Round Ligament Research Articles

Flip the Liver for Segment 7 Resection

The hepatic segment 7 is considered the most difficult segment to treat due to its anatomical location close to the diaphragm and adjacent to the ribs making it difficult to expose and access during laparoscopic liver surgery (Figure 1). Some authors proposed a transthoracic and transdiaphragmatic approach or intercostal port placement. For a transabdominal approach to Segment 7, we herein describe the “Flip the Liver” maneuver. Four steps are mandatory for success of this trick: i) Thorough mobilization of the right hemiliver including division of the round ligament and dissection of the retroperitoneal reflection ii) followed by pulling the liver caudally towards the patients left leg grasping the falciform ligament or the gallbladder. iii) Ensure anticlockwise rotation and caudalisation of segment 7 and iv) finally check that the Pringle tape exits the abdominal wall through a port at a location permitting to pull the liver in the same caudal direction on the left side. The resulting localisation of segment 7 towards former segment 6 facilitates any liver resection in this segment. “Topographically” segment 7 becomes segment 6, “a posterior segment becomes an anterior segment “(Figure 1). Moreover, the posterior part of segment 7 becomes more accessible for the subxyphoidal port and a resection, preferably using the diamond technique, can be applied safely.

Laparoscopic Surgery for Extrahepatic Cholangiocarcinoma: Focus on Biliary Reconstruction

Background: Laparoscopic surgery of perilar cholangiocarcinoma, despite technical difficulties, constitutes a milestone in the implementation of a minimally invasive program: indeed it confers significant perioperative advantages compared to the open approach. The main limitation to its large-scale diffusion is represented by the need to perform biliary reconstruction. The purpose of this video is to provide details for a reproducible, safe and effective technique focusing on this step. Methods: After locoregional lymphadenectomy, the main biliary tract is isolated and dissected in its suprapancreatic portion(distally) and at the biliary confluence(proximally). Biliary anastomosis is performed on a defunctionalized Y- loop anchored to the round ligament. The reconstruction technique reproduces the open one: in particular, the posterior wall - performed by interrupted suture - involves the use of the parachute technique. For the anterior wall, interrupted sutures are instead affixed directly. The retrieval of the specimen is done through a small enlargement of the supraumbilical incision. Results: Preoperative staging revealed a Bismuth type I cholangiocarcinoma. The overall length of the procedure was 350 minutes. Blood losses were 100 mL. The specimen was sent for intraoperative frozen section on both the proximal and distal margin which were negative for neoplastic infiltration. Ten nodes were removed by dissection of stations 8 and 12. The postoperative hospital stay (8 days) was uneventful. Final staging at pathology was pT1, pN0, G2. Conclusion: Biliary reconstruction performed laparoscopically is technically feasible, but requires careful planning of surgical steps and great attention to teamwork. The creation of the ideal conditions, i.e. a good exposure of the surgical field and the magnification provided for intraoperative images, is an essential prerequisite for the implementation of this technique.

Rare Pelvic Fibroid - Round Ligament Fibroid.

Rare Pelvic Fibroid - Round Ligament Fibroid.

Clinical case of ultrasound diagnostics of acute inflammation of the round ligament of the liver

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.

CHALLENGES TO THE 10 GOLDEN RULES FOR A SAFE MINIMALLY INVASIVE SURGERY (MIS) INGUINAL HERNIA REPAIR: CAN WE IMPROVE?

