Search

Most studies reporting the outcomes of laparoscopic ovarian prolapsed hernia operations with large sample sizes are based on intracorporeal closure, while studies on extraperitoneal closure have limited sample sizes. We proactively used the single-incision laparoscopic percutaneous extraperitoneal closure (SILPEC) technique and obtained favorable outcomes, which we report in this paper. We retrospectively reviewed patients who had undergone laparoscopic surgery for inguinal hernia at our institution. They were retrospectively classified into two groups based on the pre- or intraoperative diagnosis of hernia with a prolapsed ovary, namely the prolapse group and the non-prolapse group, respectively. The data were statistically analyzed and p

Whether to preserve the uterine round ligament during laparoscopic inguinal hernia repair in women is controversial. In this study, we aimed to compare outcomes of uterine round ligament preservation versus transection during such surgery and to explore the impact and long-term outcomes of transecting the round ligament. The study cohort comprised 419 women who had undergone laparoscopic inguinal hernia repair in Beijing Chaoyang Hospital and Qilu Hospital from January 2013 to January 2020; 393 (93.8%) of whom were successfully followed up. Patient characteristics and technical details of the operative procedure were collected and analyzed retrospectively. Early and late postoperative follow-up data, complications, especially symptoms related to retroflexed uterus, and fertility outcomes, were collected by a single follow-up nurse who was blinded to the operative procedure. There were 218 women (239 sides) in the uterine round ligament preservation group and 175 (182 sides) in the transection group. The patients in the preservation group were younger (45.9 vs. 53.6 years, p = 0.000), and had lower American Society of Anesthesiologists scores (p = 0.000). The median follow-up times in the preservation and transection groups were 41.8 ± 24.2 and 42.7 ± 24.6 months, respectively (p = 0.692). Compared with the transection group, the preservation group had longer operative times for repair of both primary and recurrent hernias. Intraoperative bleeding, length of hospital stay, development of seromas, recurrence rate, incidence of postoperative pain at the first and third postoperative months, and time of last outpatient visit were similar in the two groups. There were more premenopausal patients in the preservation group; however, we found no evidence that transection of the round ligament affected subsequent pregnancy or childbirth. Moreover, we identified no differences in dyspareunia, dysmenorrhea, chronic pelvic pain, or uterine prolapse. Transection of the round ligament during laparoscopic inguinal hernia repair in women does not increase the incidence of dyspareunia, dysmenorrhea, chronic pelvic pain, or uterine prolapse, whereas it has the advantage of reducing the operation time.

Background Accessory liver lobe (ALL) is a rare liver malformation. An ALL develops due to malformation of the endodermal caudal foregut and segmentation of the hepatic bud in the third week of gestation. Most ALLs are asymptomatic and are detected incidentally during abdominal surgery. The incidence of ALL is Case presentation The 5-year-old girl had a 3-month history of epigastralgia and vomiting, which occurred every 2 weeks. Abdominal ultrasonography with color Doppler imaging revealed an 11.8 × 13.6 mm nonvascular lesion with mixed echogenicity near the round ligament of the liver. Enhanced computed tomography confirmed a 14 × 16 × 20 mm low-attenuation mass surrounded by a hyperdense line and disproportionate fat stranding on the right side of the round ligament of the liver. There was no ascites or hemorrhage. These findings suggested an abscess of the round ligament of the liver. Her symptoms improved with the administration of oral antibiotics; thus, we planned to perform elective exploratory laparoscopy and subsequent resection. Two trocars (5 mm) were inserted through a multichannel port device at the umbilicus and one trocar (3 mm) was inserted at the right lateral abdomen. Upon observation of the abdominal cavity, the omentum was observed adhering to the round ligament of the liver. Macroscopic observation revealed no apparent mass lesions. We performed adhesiolysis of the omentum from the round ligament of the liver using a vessel sealing system. We performed resection at the site at which adhesion had formed between the round ligament of the liver with the surrounding tissue using a vessel sealing system and the resected specimen was extracted through the umbilical wound. The postoperative course was uneventful. A pathological examination revealed necrotic liver tissue. The resected tissue was founded to be an ALL with ischemic change. Conclusions The recurrent abdominal pain was induced by torsion of the ALL. Pediatric surgeons should consider ALL torsion as a differential diagnosis for epigastralgia of unknown etiology.

Accessory and cavitated uterine mass is rare developmental Mullerian anomaly. There is a non-communicating uterus-like mass that occurs contiguously along wall of uterus often underdiagnosed and needs expertise to identify. To raise awareness, provide information about this pathology and emphasize role of coronal 3D ultrasound in its diagnosis. A 28-year-old married female presented with dysmenorrhea and chronic pelvic pain. On ultrasound, a homogeneously isoechoic mass was noted in right lateral wall of uterus with central echogenicity. On 3D reconstruction, the main uterine cavity was normal and both cornu were visualized without any recognized Mullerian anomaly. No communication with the main endometrial cavity seen. On laparoscopy, mass was located under right round ligament insertion. Sectioning revealed chocolate colored fluid. ACUM is non-communicating uterus-like mass. It resembles uterus both macroscopically and microscopically. It represents a cavitated mass lined by endometrial glands and stroma surrounded by irregular smooth muscle cells. Criterias for diagnosing ACUM are (1) accessory cavitated mass located under round ligament; (2) normal uterus, fallopian tubes, and ovaries (3) surgical case with excised mass and pathological examination; (4) accessory cavity lined by endometrium with glands and stroma; (5) chocolate-brown fluid contents. On ultrasound, they appear solid isoechoic masses with central cystic areas separate from ovaries. 3D reconstruction can be used to rule out Mullerian anomaly. ACUM is a rare surgically treatable cause of dysmenorrhea, often underdiagnosed due to lack of knowledge about entity. 3D ultrasound can be highly accurate in making the diagnosis.

