Round Ligament Research Articles

VS 08 - HPB Laparoscopic cholecystectomy for left-sided gallbladder – How not to do it?

Abstract Background Left-sided gallbladder (LSG) is a rare congenital anomaly in the gallbladder, which is defined as a gallbladder located on the left side of the falciform ligament and round ligament without situs inversus. (1) The reported prevalence of sinistroposition ranges from 0.2% to 1.1%. (2) There are three recognized variants of LSG: LSG associated with situs viscerum inversus, true LSG, and gallbladder located to the left of abnormally located right-sided round ligament/ ligamentum teres. Method We present a case of a gentleman who was diagnosed as having gall bladder sinistroposition intraoperatively, after all the laparoscopic ports had been placed as per a routine laparoscopic cholecystectomy. Although the gentleman had undergone preoperative MRCP, it was not reported by the radiologists as such. The surgery was carried out using the usual ports used for standard four-port laparoscopic cholecystectomy and demonstrates the difficulty faced by the surgeon with these ports. Results Critical view of safety was demonstrated. Gall bladder was removed in piece meal. Surgery lasted for more than 90 minutes. There were no post-operative complications. Suggested modifications include Right working port from the Palmers point(3) or using a robotic approach with the same standard configuration(4). Our reflection revealed – interchanging of 5 mm and 12 mm working ports could have been helpful for better access. Conclusion The presence of a left sided gall bladder is often associated with various biliary, portal venous and other anomalies that might lead to intra-operative injuries. (5) The diagnosis is usually incidental and is done intraoperatively. Hence surgeons must be aware of these possibilities.

A Round Ligament Mesothelial Cyst Imitating an Inguinal Hernia in a Woman of Reproductive Age

Objective. A wide range of lesions, including a mesothelial cyst of the uterine round ligament, are included in the differential diagnosis of a groin mass. Our study emphasizes the rarity of this ailment and the significance of correct preoperative diagnosis in guiding our treatment approach. Case Report. A 43-year-old female patient, presented to our hospital with a five-year his- tory of swelling and slight discomfort in the right groin. A nonreducible inguinal mass with greater projection during a Val- salva maneuver was found. An abdominal CT scan revealed a well-defined lesion located near the right horn of the uterus and extending through the inguinal canal. The patient was brought to the operating room with the clinical suspicion of an inguinal hernia. A soft mass measuring 4.5×2×1.8cm was discovered in the right round ligament, and it was surgically removed. Histo- pathological examination confirmed a mesothelial cystic lesion. The patient’s condition, after a period of 12 months, continues to be satisfactory. Conclusion. Few cases of uterine round ligament mesothelial cysts have been reported worldwide. Their cause is unknown, and preoperative diagnosis is unreliable. Resection relieves symptoms, and histological examination of the surgical specimen confirms the diagnosis. Additional clinical cases are needed to create a systematic clinical approach.

Laparoscopic Non-Mesh Cerclage Pectopexy with Uterine Preservation for Pelvic Organ Prolapse.

Pelvic organ prolapse (POP) affects millions of women globally and carries a significant socioeconomic burden. Adequate apical support is essential for treating POP. Recent research has increasingly validated the efficacy and safety of laparoscopic pectopexy (LP) for addressing apical POP. However, the cost of synthetic mesh and associated complications restrict the widespread use of this technique. Our team previously published a study describing a novel, non-mesh procedure called laparoscopic non-mesh cerclage pectopexy (LNMCP), demonstrating successful outcomes with satisfactory objective and subjective success rates. Many patients express a preference for retaining their uterus during prolapse surgery due to considerations related to sexuality, partnership, and body image. The present research introduces a novel approach known as laparoscopic non-mesh cerclage pectopexy with uterine preservation (LNMCPUP) for POP, wherein the uterus is suspended to the iliopectineal ligament through the round ligament using permanent cerclage sutures. We successfully performed this procedure in 14 cases at our hospital, six of whom still had menstruation, and the remaining eight were postmenopausal, with a mean operation time of 54.43 min (± 10.18 min) and an average bleeding volume of 53.57 mL (± 48.77 mL). The mean follow-up duration was 19.71 ± 15.87 months. The objective success rate of LNMCPUP was 100%, with a subjective success rate of 92.86%. No significant complications were observed during or after surgery. LNMCPUP integrates cervical cerclage and shortening of the round ligament, as well as LP without using mesh, thereby eliminating the risk of mesh erosion and lowering healthcare costs. Moreover, this novel technique is relatively easy to master, making it accessible even in rural and underdeveloped areas where synthetic mesh is unavailable. Therefore, it is worthwhile to adopt LNMCPUP in POP patients who desire the preservation of their uterus.

