{"paper_id":"ece4029f-935b-42c4-a506-621d68508dc7","body_text":"Review began\n 06/21/2026 \nReview ended\n 07/05/2026 \nPublished\n 07/13/2026\n© Copyright \n2026\nRiggenbach et al. This is an open access\narticle distributed under the terms of the\nCreative Commons Attribution License CC-\nBY 4.0., which permits unrestricted use,\ndistribution, and reproduction in any\nmedium, provided the original author and\nsource are credited.\nDOI:\n 10.7759/cureus.112592\nRound Ligament Endometriosis Mimicking\nChronic Postoperative Inguinal Pain Following\nRobotic Inguinal Hernia Repair: A Case Report\nand Brief Literature Review\nZac W. Riggenbach \n, \nJonathan Lutgens \n, \nBrooklyn Williams \n, \nAbigail Kelly \n, \nJason Bingham \n1.\n General Surgery, Madigan Army Medical Center, Tacoma, USA\nCorresponding author: \nZac W. Riggenbach, \nzachary.riggenbach@gmail.com\nAbstract\nChronic postoperative inguinal pain (CPIP) affects an estimated 4%-21% of patients following inguinal\nhernia repair, with rates varying by technique, follow-up duration, and pain definition, and requires a\nsystematic, multidisciplinary evaluation. Inguinal endometriosis is a rare entity, representing approximately\n0.07% of all endometriosis cases, and is an uncommonly recognized cause of inguinal pain that may mimic\nCPIP. We present the case of a 37-year-old woman who developed new left-sided groin pain following an\nelective bilateral robotic transabdominal preperitoneal inguinal hernia repair. Initial workup, including\nphysical examination and magnetic resonance imaging (MRI), was unremarkable, and conservative\nmanagement with activity modification, analgesics, and a targeted nerve block provided no sustained relief.\nAt 16 months postoperatively, the patient reported a palpable tender nodule near the left pubic symphysis\nwith symptoms that had become clearly cyclical in nature. A repeat MRI timed to coincide with her\nmenstrual cycle revealed soft tissue inflammation along the left round ligament near the pubic tubercle.\nSurgical excision of the round ligament with concurrent ilioinguinal neurectomy was performed, and\nhistopathological analysis confirmed endometriosis. The patient experienced complete resolution of her\ncyclical pain postoperatively. A brief literature review of 21 published studies on inguinal and round\nligament endometriosis was performed, which demonstrated that right-sided disease predominates, cyclical\nsymptoms are common but not universal, and misdiagnosis is frequent. This case highlights the importance\nof considering inguinal endometriosis in the differential diagnosis of CPIP in women of reproductive age,\nparticularly when symptoms are cyclical or localized outside the expected operative field. Additionally, this\ncase underscores the potential diagnostic value of timing imaging studies to coincide with symptomatic\nwindows to improve sensitivity for catamenial pathology.\nCategories:\n Obstetrics/Gynecology, General Surgery, Anatomy\nKeywords:\n chronic postoperative inguinal pain, groin pain, inguinal endometriosis, robotic hernia repair, round\nligament endometriosis\nIntroduction\nChronic postoperative inguinal pain (CPIP) represents a potentially challenging condition for both surgeons\nand patients. Recent advances in technique, including laparoscopic or robotic repairs, have been associated\nwith improved long-term pain compared with traditional open repairs \n[1]\n. Despite these improvements,\nsome cohort studies estimate CPIP between 4% and 21%, with between 2% and 4% of patients with\ndebilitating chronic pain \n[1-3]\n. When present, CPIP requires a methodical, stepwise workup with a\nmultidisciplinary team \n[4]\n.\nInguinal endometriosis, however, is a rare entity representing only 0.07% of endometriosis cases \n[5]\n. It may\nbe classified by the Niitsu classification system, with type I representing the most common presentation\nwithin a hernia sac or canal of Nuck lesion, type II lesions on the round ligament, and type III lesions in the\nsubcutaneous tissue \n[6]\n. This case highlights a rare presentation of type II inguinal endometriosis\ndeveloping after a minimally invasive inguinal hernia repair and subsequently mimicking CPIP.