Postoperative pancreatic fistula in distal pancreatectomy is one of the most important complications in this surgery and it is associated with high morbidity and mortality. Pancreatic fistula after distal pancreatectomy remains an unsolved problem and none preventive procedure has been shown effectively. We present a new technique that combine pancreatic stent placement with round ligament autologous patch over pancreatic edge. A guide is introduced through Wirsung duct prior to stent placement. After stent assessment, Wirsung duct is closed. Finally, falciform ligament autologous patch is placed over pancreatic edge. After 6–8 weeks, the stent is removed by oral endoscopy. This technique introduces a new issue on the pancreatic fistula prevention.

Round ligament varices are a rare condition that usually occurs during pregnancy. Clinical findings are very similar to inguinal hernia. Patients usually present with groin pain and groin swelling that can be enlarged by the Valsalva maneuver. Since management is different, it is important to make a differential diagnosis of these two diseases. Özet Round ligament varisleri, gebelikte nadir görülen bir sağlık sorunu olup klinik bulgular kasık fıtığı ile oldukça benzerlik göstermektedir. Hastalar genellikle kasık ağrısı ve Valsalva manevrası ile büyüyen kasık şişliği şikayetiyle başvurmaktadır. Klinik yönetimi inguinal herniden farklı olduğu için bu iki hastalığın ayırıcı tanısının yapılması önemlidir.

Hydrocele of canal of Nuck is a rare disease of females. Canal of Nuck is a patent processus vaginalis in women. It usually gets obstructed but sometimes it can remain patent and forms a hydrocele or hernia in inguinal region. Hydrocele of the Canal of Nuck is usually a slow growing painless swelling which is in inguinal region but it can extend from inguinal region to labia majora. Imaging investigations such as ultrasound, CT scan, and MRI help in reaching the diagnosis if not, then it is confirmed on operation and histopathology of the sac wall. Treatment is the excision of the hydrocele. We report a case of right sided hydrocele of canal of Nuck due to its rarity and abnormal size.

Falciform ligament hernia is a very rare internal hernia and is difficult to diagnose before surgery. We report a case of falciform ligament hernia with a specific symptom and image findings, which led to an accurate diagnosis and subsequent laparoscopic surgery. A 15-year-old adolescent boy with no previous medical history showed epigastric pain and was referred to our hospital. The abdominal pain was strong in the supine position and was alleviated in the knee-chest position. Contrast-enhanced computed tomography showed that the round ligament was recognized as a cord-like structure, and the mesentery of the small intestine was located at the cranioventral side of the ligament. He was diagnosed as having falciform ligament hernia, and emergency laparoscopic surgery was performed. The small intestine passed through the falciform ligament; however, it showed no sign of ischemia, and bowel resection was not required. The malposed intestine was repositioned, and the falciform ligament was cut to prevent hernia recurrence. The specific abdominal symptom and computed tomography image finding were useful to make the correct diagnosis in this case.

Despite their ubiquitous presence, easy availability and diverse possibilities, falciform ligament and hepatic round ligament have been used less frequently than their potential dictates. This article aims to comprehensively review the applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery and assess their utility and efficacy. Medical literature/indexing databases were searched, using internet search engines, for pertinent articles and analysed. The studied flap and graft have found utility predominantly in the management of diaphragmatic hernias, gastro-oesophageal reflux disease, peptic perforations, biliary reconstruction, venous reconstruction, post-operative pancreatic fistula, post-pancreatectomy haemorrhage, hepatic cyst cavity obliteration, liver bleed, sternal dehiscence, splenectomy, reinforcement of aortic stump, feeding access, diagnostic/therapeutic access into portal system, composite tissue allo-transplant and ventriculo-peritoneal shunting where they have exhibited the desired efficacy. Hepatic round ligament/falciform ligament flap and graft are versatile and have multifarious applications in abdominal surgery with some novel and unique uses in hepatopancreaticobiliary surgery including liver transplantation. Their evident efficacy needs wider adoption to realise their true potential.

Ureteral injury during gynecological surgery can be managed in a variety of ways, from endoscopic stent placement to ureteroneocystotomy with accompanying psoas hitch and/or Boari flap. The majority of these occur during hysterectomy; therefore, gynecologic surgeons may not be as familiar with repair in women with intact uteri. Herein we present our technique for delayed robotic-assisted ureteral reimplant and psoas hitch in a woman with a ureteral injury sustained during cesarean section, which initially presented as a uretero-cervical fistula. In this video, we describe the evaluation and surgical management of a patient with delayed recognition of a left distal ureteral injury sustained during cesarean section. We present necessary modifications to robotic-assisted laparoscopic ureteroneocystostomy and psoas hitch to accommodate an intact uterus including the need for uterine manipulation, division of the round ligament, bladder mobilization from the lower uterine segment and development of the retropubic space, reimplantation steps, and psoas hitch. Simple modifications to a traditional technique of robotic-assisted ureteroneocystotomy effectively compensate for the presence of a uterus. Obstetricians should maintain a high index of suspicion for ureteral injury in women with new-onset severe urinary leakage post-cesarean section.

The round ligament of the liver is one of the peritoneal folds running from the umbilical foramen to the anterior part of the left sagittal longitudinal sulcus of the liver. Acute inflammation of the round ligament of the liver is a rather rare disease. The clinical picture of the disease has no specific signs. This article presents a rare case of ultrasound diagnostics of primary isolated inflammation of the round ligament of the liver in a patient admitted to the hospital with a clinical picture of "acute abdomen". Ultrasound signs of inflammation of the round ligament of the liver were determined. Early diagnosis of inflammation of the round ligament of the liver allows preventing the development of complications and, as a result, surgical treatment.