Morphological and Morphometric Parameters of the Liver of Newborn Male Rabbits Alexander

Introduction. At present, the study of age-related issues of the liver structure in animals is one of the most important objectives of morphology, since liver diseases occupy one of the leading places among the nosologies causing death of newborn animals, in particular rabbits. At the same time, although the data on the micromorphological structure of the digestive tract of rabbits is extensive, the data on the age-related anatomy of the liver in the animals under study is scarce in the available literature. The aim of the paper is to determine the morphofunctional features of the liver of newborn male rabbits.Materials and Methods. The objects of the study were newborn male rabbits of the “butterfly” breed (n=9), who had no deviations in development and constitution. To establish the anatomical and topographic features and morphometric parameters of the liver of the animals under study, the standard anatomical dissection, Pirogov's cuts, macromorphometric and statistical research methods were used.Results. It has been established that the liver of newborn male rabbits of “butterfly” breed has segmental nature, the caudate process is large, distinct from the other lobes. The papillary process is oval in shape, poorly developed, adjacent to the lesser curvature of the stomach. The quadrate and right lobes of the liver are well developed, and the left lobes are less developed, which entails the horizontal position of the organ. The ligamentous attachments of the liver are well developed. A round ligament of liver (ligamentum teres hepatis) with fetal hepatic vessels can be distinguished. The linear and weight parameters of the liver are characterised by the small absolute and large relative values. The liver index is inversely proportional to the body weight of an animal and is 5.91.Discussion and Conclusion. The obtained morphological and morphometric data is aimed at establishing the standard liver parameters of the clinically healthy newborn male rabbits of the “butterfly” breed. The liver boundaries have been defined taking into account the length, width, thickness parameters of each lobe separately. The organ topography has been defined including the skeletotopy, holotopy and syntopy of the individual lobes and processes of the liver.

6694 A Case of an Extraneous Organ: A Uterus Found in a Genotypic and Phenotypic Male

Abstract Disclosure: R.A. Zielinski: None. S. Shteyman: None. A.G. Samat: None. Background: Persistent Mullerian Duct Syndrome (PMDS) is a rare entity that occurs when a phenotypic male is found to have female reproductive organs. In our case we describe an XY male who was found to have an abdominal mass consistent with a uterus on pathology. Clinical Case: Our patient is a 58-year-old male with hypertension, obesity, and obstructive sleep apnea who presented to the ED with 3 weeks of left upper quadrant pain. Abdominal CT showed two homogeneous enhancing oval lesions in the pelvis superior to the urinary bladder; 8.3 x 4.6 cm on the right and 3.6 x 3 cm on the left. Exploratory laparotomy was performed, and intraoperatively the mass was firm with a left satellite lesion and two fibrous bands that appeared similar in structure to round ligaments. Microscopically the tissue contained mullerian-type epithelium and smooth muscle with cystic degeneration. It was CK7 positive, estrogen receptor variable positive, and CK20 negative. Genetic testing confirmed the patient’s karyotype to be XY without genetic mosaicism. Our patient had two children spontaneously, regular spontaneous erections, and occasional hot flashes. Physical exam revealed an obese male (BMI 51) with bilateral gynecomastia and normal testicular size. He had no history of intra-abdominal or undescended testes requiring surgery. Labs showed increased total estrogen (283.7 pg/mL, n 60-190 pg/mL) and estradiol (39 pg/mL, n <= 29 pg/mL), decreased total testosterone (86 ng/dL, n 250-1,100 ng/dL), and normal free testosterone when corrected for SHBG (140 ng/dL, n 110-574 ng/dL). Testicular ultrasound was unrevealing. 3 years postoperatively his estradiol level normalized (34 pg/mL) and his total testosterone improved from 86 ng/dL to 223 ng/dL after losing 40 pounds on semaglutide. Discussion and Conclusion: Although the exact incidence of PMDS is unknown, it is a rare phenomenon. Only 200 cases between 1964 and 2000 and 34 cases between 2013 and 2017 have been reported. Mullerian ducts are embryologic structures present in both XY and XX fetuses until week 8 of life, when XY fetuses produce anti-mullerian hormone (AMH). In PMDS, the XY fetus either fails to produce AMH, or there is a defect in the AMH receptors, leading to the persistence of mullerian ducts. These ducts can then differentiate into a uterus, fallopian tubes, and/or the upper vagina. Our patient is a genotypical and phenotypical male with a uterus-like organ. The mild elevation in his estrogen level is likely secondary to his obesity. The estrogen could have increased the size of the uterus, causing the patient’s initial symptoms of abdominal pain which prompted his presentation to the hospital.