\nCase Presentation\nA 37-year-old otherwise healthy female with no past surgical or gynecologic history presented with a two- to\nthree-year history of intermittent right groin bulge and vague pelvic pain. Her symptoms worsened with\nphysical activity, particularly lifting, and the bulge was always reducible. She was initially evaluated by a\ngynecologist and underwent a transvaginal ultrasound due to her complaints of chronic pelvic pain.\nUnfortunately, her transvaginal ultrasound was unrevealing. A subsequent CT scan identified bilateral\ninguinal hernias, and she was referred to the general surgery clinic, where she was evaluated and scheduled\nfor operative repair.\nThe patient underwent an elective bilateral robotic-assisted laparoscopic trans-abdominal pre-peritoneal\n1\n1\n1\n1\n1\n \nOpen Access Case Report\nHow to cite this article\nRiggenbach Z W, Lutgens J, Williams B, et al. (July 13, 2026) Round Ligament Endometriosis Mimicking Chronic Postoperative Inguinal Pain\nFollowing Robotic Inguinal Hernia Repair: A Case Report and Brief Literature Review. Cureus 18(7): e112592. \nDOI 10.7759/cureus.112592\n\n(TAPP) inguinal hernia repair two months after her initial evaluation. Intraoperatively, bilateral indirect\nhernia defects were identified and both repaired. The hernia sacs were found densely adherent to the round\nligaments bilaterally. To allow for complete reduction of the hernia sacs, both round ligaments were\ntransected. Both hernia defects were repaired with a macroporous, medium weight, self-adhering 10 x 15 cm\nmesh, and the peritoneal flaps were closed. The remainder of the operation was unremarkable.\nAt her one-month postoperative visit, the patient reported new-onset left groin pain near the pubic\nsymphysis. Notably, this pain was unique from her preoperative symptoms, which had been isolated to the\nright side. On examination, there was no evidence of hernia recurrence. She was otherwise progressing well\npostoperatively, so the patient trialed conservative management, including activity modification.\nEight months postoperatively, the patient returned with persistent left-sided pain again localized to the area\naround the pubic symphysis and exacerbated by activity. Examination revealed point tenderness but no\npalpable hernia. A magnetic resonance imaging (MRI) was performed and showed no evidence of hernia\nrecurrence or other significant abnormalities, as shown in Figure \n1\n. She was advised to continue rest and\noral analgesics. Additionally, she was referred to a chronic pain specialist for targeted nerve therapy. She\nunderwent a single injection targeting the ilioinguinal nerve, which provided transient relief for only a few\nminutes.\nFIGURE\n 1: MRI from eight-month follow-up\nThis figure shows MRI results of the patient, performed approximately eight months after the initial robotic-assisted\ninguinal hernia repair. Note that there appears to be no evidence of inflammation near the round ligament insertion\nand the mons pubis, or of hernia recurrence. The patient was not currently experiencing symptoms at the time of\nthis study.\nMRI, magnetic resonance imaging.\nAt 16 months postoperatively, the patient returned to the general surgery clinic with continued pain and\nnew symptoms. She reported a palpable nodule just to the left of the pubic symphysis in the area of maximal\ndiscomfort. She also noted that her symptoms had become more clearly associated with her menstrual cycle\nover the previous few months. At the time of evaluation, she was near the onset of her menstrual period, and\nexamination revealed a distinct, tender nodule with significant pain on palpation.