; I2 = 74%). CONCLUSION: Transecting the RLU reduces the operative time during MIS GHR with no difference regarding postoperative complication rates. Although transection appears safe, further prospective randomized studies with long-term follow-up and patient-reported outcomes are necessary to define the optimal management of RLU during MIS GHR.

Teratoma de ligamento redondo, reporte de caso y revisión de la bibliografía / Round ligament teratoma, case report and literature review

Resumen ANTECEDENTES: El teratoma es un tumor casi siempre benigno, con una amplia variabilidad en su localización, extremadamente rara, en el ligamento redondo. CASO CLÍNICO: Paciente de 30 años, con antecedente de un embarazo a término. En la revisión ecográfica se reportó una lesión quística paraovárica izquierda de 46 x 35 mm, sin componente sólido, graso ni calcificaciones. En el examen ginecológico se palpó una masa por encima del útero, orientada hacia el lado izquierdo, no dolorosa. El resto del examen físico trascurrió sin otras alteraciones. La impresión diagnóstica inicial fue de teratoma abdominopélvico sustentada en la ecografía transvaginal en la que los ovarios se observaron normales, con una masa de ecogenicidad mixta de 50 x 40 x 46 mm, con áreas ecolúcidas y ecogénicas de intensidad variable hacia la fosa iliaca izquierda superior, sin contacto con el ovario. El ligamento redondo se seccionó a ambos lados de la masa y se extrajo sin complicaciones; el reporte histopatológico fue de: teratoma quístico maduro. CONCLUSIONES: El ligamento redondo es una localización infrecuente de los quistes dermoides que debe considerarse en los diagnósticos diferenciales de las masas pélvicas; es susceptible de tratamiento quirúrgico por vía laparoscópica.

Abstract BACKGROUND: Teratoma is an almost always benign tumor, with a wide variability in its location; its location in the round ligament is extremely rare. CLINICAL CASE: 30-year-old patient, with a history of a full-term pregnancy. On routine ultrasound examination, a 46 x 35 mm left paraovarian cystic lesion was reported, with no solid, fatty component or calcifications. In the gynecological examination a mass was palpated above the uterus, oriented to the left side, non-painful. The rest of the physical examination passed without other alterations. The initial diagnostic impression was of abdomino-pelvic teratoma supported by transvaginal ultrasound in which the ovaries were normal, with a mass of mixed echogenicity of 50 x 40 x 46 mm, with echolucent and echogenic areas of variable intensity towards the left superior iliac fossa, without contact with the ovary. The round ligament was sectioned on both sides of the mass and removed without complications; the histopathologic report was: mature cystic teratoma. CONCLUSIONS: The round ligament is an infrequent location of dermoid cysts that should be considered in the differential diagnoses of pelvic masses; it is amenable to surgical treatment laparoscopically.

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.

Oophoropexy to the round ligament after recurrent adnexal torsion / Ooforopexia ao ligamento redondo em um caso de torção anexial recorrente

Abstract Recurrent adnexal torsion is a rare gynecological emergency. We report a case of recurrent ipsilateral adnexal torsion in a woman with polycystic ovaries, previously submitted to a laparoscopic plication of the utero-ovarian ligament. Due to the recurrence after the plication of the utero-ovarian ligament, the authors performed a laparoscopic oophoropexy to the round ligament, which is an underreported procedure. The patient was asymptomatic for 1 year, after which she had a new recurrence and needed a unilateral laparoscopic adnexectomy. Since then, she regained the quality of life without any gynecological symptoms. Oophoropexy to the round ligament may be considered when other techniques fail or, perhaps, as a first option in selected cases of adnexal torsion, as it may allow the prevention of recurrence without increasing morbidity while preserving the adnexa.

Resumo A torção anexial recorrente é uma emergência ginecológica rara. Os autores descrevem um caso de torsão anexial unilateral recorrente em uma paciente com síndrome de ovário policístico, previamente submetida a plicatura do ligamento utero-ovárico por laparoscopia. Nesta circunstância, os autores decidiram realizar uma ooforopexia laparoscópica ao ligamento redondo, uma técnica pouco descrita na literatura. A paciente manteve-se assintomática durante 1 ano, período após o qual teve nova recorrência, tendo-se decidido realizar uma anexectomia laparoscópica unilateral. Desde então, ela recuperou a qualidade de vida sem qualquer sintoma ginecológico. A ooforopexia ao ligamento redondo é uma técnica que deverá ser considerada quando outras falham e, em casos selecionados de torsão anexial recorrente, poderá ser considerada a primeira abordagem, para prevenir a recorrência e preservar o anexo.

[Round ligament cyst simulating incarcerated inguinal hernia. Report of a case]. / Quiste de ligamento redondo que simula hernia inguinal encarcelada. Reporte de un caso.

