{"paper_id":"15b471bb-566d-40df-861b-2f9dd769c4e9","body_text":"Gynecol Surg (2006) 3: 295 –297\nDOI 10.1007/s10397-006-0217-x\nCASE REPORT\nAnne Hoffbeck . David Hamid . Carole Meyer .\nMarie-Noëlle Roedlich . Renaud Haberstich .\nJean-Jacques Baldauf\nEndometriosis of the round ligament revealed by an intermittent\nhernia\nReceived: 8 December 2005 / Accepted: 9 April 2006 / Published online: 12 August 2006\n# Springer-V erlag Berlin / Heidelberg 2006\nAbstract Endometriosis is a common gynaecological\npathology with pelvic and extra-pelvic localisations. We\nreport a case of endometriosis of the round ligament\nrevealed by an intermittent hernia. The endometriosis of\nthe round ligament is unusual and the diagnosis may be\ndifficult. The appearance of a roundish lump in the inguinal\nregion associated with pain in relation to the menstrual\ncycle must raise the suspicion of endometriosis among the\npossible diagnosis. Ultrasonography and magnetic reso-\nnance imaging are the most useful examinations. But it is\nthe histological examination of the surgical specimen that\nconfirms the diagnosis.\nKeywords Endometriosis . Round ligament . Hernia\nIntroduction\nEndometriosis is a common gynaecological pathology that\naccounts for 8 –15% of women of fertile age on average in\nthe fourth decade of life [ 1, 2]. It is characterised by the\ndevelopment of ectopic endometrial tissue under the stimu-\nlus of ovarian hormones and takes on the typical proliferative\nand functional aspects of a normal endometrium.\nIt represents a disease of specific interest to the general\nsurgeon due to extra-pelvic localisations, especially the\nskin (umbilical scar, surgical scars), the viscera (small\nintestine, left colon, rectum, appendix) and the groin [ 2–7].\nIn the latter case it can be confused with other common\naffections of the inguinal region, such as primitive or\nmetastatic lymph nodes, soft tissue tumours and foreign\nbody granulomas. It rarely causes a clinical picture\nsuggestive of irreducible or strangulated hernia that\nrequires urgent surgery [ 8–10].\nCase report\nA 43-year-old, nulliparous woman, consulted for chronic\npain she had been having for 3 years. Her medical history\nconsisted of an appendicectomy. Two years earlier the\npatient had undergone an intraperitoneal exeresis of an\novarian endometriosis by laparoscopy . After the surgery\nthe patient was treated for 3 months by a gonadotrophin-\nreleasing hormone injection.\nThe patient noticed an intermittent round lump in the\nright inguinal region. At the physical examination, we\nnoted a back utero, painless, and mobile mass with normal\npalpation of the ovaries. There was nothing to suggest\nrecurrence of endometriosis.\nThe 1.5-cm lump of the right inguinal region was mobile\nunder the surface plane, but fixed in depth, and was tender\nand irreducible. The left inguinal region examination was\nnormal.\nUltrasound examination of the surface tissue showed a\n10.4×31-mm egg-shaped nodule in the right inguinal\nregion extending longitudinally along the axis of the\ninguinal canal. The mass had an unusual hypo-echogenic\nultrasound structure in the background of the hernia sac\n(Fig. 1).\nThe MRI (Fig. 2) showed a left ovarian cyst with\nhaemorragia of 2×3 cm and a 2-cm mass with hypointen-\nsity in the left ovary. An endometriosis implant is located\non the right ovary (Figs. 3, 4).\nThe patient was therefore subjected to surgery consisting\nof explorative laparoscopy followed by cure of the hernia.\nThe laparoscopy showed many peritoneal endometriosis\nimplants. We performed a biopsy of the pouch of Douglas\nand multiple electro-destruction of the implants. Cure of\nthe hernia consisted of a direct abdominal approach of the\ninguinal area. A 1-cm lump under the aponeurosis of the\nlarge abdominal muscle was found and was firmly\nadhesive to the round ligament. The dissection of the\nA. Hoffbeck . D. Hamid ( *) . C. Meyer . M.-N. Roedlich .\nR. Haberstich . J.-J. Baldauf\nObstetrics and Gynaecology, University Hospital of Strasbourg,\nAvenue Molière,\nStrasbourg, Bas-Rhin, 67018, France\ne-mail: david.hamid@chru-strasbourg.fr\nTel.: +33-3-88128335\nFax: +33-3-88127457\n\nsuspected hernia led to a cyst of the round ligament.\nExeresis of the median part of the round ligament permitted\nremoval of the cyst. Finally, the Shouldice procedure was\ncarried out to strengthen the wall of the inguinal.\nThe histological examination showed a hyaline stroma\nwith endometrial glands in the extraperitoneal round\nligament associated with peritoneal endometriosis. There\nwere no problems postoperatively.\nDiscussion\nEndometriosis of the extraperitoneal portion of the round\nligament, or more generally of the inguinal region, was first\ndescribed by Cullen in 1986, and represents a rare affliction\nthat accounts for 0.3 –0.6% of patients affected by endo-\nmetriosis [ 11].