\nGiven the presence of a palpable, tender mass and the cyclical nature of her symptoms, a repeat MRI was\nperformed, this time scheduled to coincide with the patient’s menstrual cycle. The imaging, shown in Figure\n2\n, revealed soft tissue edema and inflammation in the area of the left inguinal canal along the round\nligament near the pubic symphysis. The lesion measured approximately 1.5 cm in diameter. There remained\nno evidence of hernia recurrence. She was started on oral contraceptive pills as a trial for hormonal\nsymptom suppression, which provided mild relief. Given the suspicion for round ligament endometriosis,\nshe was taken back to the operating room. \n \n2026 Riggenbach et al. Cureus 18(7): e112592. DOI 10.7759/cureus.112592\n2\n of \n7\n\nFIGURE\n 2: MRI from 16-month follow-up\nThis MRI was performed on the patient approximately 16 months after the original robotic-assisted hernia repair\nand coincided with her cyclic maximal pain. Note: these images clearly demonstrate inflammation near the left\npubic tubercle and the round ligament, which later correlated with endometrial implants on the round ligament.\nMRI, magnetic resonance imaging.\nA standard open herniorrhaphy incision was made approximately 2 cm cephalad and parallel to the left\ninguinal ligament. Upon dissection, the round ligament was found to be inflamed, cystic, and densely\nadherent to surrounding tissues. It was dissected to its most distal extent and resected near its insertion on\nthe pubic tubercle. An ilioinguinal neurectomy was also performed at that time. The excised round ligament\nwas sent for pathological analysis, which confirmed multiple endometrial implants. Postoperatively, the\npreviously described cyclical pelvic and pubic symphysis pain had resolved, and she remains pain free. She\nnoticed some groin numbness related to her ilioinguinal neurectomy, but this did not cause her any\nsignificant distress and improved postoperatively.\nDiscussion\nLiterature review\nA brief literature review was performed by searching the PubMed database for medical subject headings\n(MeSH) terms (\"round ligament\" OR \"inguinal\" OR “canal of Nuck”) AND \"endometriosis\" AND (\"hernia\" OR\n\"herniorrhaphy\" OR \"TAPP\" OR \"TEP\" OR \"robotic\" OR \"laparoscopic\"). Case reports, comparative studies,\nevidence synthesis, meta-analysis, observational studies, review, scoping review, and systematic reviews\nwithin the last 20 years were included. A total of 35 articles were identified. Non-English language, non-\ninguinal location, and pediatric data were then excluded. This resulted in 21 articles for inclusion, as\ndetailed in Table \n1\n below \n[7-27]\n.\n \n2026 Riggenbach et al. Cureus 18(7): e112592. DOI 10.7759/cureus.112592\n3\n of \n7\n\nAuthor\nYear\nN\nSide\nPresentation\nImaging\nTreatment\nFedele et al. \n[7]\n2007\n5\nM\nRecurrent\nUS+MRI\nRL excision\nDucarme et al. \n[8]\n2007\n1\nR\nPost-repair\nUS+MRI\nExcision + herniorrhaphy\nHagiwara et al. \n[9]\n2007\n1\nR\nCyclic\nCT+MRI\nExcision + RL resection\nMashfiqul et al. \n[10]\n2007\n1\nR\nNon-cyclic\nUS\nWide excision + mesh\nKamio et al. \n[11]\n2009\n1\nR\nCyclic\nUS+MRI\nExcision\nApostolidis et al. \n[12]\n2009\n3\nR\nCyclic\nUS\nExcision\nWang et al. \n[13]\n2009\n1\nL\nCyclic\nUS+CT\nExcision + laparoscopy\nKiyak et al. \n[14]\n2010\n1\nR\nCyclic\nPath\nHernia repair + excision\nJiménez et al. \n[15]\n2011\n1\nR\nCyclic\nCT+MRI\nLaparoscopic excision\nPrabhu et al. \n[16]\n2013\n1\nL\nPain/mass\nUS\nExcision\nHusain et al. \n[17]\n2015\n1\nR\nMass\nMRI\nExcision\nFong et al. \n[18]\n2019\n1\nR\nMass\nNone\nExcision\nAzhar et al. \n[19]\n2019\n1\nR\nAcute\nCT+MRI\nHernia repair + excision\nAlSinan et al. \n[20]\n2021\n1\nL\nCyclic\nUS+CT\nExcision + mesh\nChen et al. \n[21]\n2021\n1\nR\nNodule\nUS+CT\nExcision + herniorrhaphy\nChou et al. \n[22]\n2023\n2\nM\nPain/mass\nUS+MRI\nExcision ± hormones\nRokhgireh et al. \n[23]\n2024\n1\nR\nPain\nMRI\nLaparoscopic excision\nHaghgoo et al. \n[24]\n2024\n8\nM\nSwelling\nUS±MRI\nSurgery ± hormones\nLipschultz et al. \n[25]\n2025\n1\nNR\nPain\nMRI\nLaparoscopic excision\nTakatsuka et al. \n[26]\n2025\n6\nM\nPain/mass\nMulti\nSurgical excision\nAndré et al. \n[27]\n2026\n1\nB\nPain\nMRI\nLaparoscopic RL excision\nPresent case\n2026\n1\nL\nCPIP\nMRI×2\nOpen RL excision + IIN\nTABLE\n 1: Clinical characteristics, imaging findings, and management of published cases of\ninguinal and round ligament endometriosis\nB, bilateral; CPIP, chronic postoperative inguinal pain; CT, computed tomography; IIN, ilioinguinal neurectomy; L, left; M, mixed laterality; MRI, magnetic\nresonance imaging; Multi, multiple imaging modalities; NR, not reported; Path, diagnosis established by pathology; R, right; RL, round ligament; US,\nultrasonography.