Tumors of the round ligament rarely happen; leiomyomas are considered the most common. Round ligament leiomyomas are benign tumors mimicking inguinal hernia, lymph nodes, or other inguinal masses. They are usually asymptomatic and take place in premenopausal female patients. This paper will present a case of a postmenopausal female patient who presented to our outpatient surgical clinic complaining of a right groin mass for 3 months. She was clinically diagnosed as a case of an irreducible inguinal hernia. After investigations, it turned out to be a round ligament leiomyoma, confirmed by the histopathological examination. There are broad differential diagnoses of inguinal masses. Although imaging exams could help diagnose leiomyomas, surgical excision followed by histopathological assessment is the best to confirm the diagnoses.

Round ligament varicosities (RLV) are a very rare cause of an inguinal mass, which is very similar to an inguinal hernia, and should be taken seriously by women, especially in mid-pregnancy. Ultrasound can confirm the diagnosis of the RLV and can prevent unnecessary interventions. We report a case of a patient with bilateral RLV: the primigravida was 31 years old, G1P0, gestation 30+2w. The patient presented to the clinic 1 month ago due to the discovery of bilateral inguinal masses. After the diagnosis was confirmed by ultrasound, this patient received regular reviews during labor and delivery and is currently in good maternal condition. The patient came to the clinic 1 month after the discovery of bilateral inguinal area masses for 1 month.

Round ligament endometriosis is a rare phenomenon reported in approximately 0.3% to 0.6% of endometriosis cases. Presurgical diagnosis is carried out for about 50% of the cases. The association of the right-sided inguinal hernia, nonspecific pain in the organs, and no history of surgery or labor make the diagnosis intricate. We report a case of endometriosis of the round ligament in a 39-year-old woman who complained of intense pain in the right groin during the menstrual period for about 4 years, with no complaints of bulging or change in the size of the mentioned area. The clinical suspicion of inguinal endometriosis, supported by sonography and magnetic resonance imaging, was confirmed by histological examination of the surgical specimen after laparoscopic surgery, which included the mass and the extraperitoneal segment of the round ligament. After surgery, the patient\'s pain disappeared completely. The round ligament endometriosis or endometriosis of the inguinal region could be considered an important differential diagnosis in women of reproductive age without a history of surgery who presented with inguinal region pain during menstruation but no clear mass was palpable in the physical exam.

Laparoscopic 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.
Of 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.
No 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.
The results suggest that the Kakinuma method can serve as a novel and viable NTR procedure for POP.

Anatomic variants of hepatic ligaments are rare, and complications attributable to these variants may be difficult to diagnose. Our aim is to contribute to the literature surrounding the incidental finding of a congenital absence of the falciform ligament. We report the case of a 37-year-old man who underwent a laparoscopic cholecystectomy for acute cholecystitis. During the operation, the patient was noted to have an apparent absence of the falciform ligament attachment to the liver. The round ligament was attached from the liver to the anterior abdominal wall at the level of the umbilicus. The round ligament is inserted into the inferior surface of the liver as a thick, cordlike structure encased in fat. In rare cases, the small intestine can pass through a falciform ligament defect and become trapped while remaining within the peritoneal cavity, leading to difficult-to-diagnose internal hernias. This condition can lead to intestinal obstruction, incarceration, and strangulation. This directed our decision to divide the remaining round ligament at the liver and close to the abdominal wall. When defects of hepatic ligaments are found incidentally during laparoscopic surgery, these investigators recommend that the operating surgeon consider dividing the remaining ligament as a protective procedure to prevent complications such as internal hernias, intestinal obstruction, incarceration, and strangulation.

Inflammatory necrosis of the falciform ligament is an extremely rare cause of acute right upper quadrant pain. Due to overlapping symptoms with pathologies affecting the gall bladder and liver, this poses a diagnostic challenge with limited existing literature. Here, we report a case of a 62-year-old female patient presenting in the accident and emergency department with right upper quadrant pain. The patient underwent ultrasonography and revealed thickened and echogenic falciform ligament. Further, a computed tomography revealed swollen falciform ligament with associated fat stranding. The patient was kept under conservative management and improved over 2 weeks.

BACKGROUND: Inguinal endometriosis is one of the most common forms of endometriosis. The present study introduces 8 cases of inguinal endometriosis and discusses probable theories of inguinal endometriosis by reviewing the literature.
METHODS: 8 Iranian cases of inguinal endometriosis with a mean age of 36 years were presented. Catamenial groin pain and swelling were the most common complications. Also, patients usually had accompanying symptoms such as pelvic pain and dysmenorrhea. One-half of patients had a history of previous abdominal surgery. Ultrasound was diagnostic in 4 patients (50%), and magnetic resonance imaging was used in two patients (25%). Among 6 patients who underwent hormonal therapy, 4 experienced an endometriosis size increase. Inguinal endometriosis was right-sided in 87.5% of patients, and among 4 patients who underwent surgery, 75% had proximal site involvement of the round ligament.
CONCLUSIONS: According to the rarity of inguinal endometriosis, it is more likely to be a misdiagnosis with other inguinal disorders such as inguinal hernia. Inguinal endometriosis should be considered in patients who undergo inguinal herniorrhaphy, with suspected findings such as thickening of the hernia sac wall, bloody fluid inside the sac, or thickening of the extraperitoneal round ligament during the surgery.