A 28-year-old woman presented with a 1-year history of severe progressive dysmenorrhea following suction evacuation and tubal ligation. Sonography showed a bicornuate uterus with hematometra in the left horn. Hysteroscopy ruled out a diagnosis of a congenital Müllerian anomaly, as both ostia appeared normal. Under laparoscopy, a mass was seen on the left fundal region near the insertion of the round ligament, and needle aspiration of a chocolate-colored fluid confirmed the diagnosis of an adenomyotic cyst. The cyst was excised. The patient recovered well and has been symptom-free since surgery. Adenomyotic cyst is a rare entity in young women and must be differentiated from obstructive Müllerian anomaly. Laparoscopy is the preferred minimally invasive modality for managing this rare disorder.

The search for an operation that effectively prevents and treats intrathoracic gastric migration (ITGM) after bariatric surgery has revived a long-forgotten technique: ligamentum teres cardiopexy (LTC) by which a vascularized flap of the teres ligament is wrapped around the distal esophagus. The systematic search of publications in the English language revealed 4 studies (total number of patients 53) in the non-bariatric literature with an unsatisfactory resolution of GERD. There were 5 reports from the bariatric literature with small patient numbers (total 64) and a short follow-up (6-36 months). There were no objective signs of gastric remigration in 93% of investigated patients. Acknowledging the limitations of these preliminary reports, bariatric surgeons are encouraged to further investigate the potentials of LTC in their patients.

Abdominal malignant tumors originated from cancers, such as vater ampulla carcinoma (VAC) and pancreatic cancer (PC), often invades the portal vein (PV) and the superior mesenteric vein (SMV) upon metastasis. Surgical removal of these tumors leads to sacrifice of parts of these vessels that need to be reconstructed with autograft tissues. Current options for the replacement tissue all have their limitations in certain aspects. Therefore, improved interstitial material for the reconstruction with better tissue compatibility is urgently needed. In the present study, we explored the potential of hepatic round ligament (HRL) as a candidate tissue for the task from the biomechanical point of view. We reveal that HRL and PV share similar geometrical parameters in terms of vascular cavity diameter and wall thickness. In addition, they also have similar elastic properties and tissue flexibility and intensity upon increased cavity pressure. Our study strongly supports HRL as potential replacement tissue for PV reconstruction in term of mechanical properties and encourages further biological studies to be performed on these two tissues for further verification.

Introduction: Cyst of Nuck in women is a rare development disorder corresponding to hydrocoele of the spermatic cord in males; it can be associated with inguinal hernia in 30-40% of cases. Only 400 cases have been described in literature and in there are no older than 50. Case Presentation: A 62-year-old presented a right aching inguinal swelling. On physical examination the mass was not reducible, without signs of incarceration or strangulation. On ultrasound the lesion was mostly hypoechoic. CT saw an over liquid lesion, confirmed on MRI as a lesion hypointense in T1 and hyperintense in T2. The patient underwent open surgery: the cyst was separated from the round ligament and excised in mass and the defect was repaired with a prolene mesh. The histopathological exam confirmed the hydrocoele (calretinin positive, mesothelial cells on the inner surface). Discussion: The canal of Nuck is a small evagination of the parietal peritoneum that accompanies the round ligament into the inguinal canal during the first year of female development and is normally obliterated in the first year of life. Failure of obliteration of Nuck canal results in a hydrocoele that could develop intraabdominal or extra – abdominal or both. Ultrasound shows a thin walled, well defined, echo free cystic structure but the perfect diagnosis is given by MRI. Therapy is surgical and it can be open or, more recently, laparoscopic, depending on the expertise of the surgeon. Conclusion: A cyst of Nuck is a rare condition but it should always be considered in differential diagnosis of cystic inguinal lumps in women. Most of the reported cases concern children and young men. To our knowledge this is the only case regarding a more than 50-year-old.

We aim to assess the surgical outcomes of our novel hysteropexy procedure, laparoscopic long mesh surgery (LLMS) with augmented round ligaments. Twenty-five consecutive women with stage II or greater main uterine prolapse defined by the POP quantification staging system were referred for LLMS. Long mesh is a synthetic T-shaped mesh, with the body fixed at the uterine cervix and the two arms fixed along the bilateral round ligaments. The clinical evaluations performed before and 6 months after surgery included pelvic examinations, urodynamic studies, and questionnaires for urinary and sexual symptoms. After a follow-up time of 12 to 24 months, the anatomical reduction rate was 92% (23/25) for the apical compartment. The average operative time was 65.4 ± 28.8 minutes. No major complications were recognized during LLMS. The lower urinary tract symptoms and scores on the questionnaires improved significantly after the surgery, except urgency urinary incontinence and nocturia. Neither voiding nor storage dysfunction was observed after the operations. All of the domains and total Female Sexual Function Index (FSFI) scores of the 15 sexually active women did not differ significantly after LLMS. The results of our study suggest that LLMS is an effective, safe, and time-saving hysteropexy surgery for the treatment of apical prolapse.