BACKGROUND: Round ligament cysts are rare lesions, often diagnosed as irreducible inguinal hernias. Most patients are in the third to fourth decade of life, but they can occur in younger patients. They are usually clinically asymptomatic or tend to produce subtle symptoms such as pain, discomfort, or a feeling of heaviness, and swelling. Cysts should not be resized with the Valsalva manoeuvre. Ultrasound is the diagnostic method of choice. The definitive diagnosis is made during surgery, and confirmed by pathological examination. OBJECTIVE: To present a case of round ligament cyst, initially diagnosed as an incarcerated inguinal hernia, and a review of the literature. CLINICAL CASE: A 19 year-old female, who was admitted to the emergency department due to her current condition of 5 days of onset. She had an increased volume in right inguinal region that increased with physical exertion, throbbing pain, and nausea without vomiting. A right inguinal mass of approximately of 6cm in diameter was found, which was painful on mid-superficial palpation, reaching a pre-surgical diagnosis of incarcerated right inguinal hernia with an indication of surgical intervention. CONCLUSION: Round ligament cysts are a rare pathology, often confused with incarcerated inguinal hernias. Although ultrasound is the study of choice, the final diagnosis is usually made during surgery and confirmed by histopathology.

Substituição do ligamento redondo femoral por “Loop” pediculado de fáscia lata de cães / Round femoral ligament replacement for loop of fascia lata in dogs

As luxações coxofemorais traumáticas são importantes afecções ortopédicas nos cães e gatos devido a sua grande freqüência. O tratamento primário de escolha é a redução fechada, no entanto em algumas circunstâncias faz-se necessário o uso do método aberto/ cirúrgico. O presente trabalho tem por obje¬tivo propor um método cirúrgico para o tratamento das luxações coxofemorais traumáticas em cães, estabilizando a articulação coxofemoral pela substituição do ligamento redondo femoral utilizando-se a fáscia lata. Foram utilizados 18 cães adultos, sem raça definida, machos e fêmeas, separados em três grupos de acordo com o peso corporal. A estabilização foi obtida por um loop de fáscia lata inserido a partir do terceiro trocânter, emergindo na fóvea capitis e através do acetábulo, retornando ao pon¬to de inserção. Não se utilizou em nenhum dos casos imobilização após a cirurgia. A deambulação foi avaliada diariamente e as articulações foram observadas macroscopicamente aos 60 e 90 dias de pós-operatório. Dois animais não apoiaram o membro operado no pós-operatório imediato, porém, a recuperação total não foi afetada. Os outros animais dos grupos A, B e C apoiaram o membro no pós-¬operatório imediato e a recuperação total foi obtida aos 15,5, 18 e 16,5 dias, respectivamente. Os resul¬tados desse experimento demonstram que a técnica cirúrgica proposta permite manter a estabilidade articular, com apoio precoce e uso funcional do membro em período relativamente curto

The traumatic coxofemural luxations are important orthopedics injuries in dogs and cats due to their great frequency. Close reduction is the first choice of treatment, but at some circumstances the use of open/ sur¬gical methods are necessary. The present study has as an objective to propose a surgical method for treat¬ment of traumatic hip dislocations in dogs, stabilizing the coxofemoral articulation by the replacement of the round femoral ligament using the fascia lata. For this experiment 18 adult dogs, without defined race, males and females, were used, separated in three groups according to corporal weight. The stabilization was obtained for loop of fascia lata inserted from the third trochanter, emerging in the fóvea capitis and through the acetabulum, returning to the insert point. In none of the cases immobilization after surgery was used. Walking movement was daily evaluated and articulations were macroscopically observed at 60th and 90th day of postoperative. Two animals didn't weightbear the operated member during the im¬mediate postoperative, but total recover was not affected. Other animals of groups A, B and C weightbea¬red the member at immediate postoperative and the total recover was at 15.5, 18 and 16.5 days, respective¬ly. These experiment' s results show that the surgical technique proposed allows maintaining the articulate stability, with an early weightbearing and relatively short period of functional use of the member

Substituição do ligamento redondo femoral por “Loop” pediculado de fáscia lata de cães / Round femoral ligament replacement for loop of fascia lata in dogs

As luxações coxofemorais traumáticas são importantes afecções ortopédicas nos cães e gatos devido a sua grande freqüência. O tratamento primário de escolha é a redução fechada, no entanto em algumas circunstâncias faz-se necessário o uso do método aberto/ cirúrgico. O presente trabalho tem por obje¬tivo propor um método cirúrgico para o tratamento das luxações coxofemorais traumáticas em cães, estabilizando a articulação coxofemoral pela substituição do ligamento redondo femoral utilizando-se a fáscia lata. Foram utilizados 18 cães adultos, sem raça definida, machos e fêmeas, separados em três grupos de acordo com o peso corporal. A estabilização foi obtida por um loop de fáscia lata inserido a partir do terceiro trocânter, emergindo na fóvea capitis e através do acetábulo, retornando ao pon¬to de inserção. Não se utilizou em nenhum dos casos imobilização após a cirurgia. A deambulação foi avaliada diariamente e as articulações foram observadas macroscopicamente aos 60 e 90 dias de pós-operatório. Dois animais não apoiaram o membro operado no pós-operatório imediato, porém, a recuperação total não foi afetada. Os outros animais dos grupos A, B e C apoiaram o membro no pós-¬operatório imediato e a recuperação total foi obtida aos 15,5, 18 e 16,5 dias, respectivamente. Os resul¬tados desse experimento demonstram que a técnica cirúrgica proposta permite manter a estabilidade articular, com apoio precoce e uso funcional do membro em período relativamente curto(AU)