\nClinical presentation was reported in most studies and was characterized predominantly by groin pain and a\npalpable inguinal mass. Pain was reported in 18 of 21 (85.7%) studies, while a palpable mass, swelling,\nnodule, or groin lesion was described in 16 (76.2%) studies. Cyclic or catamenial symptoms were reported in\n12 (57.1%) studies, although several reports documented non-cyclic or atypical presentations \n[23,24]\n.\nRight-sided disease predominated throughout the literature. Right-sided involvement was reported in 13\n(61.9%) studies, whereas left-sided disease was reported in 4 (19.0%) studies. Bilateral involvement was\nuncommon and described only by André et al. \n[27]\n. Several case series similarly emphasized a strong right-\nsided predominance, consistent with the historically reported distribution of inguinal endometriosis. The\npredominance of right-sided disease appears to be one of the most consistent findings across the surveyed\nliterature. However, anatomic involvement varied among reports. Round ligament involvement was\nspecifically described in 11 of 21 (52.4%) studies of the included studies \n[9,12,16,23,24]\n. Additional sites of\ninvolvement included the canal of Nuck, abdominal wall scar tissue, subcutaneous soft tissues, and other\nstructures within the inguinal canal \n[8,13,15]\n. These findings appear generally consistent with the previously\ndescribed Niitsu classification system \n[6]\n. \nMisdiagnosis or delayed diagnosis appears common, with hernias, lymphadenopathy, or hydroceles\n \n2026 Riggenbach et al. Cureus 18(7): e112592. DOI 10.7759/cureus.112592\n4\n of \n7\n\nrepresenting commonly confused pathologies \n[20,24]\n. Ultrasonography was the most commonly reported\nimaging modality and was used in 15 of 21 (71.4%) studies, while MRI was used in 14 of 21 (66.7%) studies,\noften as an adjunctive modality to further characterize lesions identified on physical examination or\nultrasonography. Computed tomography was reported in 7 of 21 (33.3%) studies. Despite advances in\nimaging, histopathologic examination following surgical excision remained the definitive diagnostic\nmethod.\nPrior abdominal or pelvic surgery was commonly reported, particularly cesarean delivery and prior\ngynecologic procedures \n[8,17,19]\n. Several studies additionally documented concurrent pelvic endometriosis,\ninfertility, dysmenorrhea, or ovarian endometrioma, suggesting substantial overlap between inguinal\ndisease and more typical manifestations of endometriosis \n[7,24]\n. Nevertheless, isolated inguinal disease\nwithout known pelvic involvement was also reported in multiple cases \n[10,16,20]\n.\nManagement was overwhelmingly surgical. Surgical treatment was reported in all 21 studies providing\ntreatment information (100%), most commonly consisting of complete excision of the lesion with resection\nof the involved round ligament, hernia sac, or adjacent soft tissue. Reported outcomes were generally\nfavorable, with most studies describing symptom resolution and low rates of recurrence following surgical\nmanagement.\nCase analysis\nThis case presentation represents a previously undescribed type II inguinal endometriosis following a\nminimally invasive inguinal hernia repair produced CPIP. Several unique components of this presentation\nwarrant discussion. First, this case represents a relatively rare left-sided presentation of inguinal\nendometriosis. Interestingly, the patient initially noted right-sided pain before her hernia repair. Her left-\nsided symptoms, however, were new following her robotic inguinal hernia repair. The relative rarity of left-\nsided inguinal endometriosis combined with the temporal relationship to her TAPP repair raises the\npossibility of direct endometrial implant seeding during her operation as a possible pathogenesis. While this\nis a single case and cannot be construed as causality, surgeons may consider a patient’s previous\ngynecologic