Solitary Round Ligament Metastasis in High-Grade Serous Carcinoma Ovary

Solitary Round Ligament Metastasis in High-Grade Serous Carcinoma Ovary

Instrumentless liver suspension for liver retraction in robotic pancreatoduodenectomy.

The popularity of robotic pancreatoduodenectomy (RPD) is increasing, yet it remains a complex procedure. Outcomes are influenced by various factors, including patient-specific variables, disease characteristics, and surgical technique. Numerous and intricate details contribute to the technical success of RPD. In this study, our focus is on achieving effective and "gentle" liver retraction. The use of liver retractors has been associated with the risk of retractor-related liver injury (RRLI), which can have serious consequences. Here, we introduce a refined technique for instrumentless liver retraction in RPD, developed progressively through a series of over 300 procedures. The core concept of this technique involves suspending the liver to the diaphragmatic dome. This is accomplished by securing the round ligament to the anterior abdominal wall using transparietal sutures and attaching the fundus of the gallbladder and the anterior margin of liver segment number 3 to the diaphragm. Our consecutive series of over 300 RPDs demonstrates the feasibility and safety of this approach, with no clinically relevant RRLI observed. Instrumentless liver retraction offers a valuable refinement in RPD, streamlining the procedure while reducing potential complications associated with dedicated retractors.

Left Hemi-Hepatectomy to Resect Metastatic Tumor of Round Ligament of Liver in Patients with Ovarian Cancer.

The objective of this study is to investigate the surgical, clinical and pathological outcomes of left hemi-hepatectomy during cytoreductive surgery (CRS) in patients with primary ovarian cancer. The electronic medical charts of patients with primary ovarian cancer who received CRS including left hemi-hepatectomy from 2000 to 2023 were reviewed and retrospectively analyzed. A total of 17 patients underwent left hemi-hepatectomy for resection of a deep peritoneal implant in the round ligament of the liver during primary CRS. Among these 17 patients, hepatic parenchymal invasion was confirmed in 10 patients (58.8%). Tumor distribution of others is as follows: Glisson's capsule, hilum, falciform ligament and gall bladder. Fourteen patients (82.4%) achieved CRS; the remaining three patients had residual tumors less than 1 cm. The median period to subsequent chemotherapy was 21 days (range, 12-35 days). No specific complications related to left hepatectomy were identified such as liver failure or bile leakage. Left hemi-hepatectomy for complete surgical resection of a deep peritoneal implant of the round ligament of the liver is surgically feasible and safe.

The Genitofemoral Nerve Is the Structure Closest to the Tendon Footprint and Is Most at Risk for Iatrogenic Injury During Proximal Adductor Longus Repair: A Cadaveric Anatomy Study