In the female, the canal of Nuck is a tubular fold of parietal peritoneum that travels along with the round ligament through the inguinal canal to its attachment on the labia majora. The canal of Nuck is analogous to the processus vaginalis in the male. In embryonic development, this pathway typically obliterates early in life; however, in some cases, it may partially or completely fail to close. This failure to obliterate can lead to complications ranging from a cyst of the canal of Nuck (also known as a female hydrocele) to herniation and incarceration of abdominal and pelvic organs. There is little information available in the medical literature concerning this rare condition; therefore, it is important for sonographers, physicians, and surgeons to be familiar with this developmental abnormality. This report represents the first prenatal case of a cyst of the canal of Nuck, along with the unique combination of a large left fetal ovarian cyst and acute polyhydramnios. The embryology, incidence, differential diagnosis, management, and treatment of these female conditions are discussed.

BACKGROUND A right-sided round ligament (RSRL) is a rare, congenital anomaly of the intrahepatic portal vein, with a reported frequency of 0.2%-1.2%. For patients with perihilar cholangiocarcinoma associated with an RSRL, an accurate understanding of the vascular and biliary anatomy is indispensable. CASE SUMMARY We report a 70-year-old male with perihilar cholangiocarcinoma associated with an RSRL. After percutaneous transhepatic embolization of the left and anterior portal branches, we conducted a left trisectionectomy of the liver with extrahepatic bile duct resection and hepaticojejunostomy. The postoperative course was uneventful, and R0 resection was achieved. When the liver volume of each section was compared between 7 patients with an RSRL and 20 patients with normal portal vein anatomy, the posterior section in RSRL patients was significantly larger than that in patients with normal portal vein anatomy (median: 457 mL vs 306 mL, P = 0.031). In patients with perihilar cholangiocarcinoma associated with an RSRL, left trisectionectomy has several surgical advantages: (1) The posterior branch of the portal vein often ramifies independently, and the division of the portal vein is easily conducted; (2) A relatively large amount of remnant liver can be retained; and (3) The anatomy of the posterior branch of the Glissonian pedicle is similar to that in patients with normal anatomy. CONCLUSION In patients with an RSRL and perihilar cholangiocarcinoma that does not involve the posterior section, left trisectionectomy may be a favorable choice.

Background: Inguinal endometriosis occurs in 0.3% to 0.6% of patients affected by endometriosis, it is a rare involvement of the extraperitoneal portion of the round ligament. It is often confused ...

INTRODUCTION AND HYPOTHESIS Chronic non-puerperal complete uterine inversion is a relatively rare condition. Abdominal Haultain's operation is the usual management. We present such a case with fundal fibroids managed by modified vaginal hysterectomy. METHODS Preoperative computerized tomography enhanced intravenous urogram depicted normal ureters and bladder. Diluted vasopressin (10 U in 100 ml normal saline) was infiltrated at the base of the myoma and a myomectomy was performed. The fundal raw area was pierced to reach the formed space between the anterior and posterior uterine serosa. The bilateral round ligaments were clamped, cut, and ligated. Diluted vasopressin was injected into the fundal anterior uterine wall and about 1 cm was excised. Then, the bilateral utero-ovarian ligaments were clamped, cut, and ligated. In the same way another 1 cm of anterior uterine wall was excised and the bilateral uterine vessels were clamped, cut, and ligated. The rest of the uterine wall area was infiltrated with diluted vasopressin circumferentially. An incision at the vesico-cervical junction was made and the bladder pushed up. The posterior fornix area was incised and the Pouch of Douglas (POD) opened. Vesico-uterine pouch opened under finger guidance placed through POD. The rest of the anterior uterine wall was excised. Exposed bilateral cardinal-uterosacral ligament complexes (CULCs) were clamped, cut, and ligated. The remaining vaginal attachments ligated hemostatically and the vault was closed. For vault prolapse prevention, vault closure suture ends were tied with ipsilateral CULC suture end, brought outside the vagina at vault angle. RESULTS A follow-up visit up to 1 year found no complications. CONCLUSION This novel reverse vaginal hysterectomy combining the principles of both abdominal and vaginal hysterectomy can successfully manage chronic non-puerperal complete uterine inversion.

Patient: Female, 35-year-old Final Diagnosis: Round ligament varices Symptoms: Painless right inguinal lump during second trimester of gestation Medication: — Clinical Procedure: — Specialty: Obstetrics and Gynecology • Radiology • Surgery Objective: Rare disease 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.

The vulval/labial leiomyomas are rare tumours and are considered to arise from smooth muscle cells within the round ligament remnants in the labia majora, erectile tissue and blood vessel walls. We present the case report of a 33 year old parous woman who presented with history of a painless swelling in the vulval region and discomfort for 3 years. Patient underwent surgical excision of the lesion in the vulval area. The histopathological diagnosis was suggestive of benign leiomyoma. There are fewer than hundred and twenty cases of vulval smooth muscles tumours reported in literature [1, 2]. Since many other vulval lesions have similar presentations, it poses a difficulty in distinguishing leiomyoma from other lesions. Surgical excision is the only curative treatment for vulvar leiomyomas [3]. Therefore it is recommended that these lesions are surgically excised and sent for histopathological examination for the confirmation of diagnosis. This case report helps to take into account other differential diagnoses of vulval masses.