history carefully when evaluating chronic inguinal or CPIP-type symptoms. \nThis case also highlights both the difficulty in diagnosing inguinal endometriosis and the need for a rigorous\nworkup during CPIP evaluation. While cyclical symptoms were reported frequently in the literature, this case\nhighlights that imaging findings diagnostic of inguinal endometriosis may also be catamenial. In this case,\nthe patient reported specific symptoms, which were consistent with inguinal endometriosis, and the surgical\nteam held a high clinical suspicion. However, the initial imaging, which was not timed with her symptoms,\ndid not provide any diagnostic utility. This case highlights the importance of timing imaging studies with\nsymptomatic windows to maximize diagnostic value. \nFinally, this case highlights the importance of providing a thorough evaluation for patients with CPIP, as\nsome causes may be reversible. Key clinical insights that this patient’s presentation did not fit typical CPIP\nincluded cyclical pain, point tenderness to palpation outside of the expected operative field, and failure of\ntraditional pain management techniques. A generic algorithmic approach to treating these patients without\na thorough history and examination may have led to unnecessary morbidity for this patient. The evaluation\nof CPIP requires a thorough history and examination not only to rule out hernia recurrence but also to\nevaluate for causes of potentially reversible symptoms, as demonstrated in this case. A multidisciplinary\napproach offers an opportunity for thoughtful and tailored evaluations and may benefit from earlier\ngynecologist involvement in cases of atypical CPIP in female patients.\nConclusions\nRound ligament endometriosis is a rare but important cause of groin pain that may mimic CPIP in women of\nreproductive age. This case demonstrates that cyclical symptoms, atypical pain location, and failure of\nconventional CPIP therapies should prompt consideration of alternative diagnoses. Key features that\nsuggested the diagnosis were point tenderness and cyclic symptom presentations. Timing imaging studies to\ncoincide with symptomatic periods may improve diagnostic yield for catamenial pathology. Surgical excision\nremains an effective treatment and can result in complete symptom resolution. \nAdditional Information\nAuthor Contributions\nAll authors have reviewed the final version to be published and agreed to be accountable for all aspects of the\nwork.\nConcept and design:\n  \nZac W. Riggenbach, Jonathan Lutgens, Brooklyn Williams, Abigail Kelly, Jason\nBingham\nAcquisition, analysis, or interpretation of data:\n  \nZac W. Riggenbach\n \n2026 Riggenbach et al. Cureus 18(7): e112592. DOI 10.7759/cureus.112592\n5\n of \n7\n\nDrafting of the manuscript:\n  \nZac W. Riggenbach\nCritical review of the manuscript for important intellectual content:\n  \nZac W. Riggenbach, Jonathan\nLutgens, Brooklyn Williams, Abigail Kelly, Jason Bingham\nSupervision:\n  \nJason Bingham\nDisclosures\nHuman subjects:\n Informed consent for treatment and open access publication was obtained or waived by all\nparticipants in this study. \nConflicts of interest:\n In compliance with the ICMJE uniform disclosure form, all\nauthors declare the following: \nPayment/services info:\n All authors have declared that no financial support\nwas received from any organization for the submitted work. \nFinancial relationships:\n All authors have\ndeclared that they have no financial relationships at present or within the previous three years with any\norganizations that might have an interest in the submitted work. \nOther relationships:\n The views expressed\nin this manuscript are those of the authors and do not necessarily reflect the official policy or position of the\nDepartment of the Army, Department of War, or the U.S. Government.\nAcknowledgements\nDuring the preparation of this work, the authors used ChatGPT (OpenAI, San Francisco, CA) and\nOpenEvidence to assist with text editing for readability and grammar, as well as synthesizing findings from\nthe literature review. 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