Round Ligament's Cyst Passing Through Ingunal Canal

Year 2017, Volume: 20 Issue: 1, 33 - 35, 30.10.2018

Aysun Tekeli Taşkömür , Osman Fadıl Kara

Abstract

Abstract

            Round ligament cysts are quite
rare.  Clinically, they generally
resemble to inguinal hernias. In this case, we will present a 44 years old
female patient applying to clinic for inguinal pain and swelling. Ultrasound
and computed tomography was used for the mass in inguinal area for differential
diagnosis. This mass, which was noticed to be related to abdomen, was confirmed
to be a round ligament cyst after operation both macroscopically and
histopathologically.

Key words: Round ligamente, cystic mass.

 

Introduction

            Masses handled in inguinal areas are
generally ingunal and femoral hernias. Lymphadenopathies, benign and malign
tumors, saphena varices, femoral venous aneurysms, abcesses, endometriotic
centres can also be included (1).

With the
aim of increasing the clinical experiences of rarely seen round ligament cysts
and indicating that should be thought in differential diagnosis, we hope that
the case with which we handle will stand as an example.

 

Case
Presentation

 

            44 years old female patient applied
to a clinic for pain in left groin, swelling in left inguinal area an
tenderness. It was understood that the patient had started having aches after
the swelling in her inguinal area for the last few months. In the physical
examination, there was a 5*5 cm sized sore swelling in left inguinal area.
Ultrasonography was followed by a superficial form. As a result of the
ultrasonography, an area of 63*34mm sized, multiseptated, thick walled anechoic
collection that started with left paraovarian area from a 11mm defect to
reaching a skin tissue was monitored. Increased echogenicity was observed
around the collection area. Then, abdominal tomography with contrast was used
for the differential diagnosis of the patient. The abdomen computed tomograhy
result was: a lesion in 23 mm sized and cystic density was monitored in left
inguinal canal. Heterogenic display was viewed in left inguinal canal proximal
wall. An operation was agreed upon the patient after these symptoms. First, a
formation thought  to be herniation after
an incision to the left inguinal area was analyzed. A collection of 6*4cm that
included hemorrhagic cystic areas were present (Picture 1(a)). It was then
proceeded to laparatomy. It was seen that left round ligament was
stretched  in the abdominal cavity (Picture
1(b)). It was observed to be a cystic hemorrhagic formation after going through
inguinal canal (Picture 1(a),1(c)). Firstly, the mass in the inguinal area was
excised. Then, it was cut loose from round ligament inguinal canal extending in
abdomen. The patient's pathology result: benign enflame cyst wall. Nuck canal
cyst, left inguinal area, cystectomi (Picture 1(d),1(e)).

 

Picture 1

Picture
1(a): The appearance
of the cystic mass from the opening incision of the vulva (b): The
stretched round ligament's appearance inside of the abdomen (c): The
appearance of the cystic mass was removed from the vulva incision (d) :
A close look to surface epithelium of nuck canal cyst which is partly cuboidal
and partly low (HE& x400). (e):
When parts of
ligament are coordinated, a nuck canal cyst, surface of which is covered with
cuboidal epithelium is monitored where straight muscle tendons are also
observed (HE& x100).

 

Discussion

            Round
ligament cysts are pathologies that faced quite rarely. When the literature
between 1980 and 2013 was searched, there is just 10 case about it. Most of
these are clinical like inguinal hernia or resemble to inguinal area masses.
The average ages of this pathology's diagnosis are third  and fourth female patients (1,2).

            Round
ligament is also known as ligamentum teres uterine and goes through the deep
fraction of ingunal circles by taking origin from both sides, follows through
the inguinal canal and end in labium majus.

 

            The
round ligament is composed mainly of nonstriated or smooth muscle fibers looped
together in bundles separated by fibrous tissue septa containing blood vessels
and nerve fibers within a mesothelial investment. Cysts can occur in any area
around ligament. Two theories are put forward for the development of round
ligament cysts. One theory involves a flamed obliteration of Nuck's canal. As a
result, a spermatic cord hydrocele occurss in men and according to this theory,
round ligament cysts have some resemblance to Nuck canal cysts (1).

            Another
theory involves the inclusion of embryonic, mesenchymal and mesothelial
elements or remnants, during the development of the round ligament (2,3). It is
only possible to diagnose the preoperatively accurately by clinic examination.
Round ligament cysts are usually asymptomatical. They clinically mimic hernias.
They manifest as aching, swelling, sensitivity. They are distinguished from
hernias by the swelling's not changing in valsalva or lying position (4).

            For
accurate diagnosis before the surgery, scanning methots can be used.
Non-invasive ultrasound is one of the most used techniques. It can be
identified by looking it's shape and size of cyst. it can also be distinguished
from hernia by doing valsalva and making the patient cough, making peristaltism
non-visible. Connection of pedunculated lesion to peritoneum cavity can be
identified (2,5).

            In
computered tomography, cystic structure and irreguler thickening on its wall
are monitored by using IV contrast. Metastasis in differential diagnosis of patients
with malignance should not be forgotten (5). Separating cystic structure from
neighbor adjacent fibers is easily done with magnetic resonance. Since it is
expensive, it should not be the first choice (6).Certain diagnosis should be
verified with macroscopic and histopathologic testing after the operation. One
layer cuboid cells in cyst perphery draw attention and contain calretinin and
pancreatin (7,8).

            There
isn't any complete evidence for the safe monitoring and treatment of rarely
seen round ligament cysts. Asympomatic patients can be scrutinized for routine
follow-up by ultrasound as the disease is benign. Cysts excision can be used
for patients who are symptomatic or whose cysts are growing. Cyst aspiration
accompanied with ultrasound may provide a state to temporary well-being for the
patient. Since cyst substance will quickly recover, it is not meaningful. Best
treatment is total excision and no patient was monitored to have relapse after
operation (7,9).