Introduction/Background* The combination of emerging target therapies and continuous technological advancement in surgical procedures support a trend toward a prolonged survival in advanced ovarian cancer (AOC) patients. Upper abdominal carcinomatosis hides challenging locations for complete gross resection in the hands of expert gynecologic oncologists. We developed an anatomo-surgical classification for ovarian cancer metastases in the liver area from a gynecological point of view, aiming to provide an anatomo-topographical tool to address each surgical task and to standardize the nomenclature in the radiological and surgical report. Methodology After the identification of four conceptually distinct anatomical areas, we used both the three-dimensional anatomical model and the surgical video report to represent them individually. Result(s)* Our anatomo-surgical classification is divided into 4 distinct categories: TYPE1 GLISSON’S CAPSULE: superficial metastases involving only the Glisson’s sheat with no parenchymal infiltration (either focal or extensive). TYPE2 LIGAMENTOUS: this is a heterogeneous group defining cancer deposits along the lines of reflection between the liver and surrounding organs. We can further divide it into ‘falciform ligament’, ‘round ligament’, ‘Arantii and hepato-gastric ligament’, ‘coronary and triangular ligament’ localizations. TYPE3 HEPATIC HILUM: the porta hepatis is considered as a single entity due to its potentially dual neoplastic involvement both peritoneal or ‘external’ as hepato-duodenal ligament and lymphatic or ‘internal’ while involving lymph-nodes along the portal triad. TYPE4 PARENCHYMAL: we identified, based on surgical management, the ‘superficial’ intra-parenchymal localization, infiltrating the less than 1 cm in depth, and the fully intra-parenchymal. Conclusion* Our classification represents a useful guide while planning the surgical strategy to AOC metastases in the liver area. Identification of each category, specific underlining anatomical pitfalls and its surgical-related management, guarantees a didactic and effective tool in supporting the daily intraoperative decision-making algorithm, and in assigning the specific procedure within a multidisciplinary team, based on surgical competence. Furthermore, the standardization of nomenclature allows an easy exchange of surgical information for scientific purposes, that are otherwise difficult to interpret and compare.

Introduction/Background* Laparoscopic Ovarian Transposition (OT) has already been proven to be a safe and effective procedure to preserve ovarian function in patients receiving pelvic radiotherapy for a variety of gynaecological malignancies. Different techniques have been described. Aim This video demonstrates our PS technique for OT in a 32-year-old patient with stage 1B3 poorly differentiated squamous cell carcinoma of the cervix who subsequently underwent radical chemoradiation. Methodology/Technique Laparoscopy was performed as usual, using a 10mm umbilical optic port and four 5mm ports placed in both iliac fossae and high in both flanks. Thorough inspection of the peritoneal cavity revealed no evidence of disseminated disease. Approximately 100mls of free blood was seen in the pelvis. Both ovaries were slightly enlarged and the right ovary had a ruptured haemorrhagic cyst. She had previously developed OHSS after ovarian stimulation and egg retrieval. The uterus was bulky and retroverted. Both tubes were normal. All the upper abdominal organs looked normal and there was no evidence of disease on the ovaries or peritoneal surfaces therefore we decided to proceed to bilateral ovarian transposition. Result(s)* Bilateral retrograde salpingectomy was performed using a Harmonic scalpel and specimens were sent for histology. Both pelvic side walls were opened and both ureters were identified. Both utero-ovarian ligaments were transected along with 2cm of round ligament on both sides and ovarian flaps were created. The ovarian flaps were mobilised and the infundibulopelvic ligaments were skeletonised. The para-colic gutters were incised approximately 10cm above the pelvic brim and were tunnelled. Both ovarian flaps were pulled through and stapled outside the irradiation fields to prevent them from falling back into the pelvis following the procedure. Titanium staples were used for easy identification of ovaries on imaging. At the end of the procedure both ovarian pedicles were tension-free with good mobility and no risk of necrosis or torsion. There were no intraoperative complications and the patient experienced a good recovery. Conclusion* We consider that the ovarian flap allows the ovaries to have a degree of natural movement, while at the same time preventing torsion and minimising ovarian damage associated with the use of transfixed stitches.

Leiomyomas are common benign tumours that can arise in any anatomical structure containing smooth muscle. Their localization in the uterine round ligament is rare, although leiomyomas are the most frequent tumour of this structure. Leiomyomas present as inguinal, labial or intra-abdominal masses, and are often misdiagnosed as hernias or enlarged lymph nodes. The aim of the present study was to describe a rare case of a large intra-abdominal mesenchymal neoplasm arising from the right round ligament of the uterus. A 51-year-old asymptomatic female patient (gravida 3, para 3) presented herself for a routine gynaecological examination. A transvaginal ultrasound examination revealed a solid heterogeneous mass with a maximum diameter of 9 cm localized at the right parametrial space. Further preoperative evaluation using magnetic resonance imaging revealed that the mass contained solid and cystic components, which was suggestive of a mesenchymal neoplasm with possible involvement of the right ovary. Complete excision of the tumour and total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed via laparotomy under general anaesthesia. The intraoperative findings, frozen section biopsies and final histological examination of the tumour established the diagnosis of an intra-abdominal myoma of the right uterine round ligament. The majority of abdominal round ligament myomas are initially asymptomatic. The role of synchronous imaging examinations, such as ultrasonography and magnetic resonance imaging, in the diagnosis of these lesions is crucial.

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

Endometriosis is a chronic, oestrogen-dependent condition, defined as extra-uterine, functional endometrial tissue. We report a case of endometriosis of extra-inguinal part of the round ligament, in near proximity to pubic bone. To our knowledge, this is the first case report in the searched English literature. A 31-year-old female patient, nullipara, presented with an unrelated to menstruation, right suprapubic painful swelling of 6 months duration. Her medical history was free. The patient has been receiving contraception for the last 3 years. Colour Doppler and computed tomography showed a spindle-shaped lobe, of inhomogeneous echomorphology, with dimensions of 2.77 × 1.29 cm and relative contamination, which appeared in continuation with the ipsilateral rectus abdominis muscle. Intraoperatively, under general anaesthesia, a mass of the right round ligament of the uterus was found in the ligament’s insertion to the pubic bone. The extra-inguinal part of the right round ligament was excised and the intra-pelvic part was sutured to the ground of the inguinal canal. The histological and immunohistochemical characteristics of the specimen were consistent with endometriosis. Her recovery was uneventful and the patient was discharged on the 2nd postoperative day. Endometriosis of the round ligament of the uterus, should be taken into consideration in the differential diagnosis in cases of extra-inguinal swelling in women of childbearing ages, even in cases with a free medical history.