The traumatic coxofemural luxations are important orthopedics injuries in dogs and cats due to their great frequency. Close reduction is the first choice of treatment, but at some circumstances the use of open/ sur¬gical methods are necessary. The present study has as an objective to propose a surgical method for treat¬ment of traumatic hip dislocations in dogs, stabilizing the coxofemoral articulation by the replacement of the round femoral ligament using the fascia lata. For this experiment 18 adult dogs, without defined race, males and females, were used, separated in three groups according to corporal weight. The stabilization was obtained for loop of fascia lata inserted from the third trochanter, emerging in the fóvea capitis and through the acetabulum, returning to the insert point. In none of the cases immobilization after surgery was used. Walking movement was daily evaluated and articulations were macroscopically observed at 60th and 90th day of postoperative. Two animals didn't weightbear the operated member during the im¬mediate postoperative, but total recover was not affected. Other animals of groups A, B and C weightbea¬red the member at immediate postoperative and the total recover was at 15.5, 18 and 16.5 days, respective¬ly. These experiment' s results show that the surgical technique proposed allows maintaining the articulate stability, with an early weightbearing and relatively short period of functional use of the member(AU)

Substituição do ligamento da cabeça do fêmur com auto-enxerto de fáscia lata na luxação coxofemoral em cães

This study describes a technique for round ligament's substitution by fascia lata and bone autografts. Experiments were carried out in 20 clinical healthy adult mongrel dogs. The animals were divided in five groups, than they were put down for macro and microscopic analysis performed on 15, 30, 60, 90 and 120 days. None of them reluxated the joint. On gross observation, the fascia lata graft was present in 65% of the dogs. Microscopic examination showed no rejection or inflammatory reactions on fascia lata used as a femoral head ligament substitute. The fascia was preserved and integrated to the bone.

Uma técnica cirúrgica para o tratamento da luxação coxofemoral que substituiu o ligamento da cabeça do fêmur por fáscia lata associada ao enxerto ósseo foi realizada em 20 cães. Estes foram separados em cinco grupos e submetidos à eutanásia para realização dos exames macro e microscópicos aos 15, 30, 60, 90 e 120 dias do pós-operatório. Na macroscopia, não foi observada luxação da articulação. Em 65% dos animais, o enxerto de fáscia lata estava presente. Microscopicamente, a fáscia lata utilizada como substituto do ligamento da cabeça do fêmur não desenvolveu reações inflamatórias, permanecendo preservada e integrada ao tecido ósseo. O uso da fáscia lata como substituto do ligamento da cabeça do fêmur mostrou-se viável, podendo ser utilizada para reforçar a estabilidade articular.

SUBSTITUIÇÃO DO LIGAMENTO DA CABEÇA DO FÊMUR COM AUTO-ENXERTO DE FÁSCIA LATA NA LUXAÇÃO COXOFEMORAL EM CÃES

This study describes a technique for round ligament's substitution by fascia lata and bone autografts. Experiments were carried out in 20 clinical healthy adult mongrel dogs. The animals were divided in five groups, than they were put down for macro and microscopic analysis performed on 15, 30, 60, 90 and 120 days. None of them reluxated the joint. On gross observation, the fascia lata graft was present in 65% of the dogs. Microscopic examination showed no rejection or inflammatory reactions on fascia lata used as a femoral head ligament substitute. The fascia was preserved and integrated to the bone.

Uma técnica cirúrgica para o tratamento da luxação coxofemoral que substituiu o ligamento da cabeça do fêmur por fáscia lata associada ao enxerto ósseo foi realizada em 20 cães. Estes foram separados em cinco grupos e submetidos à eutanásia para realização dos exames macro e microscópicos aos 15, 30, 60, 90 e 120 dias do pós-operatório. Na macroscopia, não foi observada luxação da articulação. Em 65% dos animais, o enxerto de fáscia lata estava presente. Microscopicamente, a fáscia lata utilizada como substituto do ligamento da cabeça do fêmur não desenvolveu reações inflamatórias, permanecendo preservada e integrada ao tecido ósseo. O uso da fáscia lata como substituto do ligamento da cabeça do fêmur mostrou-se viável, podendo ser utilizada para reforçar a estabilidade articular.