OBJECTIVE: To evaluate the short term-outcomes of venous reconstruction using a round ligament-covered prosthetic vascular graft and assess its effectiveness in the prevention of prosthetic vascular graft migration in right‑lobe living donor liver transplantation (LDLT).
RESULTS: Thirty patients underwent reconstruction of the middle hepatic vein (MHV) tributaries during right lobe LDLT between January, 2021 and October, 2022. These patients were divided into the autologous vascular graft group (A group, n = 24) and the round ligament-covered prosthetic vascular graft group (RP group, n = 6). The computed tomography (CT) density ratio of the drainage area in the posterior segment of patent grafts was significantly higher in the RP group than in the A group (0.91 vs. 1.06, p = 0.0025). However, the patency rates of reconstructed MHV tributaries in the A and RP groups were 61% and 67%, respectively, with no significant difference between the groups (p = 0.72). Prosthetic vascular graft migration did not occur in the RP group.
CONCLUSIONS: Venous reconstruction using round ligament-covered prosthetic vascular grafts is a feasible and simple method to prevent prosthetic vascular graft migration in right-lobe LDLT.

Post-hepatectomy liver failure (PHLF) represents a major cause of morbidity and mortality after liver resection. The factors related to PHLF are represented not only by the volume and function of the future liver remnant but also by the severity of portal hypertension. The aim of this study was to assess whether the preservation of the round ligament (RL) may mitigate portal hypertension, thus decreasing the risk of PHLF and ascites in cirrhotic patients while undergoing minimally invasive liver surgery (MILS). All the cirrhotic patients who underwent MILS for HCC from 2016 to 2021 in two international tertiary referral centers were retrospectively analyzed, comparing cases with the RL preserved vs. those with the RL divided. Only patients with cirrhosis ≥ Child A6, portal hypertension, and ICG-R15 > 10% were included. Main postoperative outcomes were compared, and the risk factors for postoperative ascites (severe PHLF, grade B/C) were investigated through a logistic regression. After the application of the selection criteria, a total of 130 MILS patients were identified, with 86 patients with the RL preserved and 44 with the RL divided. The RL-preserved group showed lower incidences of severe PHLF (7.0% vs. 20.5%, p = 0.023) and ascites (5.8% vs. 18.2%, p = 0.026) in comparison with the RL-divided group. After uni/multivariate analysis, the risk factors related to postoperative ascites were RL division and platelets < 92 × 103/µL, calculated with ROC analysis. The preservation of the round ligament during MILS may mitigate portal hypertension, preventing PHLF and ascites in cirrhotic patients with borderline liver function.

Ectopic pregnancies, characterized by the implantation of a fertilized ovum outside the uterine cavity, typically occur in the fallopian tubes. However, rare cases have been reported where implantation occurs in atypical locations. Round ligament pregnancy, a rare form of ectopic pregnancy, poses significant risks and can lead to life-threatening complications. This case report describes the presentation and management of a 31-year-old gravida four, para two (G4P2012) female who presented with acute left lower quadrant and pelvic pain. The patient\'s medical history included a prior bilateral salpingectomy. Physical examination revealed severe left lower quadrant tenderness with guarding. A positive urine pregnancy test and elevated serum quantitative beta-human chorionic gonadotrophin level of 1,735 mIU/mL (normal range: <5 mIU/mL) confirmed pregnancy. Transvaginal ultrasound revealed an empty intrauterine cavity with no gestational sac or fetal pole. A 2 cm cystic structure was identified attached to the left ovary. Ectopic pregnancy was diagnosed, methotrexate was administered, and the patient was discharged with a scheduled outpatient follow-up. However, she returned to the emergency room within 48 hours reporting persistent pelvic pain. At this moment, it was decided that emergent surgical intervention was required. The surgical exploration confirmed the presence of a ruptured ectopic pregnancy in the round ligament, requiring excision and hemostasis. This case report highlights the importance of considering abnormal localization of ectopic pregnancy as a differential diagnosis in women presenting with pelvic pain, even after bilateral salpingectomies. It emphasizes the challenges in diagnosis and management when ectopic pregnancy occurs in atypical sites and highlights the necessity for vigilant follow-up and prompt surgical intervention when medical management fails.