\nAfter reviewing the literature, it was possible to add\nanother seven cases to the 61 reported by Proposito et al. in\nFig. 1 Ultrasonography: hernia sac with an unusual hypoechogenic\nultrasound structure in its background\nFig. 2 Pelvic T1 magnetic resonance image (MRI) with fat\nsuppression sequence, axial slice showing endometriosis of the\nright round ligament ( white arrow )\nFig. 3 Magnetic resonance imaging: endometriosis implant on the\nright ovary ( white arrow )\nFig. 4 Pelvic T1 MRI, sagittal slice showing endometriosis of the\nright round ligament ( white arrow )\n296\n\n2002 [1, 12, 13]. It is interesting to note that more than half\nof these cases ( 62% ) date back 20 years, and that these\ndata show that inguinal endometriosis is a pathology that\nhas been previously underestimated. It is likely that in the\nfuture it may be diagnosed preoperatively with greater\nfrequency than reported in the past, namely by Sataloff et\nal. in 1989 (in 38 % of the cases) [ 10].\nThe mean age of the patients at diagnosis is 37 years\n(range: 22 –67). The disease appears with the onset of a\nlump of ∼2–3 cm in diameter in the inguinal region,\nassociated with increased bulk and more painful symptoms\nduring the menstrual period in 50% of the cases [7, 11]. The\nright side is far more frequently involved (94% of the\ncases), while bilateral involvement is exceptional (only one\ncase described) [ 3].\nIn 37% of the patients, endometriosis of the round\nligament is associated with a groin hernia (23 inguinal\nhernias and 2 crural hernias). Though rare, malignant\ndegeneration is possible, as testified by the two cases of\nadenocarcinoma that have recently been described [13, 14].\nAmong the diagnostic tools, colour Doppler ultrasound\nis the examination of choice. The pedicular characteristics\nof the ultrasound semeiotics are the nodular aspect of the\nlesion, its hypoechoic structure, and the absence of\nvascular flow around the lesion [ 15].\nComputed tomography proved useful for ruling out most\nof the pathologies of the inguinal region, but it is often\nunable to distinguish a nest of endometriosis from a\nhaematoma [ 16]; such a distinction resulted in the present\ncase being detected on MRI, which was able to detect the\nsmall deposit of haemosiderin and methaemoglobin typical\nof endometriosis [ 17].\nSurgery is based upon radical excision of the lesion en\nbloc with the extraperitoneal portion of the round ligament.\nCare should be taken not to weaken the posterior abdominal\nwall. After surgery, a careful gynaecological assessment is\nrecommended, considering that further intraperitoneal\nlocalisations may be associated in 91% of the cases [ 1]\nand considering this localisation as an extrapelvic peri-\ntoneal endometriosis. This leads to proposing laparoscopic\nexplorative surgery during the hernia repair procedure\nfollowed by treatment with gonadotrophin-releasing hor-\nmone injection.\nConclusion\nEndometriosis of the round ligament must always be\nsuspected in the presence of an inguinal-crural lump\nassociated with pain and increased bulk during menstrual\nperiods. Explorative laparoscopy can lead to diagnosis and\nto radical surgical excision to reduce the risk of relapse.\nReferences\n1. Bergqvist A (1993) Different types of extragenital endometri-\nosis: a review. Gynecol Endocrinol 7:207 –221\n2. Cameron IC, Rogers S, Collins MC, Reed MW (1995)\nIntestinal endometriosis: presentation, investigation and surgi-\ncal management. 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Hernia 5:47 –49\n10. Sataloff DM, La V orgna KA, McFarland MM (1989) Extra-\npelvic endometriosis presenting as a hernia: clinical reports and\nreview of the literature. Surgery 105:109 –112\n11. Strasser EJ, Davis RM (1977) Extraperitoneal inguinal endo-\nmetriosis. Am Surg 43:421 –422\n12. Licheri S, Pisano G, Erda E, Ledda S, Casu B, Cherchi MV\n(2005) Endometriosis of the round ligament: description of a\nclinical case and review of the literature. Hernia 9:294 –297\n13. Boggi U, Del Chiaro M, Pietrabissa A, Mosca F (2001)\nExtrapelvic endometriosis associated with occult groin hernias.\nJ Can Chirurg 44:224\n14. Klein AE, Bauer TW, Marks KE, Belinson JL (1999) Papillary\nclear cell adenocarcinoma of the groin arising from endome-\ntriosis. Clin Orthop 361:192 –198\n15. Elemenoglu J, Skopelitou A, Nomikos I (1993) Carcinoma in\nthe inguinal region arising from endometriosis of the round\nligament. Report of a case. Eur J Gynaecol Oncol 4:28 –32\n16. Wolf C, Obrist P , Esinger C (1997) Sonographic feature of\nabdominal wall endometriosis. Am J Roentgenol 169:916 –917\n17. Gitelis S, Petasnick JP , Turner DA, Ghiselli RW, Miller AW III\n(1985) Endometriosis stimulating soft tissue tumor of the thigh.\nJ Comput Assist Tomogr 9:573 –576\n297","source_license":"CC0","license_restricted":false}