ABSTRACT Background: Since publication of our paper “Ten Golden Rules for a Safe MIS Inguinal Hernia Repair” we have received many questions. As the authors, we feel it is important to address these topics as a follow-up to our paper. Aim: To discuss in more details the main points of controversy, review the rules and update de recommendations. Method: The questions and discussions came mainly over five rules, numbered 3, 5, 6, 7, 10. We analyzed all the comments about recommendations and update some technical principles. Results: Rule 3 - Removing normal fat plugs from the obturator canal is unnecessary and therefore is not recommended; Rule 5 - transection of the uterine round ligament (1 cm proximal to the deep ring) facilitates adequate dissection. When performed in this way it does not appear to be associated with complications; Rule 6 - transection of huge sacs are safer than over-dissection of the cord structures. Whether dissecting completely the sac or abandon the distal part it results in less postoperative seromas is an ongoing debate; Rule 7 - any retroperitoneal structure traversing the internal ring is or play a role like a hernia. Failing to identify and remove the lipoma will ultimately result in the patient experiencing a recurrence; Rule 10 - in TAPP peritoneum should preferably be closed with suture than tackes. Conclusion: 10 Golden Rules emphasize the most important surgical tips and technical steps that allow the safe performance of MIS repairs of inguinal hernias, regardless the technique.

A Case of Sigmoid Colon Cancer with Round Ligament Metastasis in the Inguinal Canal

A Case of Sigmoid Colon Cancer with Round Ligament Metastasis in the Inguinal Canal

Round ligament leak

Round ligament leak

Non-contrast Computed Tomography Volume Rendered Imaging in an Elderly Woman with Round Ligament Varicosity and Lower Extremity Varicose Veins

Non-contrast Computed Tomography Volume Rendered Imaging in an Elderly Woman with Round Ligament Varicosity and Lower Extremity Varicose Veins

A Case of Abscess of the Round Ligament of the Liver: Single-Port Laparoscopic Resection

A Case of Abscess of the Round Ligament of the Liver: Single-Port Laparoscopic Resection

A Case Report of Laparoscopic Resection of Primary Round Ligament Leiomyoma

53歳，女性．3年前から2カ月に一度，右下腹部の間欠的な疼痛を自覚したため近医産婦人科を受診．精査で卵巣腫瘍が疑われ，当院産婦人科へ紹介された．経膣超音波検査で子宮および両側付属器に明らかな病変を認めず，また腹部造影CTでは右骨盤内に小腸と接する造影効果を有する3.5cm大の類縁形腫瘤を認め，骨盤造影MRIではT1強調脂肪抑制像で内部不均一な高信号病変を認めた．PET-CTで同病変に異常集積を伴っていたため，小腸GIST疑いで当科へ紹介となった．腹腔鏡観察では腫瘤は類円形，表面平滑で可動性は良好であり，腫瘍径・腫瘍局在が画像診断と一致していたため，切除の方針とした．腫瘍周囲を剥離すると子宮円靱帯由来の腫瘍と判明し，腹腔鏡下に腫瘍摘出術を施行した．病理組織学的検査では紡錘状の平滑筋細胞が錯綜する像を認め，腫瘍細胞はα-SMA陽性，Desmin陽性，DOG-1陰性であったため，子宮円靱帯平滑筋腫の診断であった．子宮円靱帯由来の平滑筋腫は稀であり，文献的考察を含め報告する．

Colocación intraoperatoria anterógrada de stent pancreático y plastia de ligamento redondo para prevenir la fístula pancreática tras la pancreatectomía distal

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.

Mesothelial cyst in inguinal hernial sac in a male child: a case report

Mesothelial cysts of inguinal area are extremely rare and few cases have been reported in females, arising from round ligament of uterus. Inguinal hernias are a common surgical problem in children presenting as an inguinal or inguino scrotal swelling. Usually the contents of hernial sac in a male child are intestine or omentum and in females it may contain ovary. Mesothelial cyst of round ligament may present as an inguinal mass in females, but it is very rare to find in side inguinal hernial sac of a male child. Here in we report a case of 2 year 9-month-old male child, who was operated for irreducible right congenital inguinal hernia. A pedunculated cystic mass was found to be the content and was removed. Histopathology confirmed the diagnosis of mesothelial cyst. Because of rarity, we report this case.