Lipoma of the spermatic cord or the round ligament is called inguinal canal lipoma. It may present as an inguinal herniating mass of fat tissue, with or without an accompanying herniating sac. There are few reports about large lipomas of the spermatic cord. We describe a case of a large spermatic cord pure lipoma, initially suspected to be an inguinal hernia upon physical examination. We diagnosed the lipoma with ultrasound and magnetic resonance imaging. The patient subsequently underwent left orchiectomy.

Liver’s ligament cysts, especially uncommon and the liver’s round ligament cysts, have been sporadically presented in some case reports during the past decade. All reported cases were treated by laparotomy. This report discusses the case of asymptomatic liver’s round ligament cyst. The patient was hospitalized due to progressive epigastric pain for 1 week. Abdominal ultrasound and computed tomography scans showed a fluid density bulk in the pre-peritoneal space, suggestive of a cyst in the liver’s ligament. A laparoscopy was indicated to excise this cyst and the specimens were sent to a pathologist. The patient recovered uneventfully and discharged after 1 day of operation. In conclusion, exploratory laparoscopy and total resection of these lesions are necessary to exclude malignancy. Furthermore, laparoscopic round ligament cyst removal is applicable and it helps the patient with enhanced recovery.

A 43-year-old woman was diagnosed with a hydrocele of the canal of Nuck, for which laparoscopic total extraperitoneal excision was successfully undertaken. The hydrocele was located entirely within the inguinal canal and was barely visible at the internal inguinal ring, even with strong retraction. The inferior epigastric vessels were at risk of injury secondary to excessive tension when retracting the round ligament. To overcome these problems, the hydrocele was approached from the medial side of the inferior epigastric vessels across the transversalis fascia. This approach allowed us to reach the distal end of the hydrocele and avoid excessive traction on the vessels. Thus, a hydrocele of the canal of Nuck can be addressed successfully with minimally invasive laparoscopic total extraperitoneal excision. Approaching the hydrocele from the medial side of the inferior epigastric vessels across the transversalis fascia may be useful.

Introduction. Most cases of ovarian torsion occur in the reproductive age and many are related to ovarian and paraovarian masses. If it occurs without any subtle anatomic etiology or ovarian and paraovarian masses, recurrence of ovarian torsion is more likely. Recurrent left ovarian torsion is much less common than recurrent right ovarian torsion. The authors describe a rare case with their new ovarian fixation technique. Case and Method. A 21-year-old female patient with polycystic ovarian syndrome had a 7th recurrence of left ovarian torsion. Although ovarian fixation was performed in addition to detorsion at the 5th and the 6th laparoscopic surgeries, it had failed. Due to recurrence ovarian torsion after ovarian fixation, the authors performed a different technique:folding the utero-ovarian ligament which folded on itself. The distal part of the utero-ovarian ligament with the ovary was both fixed to the proximal part of the round ligament which was adjacent to the uterus. Conclusion. Although a wide range of oophoropexy methods have been described in the literature, the best method remains a matter for debate. This technique can be performed even when the ovarian tissue is necrotic. Because of this, we think that this technique is useful and effective technique.

On the posterior aspect of the anterior abdominal wall, there are four kinds of "fine" ligaments. They are: the round ligament of the liver, median umbilical ligament (UL), a pair of medial ULs, and a pair of lateral ULs. Four of them (the round ligament, median UL, and paired medial ULs) meet at the umbilicus because they originate from the contents of the umbilical cord. The round ligament of the liver originates from the umbilical vein, the medial ULs from the umbilical arteries, and the median UL from the urachus. These structures help radiologists identify right-sided round ligament (RSRL) (a rare, but surgically important normal variant), as well as to differentiate groin hernias. The ligaments can be involved in inflammation; moreover, tumors can arise from them. Unique symptoms such as umbilical discharge and/or location of pathologies relating to their embryology are important in diagnosing their pathologies. In this article, we comprehensively review the anatomy, embryology, and pathology of the "fine" abdominal ligaments and highlight representative cases with emphasis on clinical significance.

Hysterectomy is the most common gynecological surgical intervention; therefore, there are many technical variations in different healthcare systems around the world. We aimed to review, step by step, the technique of laparoscopic hysterectomy as well as to present the available variety of surgical instruments impartially so that the operative team can decide in an informed manner the model and characteristics of the equipment used. The surgical technique is presented based on the experience of the authors, focusing mainly on intraoperative recommendation and suggestions. Advantages and disadvantages of the available instruments are also extensively detailed. Surgical positioning, as well as inserting the uterine manipulator are essential steps. The open technique is used to create pneumoperitoneum. The utero-ovarian ligament or the infundibulopelvic ligament is identified, coagulated and cut. The round ligament is incised, entering the space between the two layers of the broad ligament and advancing caudally in this space, which, if correctly identified, should be avascular. The uterine vessels located on the posterior sheet of the broad ligament are dissected and coagulated. The vaginal wall is sectioned with the help of the manipulator’s cap, making it easier to expose the insertion line of the vagina on the cervix. The uterus is removed through the vagina or through a trans-parietal incision. Thereafter, the vagina is sutured using separate Vicryl sutures. Between 2011 and 2016, laparoscopic hysterectomy had an increasing trend all over Europe. With a reported percentage of 3%, Romania ranks last in hysterectomies performed laparoscopically. The laparoscopic approach offers the advantages of minimal invasiveness: less pain, faster recovery and early social reintegration; therefore, this trend of improvement should become more accepted.