To identify structures at risk during proximal adductor longus repair and to report observed distances between these structures and the adductor longus (AL) footprint. Eight hemipelves from fresh cadaver whole-body specimens were dissected using a previously established surgical approach. The tendinous attachment of the AL was scored into the underlying bone and the footprint size was measured in millimeters. A guidewire was placed at the footprint center along the longitudinal axis of the resected AL muscle. Utilizing a digital caliper, the proximity of key anatomic structures was measured as the radial distance from the guidewire and distance distal to the footprint along the guidewire axis. The AL footprint was on average 16.95 ± 3.02 mm wide by 9.36 ± 1.66 mm high. The ilioinguinal nerve was 27.10 ± 7.25 mm distal to the AL footprint and 31.75 ± 7.51 mm medial, with a resulting mean surface area of 158.12 ± 39.90 (110.9-230.2). mm2 The genital branch of the genitofemoral nerve was found 7.79 ± 4.05 mm proximal and 15.37 ± 4.54 mm medial. The round ligament (n= 6) was 14.00 ± 2.75 mm and the spermatic cord (n= 2) was 13.57 ± 3.02 mm directly superficial to the AL footprint. The obturator nerve was 63.98 ± 4.57 mm distal as it crossed the adductor brevis muscle laterally. The location of the external pudendal artery was variable but was found to have a mean distance of 37.01 ± 17.97 mm distal and immediately deep to the AL. When repairing AL tendon injuries, the genitofemoral nerve is the structure anatomically nearest the footprint of the tendon, and this structure is most at risk for iatrogenic injury. This study investigates the structures at risk during AL repair and seeks to define their location relative to the footprint. These findings will assist surgeons in identifying the crucial anatomic structures at risk to safely perform an anatomic repair of the tendon and avoid iatrogenic complications.

Fertility-sparing uterine displacement for pelvic malignancies: surgical options and radiotherapy dosimetry on a human cadaver

BackgroundRadio(chemo)therapy is often required in pelvic malignancies (cancer of the anus, rectum, cervix). Direct irradiation adversely affects ovarian and endometrial function, compromising the fertility of women. While ovarian transposition is an established method to move the ovaries away from the radiation field, surgical procedures to displace the uterus are investigational. This study demonstrates the surgical options for uterine displacement in relation to the radiation dose received. MethodsThe uterine displacement techniques were carried out sequentially in a human female cadaver to demonstrate each procedure step by step and assess the uterine positions with dosimetric CT scans in a hybrid operating room. Two treatment plans (anal and rectal cancer) were simulated on each of the four dosimetric scans (1. anatomical position, 2. uterine suspension of the round ligaments to the abdominal wall 3. ventrofixation of the uterine fundus at the umbilical level, 4. uterine transposition). Treatments were planned on Eclipse® System (Varian Medical Systems®,USA) using Volumetric Modulated Arc Therapy. Data about maximum (Dmax) and mean (Dmean) radiation dose received and the volume receiving 14 Gy (V14Gy) were collected.ResultsAll procedures were completed without technical complications. In the rectal cancer simulation with delivery of 50 Gy to the tumor, Dmax, Dmean and V14Gy to the uterus were respectively 52,8 Gy, 34,3 Gy and 30,5cc (1), 31,8 Gy, 20,2 Gy and 22.0cc (2), 24,4 Gy, 6,8 Gy and 5,5cc (3), 1,8 Gy, 0,6 Gy and 0,0cc (4). For anal cancer, delivering 64 Gy to the tumor respectively 46,7 Gy, 34,8 Gy and 31,3cc (1), 34,3 Gy, 20,0 Gy and 21,5cc (2), 21,8 Gy, 5,9 Gy and 2,6cc (3), 1,4 Gy, 0,7 Gy and 0,0cc (4).ConclusionsThe feasibility of several uterine displacement procedures was safely demonstrated. Increasing distance to the radiation field requires more complex surgical interventions to minimize radiation exposure. Surgical strategy needs to be tailored to the multidisciplinary treatment plan, and uterine transposition is the most technically complex with the least dose received.