N.I. Kuskov. - The case of the absence of the left kidney in combination with a bifid uterus. - (Collected Works. Doctors of St. Petersburg. Maryinsky Hospital. Issue II, St. Petersburg., P. 80).

In the corpse of a consumptive woman, 46 years old, in place of the left kidney was only the adrenal gland of normal structure. The right kidney is enlarged, parenchymal inflamed. Heart is small, 230 grm. vѣsom. Two uterus, as if spliced ​​by their necks over a length of 2.3 cm. Does the stigma have only one hole? for the canal of the right uterus, and resembles the stigma of the giving birth uterus. The size of the right uterus is normal, its left corner is rounded. This uterus has one round ligament, one wide and solitary appendages. The fallopian tube comes from the left corner. A thin fold of the peritoneum goes from the back surface of this uterus to the rectum, the same fold goes from the left edge to the left uterus. The left uterus is smaller in size, with a narrow cavity. She has two round ligaments and one wide ligament. There are no appendages. Densely augmented with old connective tissue to the rectum.

Способ хирургической коррекции пролапса гениталий у пациентки со сниженным уровнем экспрессии гена CACNA1C в круглых связках матки

Способ хирургической коррекции пролапса гениталий у пациентки со сниженным уровнем экспрессии гена CACNA1C в круглых связках матки

Effect of nodule size on symptoms and the choice of surgical technique in patients with bladder endometriosis

Introduction: In this study, we evaluated the relationships between symptoms of bladder endometriosis (EDT), lesion size, and the subsequent surgical technique used to excise the lesion. Methods: This is retrospective observational study of patients who underwent surgery in the Gynecological Endoscopy and Endometriosis Section at Hospital da Santa Casa of São Paulo, Brazil. A sample population of 39 women diagnosed with bladder EDT was included from 463 women presenting with deep pelvic EDT between January 2010 and March 2017. Clinical evaluations and surgical treatments for each EDT were performed. Results: Of the 39 women, 43.58% had dysmenorrhea or dyspareunia and 2.56% had hematuria. Furthermore, 21.10% presented with dysuria and endometriotic nodules on the bladder ( p < 0.04). The nodules had reached the muscle layer in 97.30% of patients, and a further 2.60% had reached the mucosal layer. In addition to bladder involvement, other pelvic regions were affected, including the left (15.8%) and right (13.2%) round ligament, left (68.4%) and right (65.8%) uterosacral ligament, retrocervical region (84.20%), and ureter (45.71%). Conclusion: The patients’ pain symptoms were found to be associated with bladder endometriosis and nodule size. Partial cystectomy with complete lesion excision might be an effective treatment option to relieve these symptoms. A study with a larger sample population is needed to confirm these findings.

Assessment of irreducible aspects in developmental hip dysplasia by magnetic resonance imaging

BackgroundThe developmental dysplasia of the hip (DDH) can cause a wide range of pathological changes, and often requires surgical treatment. Preoperative evaluation is very important for DDH. We aimed to assess the diagnostic capability of magnetic resonance imaging (MRI) for irreducible aspects preventing hip reduction in DDH.MethodsA total of 39 pediatric patients who received DDH evaluation in pediatric orthopedics from January 2015 to December 2019 were included. The samples included 4 cases of bilateral DDH and 35 cases of unilateral DDH, a total of 43 hip joint samples. All patients underwent surgical treatment, pathological examination and MRI of hip joint.ResultsWith pathological results or intraoperative findings as the gold standard, the sensitivity and specificity of MRI were 90.3% and 83.3% for the affected labrum, 92% and 83.3% for thickening of the round ligament, 90.0% and 91.3% for atrophy of the iliopsoas muscle, and 100% and 100% for fibrofatty pulvinar tissue and joint effusion, respectively.ConclutionsThe MRI showed an extraordinary capability of detecting these irreducible factors and helped surgeon choose the appropriate treatment strategies.