Solitary fibrous tumors (SFT) rarely arise in the pelvis. Here, we report two cases of SFT arising from the pelvic retroperitoneum. The first case involves a 64-year-old woman diagnosed with a 5-cm pelvic mass. Magnetic resonance imaging revealed a solid and cystic mass with marked enhancement, but limited water restriction. During surgery, intraligamental tumor arising near the round ligament was resected. Pathologically, the tumor comprised dilated vessels and spindle-shaped cells positive for STAT6 and CD34. The second case involves a 53-year-old woman diagnosed with a 4.5-cm pelvic mass through computed tomography. Magnetic resonance imaging demonstrated a solid mass with multiple cysts with strong enhancement and slight water restriction. During surgery, the tumor was found in the retroperitoneum. Pathologically, spindle-shaped tumor cells positive for STAT6 and CD34 had proliferated around the prominent hyalinized vessels. Although rare in the pelvis, SFT should be suspected when a mass with strong enhancement is found.

The aim of this study was to clarify the relationship between the length of the round ligament and the presence of a patent processus vaginalis (PV) based on the hypothesis that a short round ligament is the cause of ovarian inguinal hernia in female infants. Between April 2011 and March 2017, 132 girls underwent laparoscopic surgery for inguinal hernia. Before surgery, the presence of ovarian prolapse was diagnosed. We observed the internal inguinal ring laparoscopically and examined the diameter of the PV orifice as well as the round ligament length. Medical records and video records were reviewed to evaluate PV patency and round ligament length. Seventeen of the 132 cases had an ovarian inguinal hernia; all of them were infants. In all infants, with or without a prolapsed ovary, the round ligament was short, causing the ovary and fallopian tube to be close to the hernia orifice over the pelvic brim. In girls aged over 12 months, the round ligament lengths on the hernia side, contralateral open PV side, and contralateral closed PV side were 33.0 ± 9.3, 36.8 ± 7.5, and 41.4 ± 8.5 mm, respectively. The round ligament length in open PV was significantly shorter than in the closed PV, but the difference was smaller in older patients. The round ligament, which is the female gubernaculum in the fetus, was shorter in the open PV than in the closed PV in younger girls. The short round ligament results in the ovarian prolapsed hernia.

Study Objective Demonstrate robotic-assisted resection of a large retroperitoneal lipomatous mass. Design Surgical video Setting Tertiary-care operating room using DaVinci Xi system with four 8 mm trocars, and a 12 mm assistant port. Patients or Participants A 48-year-old female with a multi-fibroid uterus and seven centimeter lipomatous mass in her right hemipelvis Interventions The patient underwent robotic-assisted excision of the right retroperitoneal mass, total hysterectomy, right salpingo-oophorectomy, left salpingectomy, and cystoscopy. Measurements and Main Results Although superficial lipomas are common and most likely benign, retroperitoneal lipomatous tumors are rare. Tumors greater than ten centimeters have a higher malignant potential and are typically found in the deep retroperitoneal space. Robotic-assisted laparoscopy revealed a large lipomatous mass in the right retroperitoneal space consistent with radiographic imaging. The surgeon divided the round ligament and extended the incision parallel to the infundibulopelvic ligament to enter the right retroperitoneum. He then carefully dissected and resected the lipomatous tumor from the pararectal space and performed the remainder of the procedures without complication. Benign lipomas and low grade liposarcoma are difficult to differentiate. The latter has a high rate of local recurrence if incompletely resected, therefore complete resection should be the surgical goal. Pathology revealed partially encapsulated mature adipose tissue consistent with lipoma with negative fluorescent in situ hybridization (FISH) analysis using a dual color MDM2/CEN12 probe set confirming the likely benign behavior of the mass. Conclusion Retroperitoneal lipomatous tumors are rare. Distinguishing between lipomas and liposarcomas is a diagnostic challenge both radiographically and intraoperatively. Confirmatory histopathology, and often molecular pathology, is necessary for the final diagnosis. Knowledge of the pathology of retroperitoneal lipomatous masses and the related surgical anatomy and goals are imperative to optimal management.

BACKGROUND: At present, the materials commonly used for venous reconstruction in radical surgery for pancreatic cancer combined with vascular reconstruction include artificial blood vessels, autologous veins, and allogeneic blood vessels, but these materials all have their own disadvantages. In contrast, the use of the peritoneum and the round ligament of the liver for radical surgery for pancreatic cancer combined with vascular reconstruction provides new options. METHODS: A retrospective descriptive study was performed. Clinical data were collected from 11 patients (5 males and 6 females with a median age of 62 years and an age range of 48–72 years) who underwent pancreatic cancer surgery combined with resection and reconstruction of the portal vein (PV) and superior mesenteric vein (SMV) using the peritoneum (including the round ligament of the liver) from November 2018 to November 2020 in the Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, and the Department of General Surgery, Affiliated Hospital of Shaoxing University. Intraoperative conditions and postoperative conditions were observed. Data were analyzed using SPSS 19.0 Normally distributed measurement data are expressed as the mean ± SD, whereas nonnormally distributed measurement data are expressed as the median (range). Count data are expressed as absolute numbers. RESULTS: (I) Intraoperative condition: all 11 patients completed the operation successfully, including total pancreatectomy (TP) in 4 patients and pancreatoduodenectomy (PD) in 7 patients. In the 11 patients, the duration of surgery was 503±183 min, and the volume of intraoperative bleeding was 332±268 mL. (II) Postoperative condition: of the 11 patients, 5 presented with complications, including pancreatic leak in 3 patients, bleeding in 1 patient, and thrombosis in 1 patient. Postoperative pathological examination showed that 10 of the 11 patients had adenocarcinoma, and 1 had a neuroendocrine tumor. CONCLUSIONS: The peritoneum and the round ligament of the liver are feasible materials and provide clinical options for reconstruction of the PV and SMV.