CYSTIC INGUINAL LYNFHANGIOMA IN ADULT FEMALE

Abstract Background To present a clinical case of cystic inguinal lymphangioma in an adult female, an atypical site and age of presentation. Method A 42-year-old woman was referred for consultation due to persistent pain and swelling in the right inguinal region, with initial suspicion of inguinal hernia. A mobile, irreducible mass without protrusion during the Valsalva maneuver was identified. Faced with diagnostic uncertainty, inguinal ultrasound and magnetic resonance imaging were requested, revealing a cystic lesion indicative of cystic inguinal lymphangioma. Results Elective surgery was decided. A right inguinal incision revealed a cystic tumor extending along the inguinal canal from the labium majus to the preperitoneal space. Complete excision was performed, requiring section of the round ligament. Subsequently, closure of the deep inguinal ring was conducted, with the conjoint tendon approximated to the inguinal ligament using a continuous suture of slowly absorbable monofilament. Hernioplasty with self-adhesive polypropylene mesh was employed to repair the inguinal defect. The procedure was carried out in the ambulatory major surgery program. At the one-month post-surgery follow-up, the patient exhibited satisfactory recovery with no signs of clinical recurrence. Histopathological examination of the surgical specimen confirmed the diagnosis of cystic inguinal lymphangioma, with no additional pathological findings. Conclusion Cystic lymphangioma is a benign and uncommon malformation of the lymphatic system. It should be considered in cases of inguinal masses with progressive growth whose examination is not consistent with an inguinal hernia. Ultrasound is the imaging test of choice, with definitive diagnosis confirmed by histopathology. Surgery with complete resection is recommended due to the risk of recurrence.

Ligamentum teres hepatis incarcerated within linea alba hernia: A case report

Abstract Incarcerated linea alba hernia is a rare form of ventral hernia. Most of these contain pre-peritoneal fat or the omentum. Herniation of containing ligamentum teres hepatis is seldom seen. A 52-year-old man presented with an abdominal wall mass and dull pain for 2 weeks. Computed tomography and ultrasound examination of the abdomen revealed an epigastrium linea alba hernia containing the liver round ligament. A hernial sac of size 3 cm × 4 cm was explored by laparoscopic surgery and successfully managed with hernia repair.

Mid-term outcomes of laparoscopic vaginal stump?round (Kakinuma method) and stump?uterosacral (Shull method) ligament fixation for pelvic organ prolapse: A retrospective comparative study

BackgroundLaparoscopic sacrocolpopexy (LSC) and robot-assisted sacrocolpopexy (RSC) using mesh are popular approaches for treating pelvic organ prolapse (POP). However, it is not uncommon that native tissue repair (NTR) should be presented as an option to patients who are expected to have extensive intraperitoneal adhesion or patients for whom LSC or RSC is difficult owing to various risk factors. Laparoscopic vaginal stump–uterosacral ligament fixation (Shull method) has been introduced as a method for NTR in case of POP. However, effective repair using this surgical procedure may not be possible in severe POPs. To solve the problems of the Shull method, we devised the laparoscopic vaginal stump–round ligament fixation (Kakinuma method) in which the vaginal stump is fixed to the uterine round ligament, a histologically strong tissue positioned anatomically higher than the uterosacral ligament. This study aimed to retrospectively and clinically compare the two methods.MethodsOf the 78 patients who underwent surgery for POP between January 2017 and June 2022 and postoperative follow-up for at least a year, 40 patients who underwent the Shull method (Shull group) and 38 who underwent the Kakinuma method (Kakinuma group) were retrospectively analyzed.ResultsNo significant differences were observed between the two groups in patient background variables such as mean age, parity, body mass index, and POP-Q stage. The mean operative duration and mean blood loss in the Shull group were 140.5 ± 31.7 min and 91.3 ± 96.3 ml, respectively, whereas the respective values in the Kakinuma group were 112.2 ± 25.3 min and 31.4 ± 47.7 ml, respectively. Thus, compared with the Shull group, the operative duration was significantly shorter (P < 0.001) and blood loss was significantly less (P = 0.003) in the Kakinuma group. Recurrence was observed in six patients (15.0%) in the Shull group and two patients (5.3%) in the Kakinuma group. Hence, compared with the Shull group, recurrence was significantly less in the Kakinuma group (P = 0.015). No patients experienced perioperative complications in either group.ConclusionsThe results suggest that the Kakinuma method can serve as a novel and viable NTR procedure for POP.

