Laparoscopic Treatment of Bilateral Inguinal Round Ligament Endometriosis

OBJECTIVE: To demonstrate the laparoscopic management of bilateral round ligament endometriosis. SETTING: A tertiary referral center specializing in minimally invasive gynecologic surgery. PARTICIPANTS: An obese woman who had previously undergone a hysterectomy with ovarian preservation and excision of uterosacral endometriosis nodules 2 years prior. She later developed recurrent daily pelvic pain. MRI revealed two nodules suggestive of endometriosis: a 6 cm-long lesion extending through the right deep inguinal ring, and a 3 cm-long lesion located 15 mm from the left deep ring both measuring 18 mm in diameter. Her pre-hysterectomy imaging had shown no involvement of the round ligaments. INTERVENTIONS: Because the nodules were nonpalpable, ultrasound-guided percutaneous barbed metal wires were placed preoperatively to ensure accurate identification if visualization during laparoscopy proved difficult or if conversion to an open approach was required. One wire was inserted directly into the right lesion and another 3 mm from the left. Laparoscopic resection began with a peritoneal incision overlying the endometriotic nodule, followed by careful dissection of the lesion along the inguinal canal. Affected segments of the round ligament were excised bilaterally. Both procedures were completed without complication, and the patient was relieved from pain. Histopathological examination confirmed bilateral endometriotic nodules with fibrotic remodeling. CONCLUSION: Inguinal round ligament endometriosis is atypical (1-3). In the review by Dalkalitsis et al. (4), 94% of reported cases presented as a painful inguinal mass, whereas only 1 case presented with lower abdominal pain, as in our patient. Most were managed by a direct extraperitoneal approach with only one case (0.75%) treated laparoscopically (5). This case demonstrates that a laparoscopic approach is a feasible and effective alternative, permitting precise excision while limiting peritoneal dissection and avoiding inguinal canal widening, thereby minimizing the risk of hernia formation particularly in obese patients. VIDEO ABSTRACT.