Result

            Round
ligament cysts are generally rare pathologies. These pathologies, which are
similar to inguinal pathologies can be clinically distinguished. Especially in
differential diagnosis, ultrasound, computed tomography and magnetic resonance
can be used. The patient gets better in the clinic after the complete removal
of round ligament cysts. Diagnosis of the case is verified with post-operative,
macroscopic and histopathologic analysis.

Disclosure:All authors of
this work declare that there is no conflict of interest regarding the publication
of this article. And all of them have no current or recent funding and other
payments, good or servise that might influence the work.

References:

1- Harper, G.B., Awbrey, B.J., Thomas, C.G., Askin,
F.B. (1986, April). Mesothelial cysts of the round ligament simulating inguinal
hernia. The American Journal Surgery, 151(4):515-517. doi:
https://doi.org/10.1016/0002-9610(86)90116-9

2- Oh, S.N., Jung, S.E.,
Lee, J.M., Chung, J.H., Park, G.S. (2007, May). Sonographic diagnosis of a
round ligament cyst in the inguinal area. Journal of Clinical Ultrasound,
35(4):226-228. doi: https://doi.org/10.1002/jcu.20282

3- Stickel, W.H.,
Manner, M. (2004, March). Female hydrocele ( Cyst of the canal of Nuck):
Sonografhic appearance of a rare and little-known disorder. Journal of
Ultrasound in Medicine, 23(3): 429-432. doi:
https://doi.org/10.7863/jum.2004.23.3.429

4- Tomkinson, J.S.,
Winterton, W.R. (1955). Varicoceles of the round ligament in pregnancy,
stimulating inguinal herniae. British Medical Journal, 1(4918):889-890.

5- Kim, B.M., Lee, J.Y.,
Han, Y.H., et al. (2010, April). Mesothelial cyst of the round ligament
mimicking a metastasis: a case report. Korean Journal of Radiology,
11(3):364-367. doi: https://doi.org/10.3348/kjr.2010.11.3.364

6- Choi, Y.M., Lee,
G.M., Yi, J.B., et al. (2012). Two cases of female hydrocele of the canal of
nuck. Korean Journal of Pediatrics, 55(2):81-87.

7- Ryley, D.A., Moorman,
D.W., Hecht, J.L., Alpe, M.M. (2004, October). A mesothelial cyst of the round
ligament presenting as an inguinal hernia after

gonadotropin stimulation
for in vitro fertilization. Fertility and Sterility, 82(4):944-946. doi:
https://doi.org/10.1016/j.fertnstert.2004.03.042

8- Ubanczyk, K.,
Skotniczny, K., Kucinski, J., Friediger, J. (2005). Mesothelial inclusion
cysts(so-called benign cystic mesothelioma)-a clinicopathological analysis of
six cases. Polish Journal of Pathology, 56(2):81-87.

9- Stickel, W.H.,
Manner, M. (2004, March). Female hydrocele (cyst of the canal of Nuck):
Sonographic appearance of a rare and little-known disorde. Journal of
Ultrasound in Medicine, 23(3):429-432.
https://doi.org/10.7863/jum.2004.23.3.429

Keywords

Round ligamente

References

• References1: Harper, G.B., Awbrey, B.J., Thomas, C.G., Askin, F.B. (1986, April). Mesothelial cysts of the round ligament simulating inguinal hernia. The American Journal Surgery, 151(4):515-517. doi: https://doi.org/10.1016/0002-9610(86)90116-9
• References2: Oh, S.N., Jung, S.E., Lee, J.M., Chung, J.H., Park, G.S. (2007, May). Sonographic diagnosis of a round ligament cyst in the inguinal area. Journal of Clinical Ultrasound, 35(4):226-228. doi: https://doi.org/10.1002/jcu.20282
• References3: Stickel, W.H., Manner, M. (2004, March). Female hydrocele ( Cyst of the canal of Nuck): Sonografhic appearance of a rare and little-known disorder. Journal of Ultrasound in Medicine, 23(3): 429-432. doi: https://doi.org/10.7863/jum.2004.23.3.429
• References4: Tomkinson, J.S., Winterton, W.R. (1955). Varicoceles of the round ligament in pregnancy, stimulating inguinal herniae. British Medical Journal, 1(4918):889-890.
• References5: Kim, B.M., Lee, J.Y., Han, Y.H., et al. (2010, April). Mesothelial cyst of the round ligament mimicking a metastasis: a case report. Korean Journal of Radiology, 11(3):364-367. doi: https://doi.org/10.3348/kjr.2010.11.3.364
• References6: Choi, Y.M., Lee, G.M., Yi, J.B., et al. (2012). Two cases of female hydrocele of the canal of nuck. Korean Journal of Pediatrics, 55(2):81-87.
• References7: Ryley, D.A., Moorman, D.W., Hecht, J.L., Alpe, M.M. (2004, October). A mesothelial cyst of the round ligament presenting as an inguinal hernia after gonadotropin stimulation for in vitro fertilization. Fertility and Sterility, 82(4):944-946. doi: https://doi.org/10.1016/j.fertnstert.2004.03.042
• References8: Ubanczyk, K., Skotniczny, K., Kucinski, J., Friediger, J. (2005). Mesothelial inclusion cysts(so-called benign cystic mesothelioma)-a clinicopathological analysis of six cases. Polish Journal of Pathology, 56(2):81-87.
• References9: Stickel, W.H., Manner, M. (2004, March). Female hydrocele (cyst of the canal of Nuck): Sonographic appearance of a rare and little-known disorde. Journal of Ultrasound in Medicine, 23(3):429-432. https://doi.org/10.7863/jum.2004.23.3.429