Retromesenteric omental flap as arterial coverage in pancreaticoduodenectomy: A novel technique to prevent postpancreatectomy hemorrhage

BackgroundClinically relevant postpancreatectomy hemorrhage occurs in 10% to 15% of patients after pancreaticoduodenectomy, mainly in association with clinically relevant postoperative pancreatic fistula. Prevention of postpancreatectomy hemorrhage by arterial coverage with a round ligament plasty or an omental flap is controversial. This study assessed the impact of arterial coverage with an original retromesenteric omental flap on postpancreatectomy hemorrhage after pancreaticoduodenectomy. MethodsThis single-center retrospective study included 812 open pancreaticoduodenectomies (2012–2021) and compared 146 procedures with arterial coverage using retromesenteric omental flap to 666 pancreaticoduodenectomies without arterial coverage. The Fistula Risk Score was calculated. The primary endpoint was a 90-day clinically relevant postpancreatectomy hemorrhage rate according to the International Study Group of Pancreatic Surgery classification. ResultsThere were more patients with a Fistula Risk Score ≥7 in the arterial coverage-retromesenteric omental flap group: 18 (12%) versus 48 (7%) (P < .01). Clinically relevant postpancreatectomy hemorrhage was less frequent in the arterial coverage- retromesenteric omental flap group than in the no arterial coverage group: 5 (3%) versus 66 (10%), respectively (P = .01). Clinically relevant postoperative pancreatic fistula occurred in 28 (19%) patients in the arterial coverage- retromesenteric omental flap group compared with 165 (25%) in the no arterial coverage group (P = .001). There were fewer reoperations for postpancreatectomy hemorrhage or postoperative pancreatic fistula in the arterial coverage- retromesenteric omental flap group: 1 (0.7%) versus 32 (5%) in the no arterial coverage group (P = .023). In multivariate analysis, arterial coverage with retromesenteric omental flap was an independent protective factor of clinically relevant postpancreatectomy hemorrhage (odds ratio 0.33; 95% confidence interval [0.12–0.92], P = .034) whereas postoperative pancreatic fistula of any grade (odds ratio = 10.1; 95% confidence interval: 5.1–20.3, P < .001) was predictive of this complication. ConclusionArterial coverage with retromesenteric omental flap can reduce rates of clinically relevant postpancreatectomy hemorrhage after pancreaticoduodenectomy. This easy and costless technique should be prospectively evaluated to confirm these results.

Correlation of sonographic with intraoperative findings in laparoscopic managed ectopic pregnancies, a 10-year synopsis: a restrospective observational study

BackgroundEctopic pregnancies (EP) are a common pregnancy complication that’s associated with significant morbidity and rarely mortality if not managed properly. Ultrasound examination forms the cornerstone of diagnosis of EP with some sonographic features occasionally not correlating with intraoperative findings. We set out to conduct an audit of EP managed surgically at our hospital for a 10-year period and discern the correlation and prediction of sonographic findings to intraoperative findings.MethodsThis study was designed as a Retrospective Observational Study based at the Aga Khan University Hospital (AKUH). Study population was all women admitted to AKUH with a diagnosis of ectopic pregnancy that was surgically managed between the period of January 1st 2011 to December 31st 2020. Analysis of data was done against a pre-set checklist. Descriptive statistics for continuous variables was calculated and tabulated in graphs and tables. SPSS version 22 was used for analysis of data.ResultsA total of 337 patients in this study had ultrasound findings. 99.7% (n = 336) of these patients had an intraoperatively confirmed EP. The commonest ultrasound finding was an adnexal mass in 97.1% (n = 309) of patients. These were confirmed surgically in 290 patients at the following locations: 76.6% (n = 222) were ampullary in location; 10.7% (n = 31) were fimbrial in location; 8.6%(n = 25) were isthmic in location; 2.4%(n = 7) were interstitial in location; 1%(n = 3) were abdominal in location; while 0.3% were located in the ovary(n = 1) or round ligament(n = 1) each. Interstitial EP on ultrasound were all (100%) confirmed in the same location intraoperatively, with ampullary EP also correlating fairly well with intraoperative location (75%). The distribution of location in the minor hemoperitoneum (HP) versus major HP groups were similar except for interstitial EP that increased from 1.4% in the minor HP group to 9.5% in the major HP group.ConclusionIn conclusion, ultrasonography still represents the best imaging modality for EP. The most common finding is usually an adnexal mass with no specific location. Most (99.7%) of the patients with this sonographic finding usually have a confirmed EP. Interstitial EP are the most well localized with ultrasound followed by ampullary EP. Furthermore, the presence of major (> 500mls) hemoperitoneum may act as an adjunct for diagnosis of an interstitial EP.