Comporative morphomeric characteristics of the round ligament of the uterus of two groups of fetuses

Anomalies in the development of female genital organs account for 4% of all congenital malformations. They occur in 1-3% of the female population, regardless of the preservation of fertile function, and often cause infertility.The purpose of the work is to establish the typical and variant anatomy of the round ligaments of the uterus. Compare the morphometric parameters of the round ligaments of the uterus in two distant fetal groups.Material and methods. The features of the typical and variant anatomy of the round ligaments of the uterus of the fetus were studied on 160 preparations of fetuses and newborns using a complex of morphological research methods: macroscopic, conventional and fine preparation, microscopic, vascular injection, making topographic and anatomical sections, X-ray, computed tomography, three-dimensional computer reconstruction, morphometric and statistical.Results. The round ligaments of the uterus, as well as the own ligaments of the ovaries, in the overwhelming majority of cases, are visualized in the form of dense elongated white cylinders in which it is possible to trace the blood vessels. In our opinion, these ligaments are of unequal decisive importance for establishing one or another topography of the internal female genital organs in the perinatal period. When a displacement of the uterus in the frontal plane was detected, one of the round ligaments of the uterus was shorter, in accordance with the side of its inclination.Conclusions. 1. Already at the beginning of the fetal period, the round ligaments of the uterus provide not only the corresponding inclination of the uterus in the sagittal plane but also its inclination in the frontal plane, giving a defined version of the topography of the internal female genital organs. 2. When comparing the first and second groups of fetuses, there was no significant difference in the length of the right round ligament of the uterus at each of the age stages (p>0.05). However, within the same group, we observe a period of accelerated growth in the length of the round ligaments of the uterus from the 7th month of intrauterine development.

Huge Subserosal Leiomyoma fed by serpentine omental blood vessels

Leiomyoma is considered the most common benign tumor of genital tract with variable presentation and diverse operative findings. We are presenting a case of asymptomatic huge subserosal pedunculated leiomyoma in a 37 years unmarried nullipara lady diagnosed as highly vascular abdominopelvic mass preoperatively as suggested by imaging studies but of uncertain origin, imposing surgical challenge due to diagnostic dilemma and its vascularity. Laparotomy revealed solid mass of 26 x 24 cm occupying whole abdomen covered with torturous dilated serpentine vessels derived from omentum. The mass was arising from the fundus of bulky uterus with small pedicle suggesting suserosal pedunculated leiomyoma. Myomectomy with infracolic omentectomy with round ligament plication was done and her post operative recovery was smooth. Histological examination confirmed it as leiomyoma.
 Keywords: Omentum, Pedunculated Leiomyoma, Serpentine

Accessory Caveatted Uterine Mass: A Case Report

Accessory caveatted uterine mass (ACUM) represents a new verity of mullein anomaly that is usually located at the level of insertion of round ligament and is probably related to a dysfunction of female Gebrnaculum.

Accessory Caveatted Uterine Mass: A Case Report

Accessory caveatted uterine mass (ACUM) represents a new verity of mullein anomaly that is usually located at the level of insertion of round ligament and is probably related to a dysfunction of female Gebrnaculum. ACUM is described in literature as an accessory isolated caveatted uterine mass which is lined by endometrium but with no communication to normal uterine cavity. Usually it protrudes from a normally shaped and functional uterus and mostly is located on lateral uterine wall below the insertion of round ligament. Till now this condition is not included in ESHRE Classification system and because of this it is not so commonly diagnosed, these patients are usually presented with severe dysmenorrhea and chronic pelvic pain and some report showed coincidence of ACUM and endome-triosis in 5-6%of patients which are usually less than 30 years old [1]. ACUM needs to be differentiated from other similar conditions such as 1. Rudimentary and caveatted uterine horns 2. Adeno-myosis with cystic or degenerated areas. 3. Essential and primary dysmenorrhea. 4. Degenerated fibroids. So proper diagnosis and raised awareness of ACUM can leads to earlier access to treatment.