Endometriosis of the round ligament simulating hernia

Abstract

Endometriosis in its protean manifestations gives rise to a confusing clinical picture at times, and it is the purpose of this paper to record an instance of rather unusual site of endometrial tissue.Endometrial tumors of “implants” as Sampson calls them have rather wide-spread distribution within the peritoneal cavity, commonly involving the ovary, the peritoneum, the rectovaginal septum, etc. Less frequently they occur in the umbilicus, in the round ligaments and in laparotomy scars. The method of extension of the process to the round ligament and inguinal region is as much in dispute as the etiology of endometriosis in general. The lesion of the round ligament may consist of a more or less solid tumor, an adenomyoma, or may be in the nature of a hemorrhagic cyst. The frequent association of hernia and inguinal endometriosis has been a matter of comment with several writers. Errors in the differential diagnosis between hernia and inguinal endometriosis are not infrequent. Cullen who described the first case of inguinal endometriosis in 1896 thought his patient had a hernia; likewise Sampson, Schmitz, Christopher, Neel and others made similar errors.Involvement of the intraperitoneal portion of the round ligaments gives rise to no important symptoms; involvement of the extraperitoneal portion does. With endometriosis of the round ligament usually a tumor of the inguinal region occurs; this may be either cystic or solid; it may or may not be painful; it will disappear when the patient lies down, if it is the cystic type, and there may be an impulse on coughing; the solid type of lesion as a rule is not reducible.From this brief description it becomes apparent how inguinal endometriosis may readily be mistaken for a hernia.