Advantages of Laparoscopic Treatment in Pelvic Static Disorders by Lateral Hystero/Colpopexy - A Single Center Experience.

Introduction: Pelvic organ prolapse is the most frequent and common health problem faced by most patients, representing the descent into the vagina or beyond the introitus of one or more pelvic organs, involving three compartments: anterior-bladder, apical-uterus and posterior-rectus. Lateral hystero/colpopexy is an alternative approach in the repair of symptomatic anterior and apical pelvic prolapse. The main objective is to correct pelvic floor defects, restore anatomy, relieve pressure and maintain normal sexual function. Material and Methods: Surgical intervention was applied to patients with prolapse greater than grade II according to the international prolapse quantification system (POP-Q). For apical, anterior prolapse, the bladder peritoneum is dissected and a polypropylene mesh is fitted to the round ligaments with suspension of the isthmus and cervix and fixation of the mesh with CapSure tacks followed by closure of the vaginal peritoneum. Results: During the performance of the technique I had no intraoperative or postoperative complications. Conservation of the uterus proved to be effective for prolapse correction, significant improvements in patient quality of life, frequency of nocturia, degree of dyspareunia and urgency symptoms were observed. Conclusion: Uterine preservation by lateral hystero/colpopexy is a new, feasible and successful method for treating prolapse.

Anatomical, Radiological, and Corrosion Casting of the Liver, Gallbladder, and Biliary Duct System of Local Breed Cattle (Bos ttaurus)

Local breed cattle's liver, reddish-brown, occupies the right hypochondriac region with 35.2 ± 3.24 cm long and 5.5 ± 0.5 kg weight. Connected by left and right triangular ligaments; and falciform ligaments with the diaphragm, and hepatorenal ligament with the right kidney. While the coronary ligament encompassing the caudal vena cava divides into dorsal and ventral branches, enclosing the nuda region. The round ligament connects the umbilical fissure to the umbilicus. The lesser omentum on the liver's visceral surface connects the stomach and duodenum through hepatogastric and hepatoduodenal ligaments, respectively. The liver has, parietal and visceral surfaces; right, left, ventral, and dorsal borders; and left, right, caudate, and quadrate liver lobes that are not clearly separated, except for the caudate. The gallbladder has a dark green color and pear-shaped morphology, measures 16 ± 1.5 cm, and is located in a shallow cystic fossa. Consisting of the neck, forms an inverted funnel shape, body, and fundus. The diameters were 2 ± 0.3, 6 ± 1.2, and 4 ± 1.3 cm, respectively. The biliary tract consists of extrahepatic and intrahepatic ducts. The extrahepatic ducts have a left duct of 3 ± 0.5 cm and a right duct of 2 ± 0.25 cm. Converging to form a common hepatic duct 8 ± 0.5 cm. The cystic duct is 3± 0. cm, joins with the common hepatic duct ventrally. The intrahepatic ducts consisted of primary, secondary, tertiary, interlobular, intralobular, and intercalated ducts. The left hepatic duct received 9 ± 1 of dorsal primary ducts and 8 ± 2 ventral primary ducts. The right hepatic duct receives 4 ± 1 dorsal ducts and 2 ± 1 ventral ducts.

Laparoscopic Approach for Ectopic Pregnancy in a Rudimentary Horn: Stepwise Demonstration of Surgical Technique