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.

Introduction Peptic ulcer perforation (PUP) is one of the most common critical surgical emergencies. The omentum flap is commonly used to cover a PUP. However, the omentum cannot be used in cases of severe peritonitis or previous surgical removal. This is the first study conducted in Vietnam that was designed to analyse the outcomes of patients with PUPs who were treated using the falciform ligament. Method In this study, we retrospectively identified 40 consecutive patients who were treated for PUP at a single high-volume centre in Vietnam from February 2018 to February 2021. Peptic ulcer perforation was measured during diagnostic evaluation based on preoperative imaging, such as X-ray, and CT scan. Patients who had malignancy, laparoscopic surgery, omentopexy and nonoperative treatment were excluded from this research. Results Forty patients were included; the mean age of the patients was 66.3 years (range 33–99 years), and some patients had comorbid disease (57.5%), hypertension (30%), diabetes (10%), cirrhosis (7.5%), and chronic renal failure (7.5%). The PUPs were located in the duodenum (80%), or the pyloric (15%) and prepyloric (5%) regions. The procedures used to treat the patients included duodenostomy (32.5%), gastrojejunostomy (37.5%), and antrum resection (2.5%). The average operative time was 88.6 min (45–180 min), hospital stay was 9.6 days (2–35 days), and oral intake was started at 4.1 days (3–8 days); additionally, the 30-day mortality (17.5%) and incidences of pneumonia (25%), multiorgan failure (15%), acute liver failure (5%), wound infection (7.5%), and ulcer peptic fistula (0%) were assessed. Univariate tests showed that an ASA ≥ III and comorbidities, such as pulmonary complications, liver failure and multiorgan failure, were associated with mortality. The multivariate test showed that multiorgan failure was the only factor related to mortality. Conclusion The falciform ligament can be efficiently used for the closure of a PUP. Although there were no instances of complication with a reperforated peptic ulcer, the mortality rate was slightly highly related to severe comorbidities and postoperative multiorgan failure., Highlights • Peptic ulcer perforation is one of the most common surgical emergencies with an overall mortality rate is between 1.3% and 20%. • Comorbidities, over 70 years old, having surgical therapy after 36 hours, and postoperative complications are associated with mortality. • Using falciform ligament to replace the traditional omental patch is interesting, easy applying and efficiently in the closure of PUP. • The mortality and complications were still high related to severe comorbidity and multiorgan failure after surgery.

Knowledge of the anatomy of the portal system is essential for safe liver resection. We report a very rare anatomic anomaly of the portal system in a living liver donor. A 24-year-old female living liver donor was found to have anomalies of the portal system on preoperative contrast-enhanced computed tomography. The ventral branch of the right anterior segment arose from the transverse portion of the left portal vein. The gallbladder and round ligament were positioned normally. Intraoperative cholangiography for evaluation of biliary anatomy revealed very low confluence of the right and left hepatic ducts. All the bile ducts from the right lobe merged into the right hepatic duct. A right lobe graft was performed, including the ventral area of the right anterior segment. The portal branch of the ventral area of the right anterior segment could be transected extrahepatically. In the recipient operation, each of the right main portal branches, including the right posterior segment branch and the dorsal branch of the right anterior segment, and the ventral branch of the right anterior segment, were anastomosed to the right and left branches of the portal vein, respectively, of the recipient. The transected right hepatic duct of the graft was anastomosed with the recipient's common hepatic duct. Sixteen years after the liver transplant, the recipient continues to do well and has good portal flow.

Background Intrahepatic cholangiocarcinoma (ICC) is primary cancer of the liver with poor prognosis because of its high potential for recurrence and metastasis. We experienced a rare case of ICC with hematogenous metastasis to the falciform ligament. We aimed to clarify the route of metastasis to the mesentery by increasing the accuracy of preoperative imaging and establish a hepatectomy to control cancer. Case presentation An 85-year-old woman was referred to our hospital for a detailed study of progressively increasing liver tumors. She had no subjective symptoms. Her medical history showed hypertension, aneurysm clipping for cerebral hemorrhage, and gallstones. A detailed physical examination and laboratory data evaluation included tumor markers but did not demonstrate any abnormalities. On computed tomography scan, contrast-enhanced ultrasound, and magnetic resonance imaging with gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid, the tumor appeared to be located in liver segment IV, protruding outside the liver. It appeared to contain two distinct components; we suspected ICC in the intrahepatic tumor component. Laparoscopic observation revealed that the extrahepatic lesion was an intra-falciform ligament mass; laparoscopic left hepatectomy was performed. Microscopically, the main tumor in segment IV was 15 mm in diameter and was diagnosed as moderately and poorly differentiated ICC. The tumor of the intra-falciform ligament was not continuous with the main intrahepatic nodule and was also diagnosed as ICC with extensive necrosis. There were no infiltrates in the round ligament of the liver, and several tumor thrombi were found in the small veins of the falciform ligament. Conclusions To date, there have been a few reports of metastases of primary liver cancer to the falciform ligament. At the time of preoperative imaging and pathological diagnosis, this case was suggestive of considering that the malignant liver tumor might be suspected of metastasizing to the falciform ligament. Our case improves awareness of this pathology, which can be useful in the future when encountered by hepatic specialists and surgeons.