ObjectiveTo provide a comprehensive, step-by-step presentation of the laparoscopic resolution of ectopic pregnancy within a rudimentary uterine horn. DesignA detailed demonstration of the laparoscopic technique presented through narrated video footage. SettingPregnancy occurring in the rudimentary horn of a unicornuate uterus represents a rare form of ectopic pregnancy [1]. This condition is associated with a high risk of uterine rupture. Early detection is crucial for effective management and prevention of potential complications [2,3]. In this manuscript, we present a case study of a patient diagnosed with ectopic pregnancy in a rudimentary horn, who underwent successful laparoscopic resection. InterventionsTen main steps were identified and described in detail during the laparoscopic resection: Step 1: identification of the anatomy; Step 2: uterine mobilization; Step 3: Open retroperitoneum; Step 4: Coagulation and section of left round ligament; Step 5: Bladder dissection; Step 6: Identification of vessels; Step 7: Coagulation and section of left utero-ovarian vessels; Step 8: Coagulation and section of uterine vessels; Step 9: Section of uterine septum; Step 10: Specimen removed. ConclusionThis publication offers a detailed and instructive account of the laparoscopic resection of ectopic pregnancy within a rudimentary uterine horn. The stepwise approach demonstrated in the accompanying video contributes to a deeper understanding of this complex surgical technique. Video Abstract [Display omitted]

Laparoscopic Versus Open Surgical Management of Hydrocele of the Canal of Nuck: A Retrospective Analysis of 20 Cases.

Hydrocele of the canal of Nuck is a condition that arises due to incomplete obliteration of the processus vaginalis or an abnormal outpouching from the round ligament during fetal development. It usually presents as a painless, rarely painful, groin swelling.The definitive diagnosis for this condition is magnetic resonance imaging. Various management options have been proposed for this condition, including open surgery, transabdominal preperitoneal approach, totally extraperitoneal approach, and a combination of laparoscopic and open surgery. The present study highlights the benefits of the transabdominal preperitoneal approach when compared with the open anterior approach and addresses the intraoperative challenges faced during laparoscopic surgery. The study is a retrospective study inclusive of 20 patients who underwent surgery for the hydrocele of the canal of Nuck from June 2019 to December 2023. Case records of patients were studied for information such as demographic features, type of pathology, the surgery performed, intraoperative challenges encountered, operative time, duration of hospital stay, scores from the visual analog scale pain assessment chart at various intervals, and time taken to return to work. The variables were documented and statistically analyzed. The average age group of the study population was 27.8 ± 8.34 years. Of the 20 patients, 10 had undergone a transabdominal preperitoneal approach (Group A), and 10 had undergone an open anterior approach (Group B). Eleven out of 20 patients had an associated inguinal hernia, of which three were identified preoperatively and eight were identified incidentally during surgery. The mean operative time of Group A cases was 97.95 ± 7.54 minutes, while it was 66.3 ± 6.20 minutes for Group B cases. The Mann-Whitney U test showed a statistically significantly lesser operative time for Group B than for Group A (p-value < 0.001). The duration of hospital stays was comparable for the two groups with no significant difference (two days versus 3.8 ± 3.08 days, respectively). When the difference in the means of time taken to return to normal work was compared using the Mann-Whitney U test between Group A and B (6.1 ± 0.87 days and 11.2 ± 1.81 days, respectively), a statistically significant early return to normal work in the former group (p-value = 0.001) was revealed. Similarly, the Mann-Whitney U test when used to compare the median postoperative pain score of both groups at 12-24 hours, 48-72 hours, seven days, and three months showed a significantly lesser pain score amongpatients of Group A at all intervals (p-value< 0.001, p-value = 0.005, p-value = 0.005, p-value< 0.001, respectively). The incidence of intraoperative challenges, sero-hematoma, and surgical site infection were insignificant in comparison. The transabdominal preperitoneal approach for the hydrocele of the canal of Nuck is ideal as it offers excellent intraoperative delineation of pathology and postoperative outcomes. Prophylactic placement of a mesh in all cases can help prevent a future occurrence of inguinal hernia in these cases.

Perivascular Epithelioid Cell Tumor with Uncertain Malignant Potential Arising in the Round Ligament.

A 12-year-old adolescent was diagnosed with a right-sided solid mass in the round ligament of the uterus. The chief complaints were abdominal pain and pelvic discomfort. She underwent laparoscopic tumor resection. Histological examination demonstrated a trabecular growth pattern of epithelioid cells with mitotic activity (3 per 50 HPF), which expressed melanocytic and myoid markers. Due to aforementioned findings, a final diagnosis of perivascular epithelioid cell tumor (PEComa) with uncertain malignant potential was made. To the best of our knowledge, this localization of PEComa is considered to be infrequent with only occasionally reported cases.