The round ligament of the uterus: Questioning its distal insertion

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

BACKGROUND

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.

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.

RESULTS

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.

CONCLUSIONS

The results suggest that the Kakinuma method can serve as a novel and viable NTR procedure for POP.

Comparison of outcomes between preservation or division of the uterine round ligament in laparoscopic groin hernia repair in females: a meta-analysis and trial sequential analysis

PURPOSE

The purpose of this study was to perform a meta-analysis comparing the short-term and long-term outcomes in laparoscopic groin hernia repair with or without preservation of the uterine round ligament (URL) in females.

METHODS

We searched several databases including PubMed, Web of Science, Cochrane Library, and and CNKI databases. This meta-analysis included randomized clinical trials, and retrospective comparative studies regarding preservation or division of the URL in laparoscopic groin hernia repair in females. Outcomes of interest were age, BMI, type of hernia, type of surgery, operating time, estimated blood loss, time of hospitalization, seroma, concomitant injury, mesh infection, recurrence, uterine prolapse, foreign body sensation, chronic pain, and pregnancy. Meta-analyses and trial sequential analysis were performed with Review Manager v5.3 and TSA software, respectively.

RESULTS

Of 192 potentially eligible articles, 9 studies with 1104 participants met the eligibility criteria and were included in the meta-analysis. There were no significant difference in age (MD-6.58, 95% CI - 13.41 to 0.24; P = 0.06), BMI (MD 0.05, 95%CI - 0.31 to 0.40; P = 0.81), blood loss (MD-0.04, 95% CI - 0.75 to 0.66; P = 0.90), time of hospitalization (MD-0.22, 95% CI-1.13 to 0.69; P = 0.64), seroma (OR 0.71, 95% CI 0.41 to 1.24; P = 0.23), concomitant injury (OR 0.32, 95% CI 0.01 to 8.24; P = 0.68), mesh infection (OR 0.13, 95% CI 0.01 to 2.61; P = 0.18), recurrence (OR 1.13, 95% CI 0.18 to 7.25; P = 0.90), uterine prolapse(OR 0.71, 95% CI 0.07 to 6.94; P = 0.77), foreign body sensation (OR 1.95, 95% CI 0.53 to 7.23; P = 0.32) and chronic pain(OR 1.03 95% CI 0.4 to 2.69; P = 0.95). However, this meta-analysis demonstrated a statistically significant difference in operating time (MD 6.62, 95% CI 2.20 to 11.04; P = 0.0003) between the preservation group and division group. Trial sequential analysis showed that the cumulative Z value of the operating time crossed the traditional boundary value and the TSA boundary value in the third study, and the cumulative sample size had reached the required information size (RIS), indicating that the current conclusion was stable.

CONCLUSION

In summary, laparoscopic groin hernia repair in women with the preservation of the round uterine ligament requires a longer operating time, but there was no advantage in short-term or long-term complications, and there was no clear evidence on whether it causes infertility and uterine prolapse.

Retrospective study of preservation and transection of the round ligament of uterus during laparoscopic transabdominal preperitoneal inguinal hernia repair in adult women

PURPOSE

The processing of the round ligament of uterus in laparoscopic transabdominal preperitoneal (TAPP) repair of inguinal hernia in women has contended. This study aimed to explore whether there is any difference in the surgical outcome and postoperative complications between the two processing modalities, preservation, and transection of the round ligament of uterus, in adult female inguinal hernia patients undergoing TAPP.

METHODS

Retrospective analysis of 84 female patients (117 sides) who underwent TAPP in XXX Hospital from July 2013 to August 2022. Patient characteristics and technical details of the surgical procedure were collected and divided into two groups according to whether the round ligament of uterus was severed intraoperatively or not. There were 52 cases (77 sides) in the group with preservation of the round ligament of uterus and 32 cases (40 sides) in the group with transection of the round ligament of uterus, comparing the general condition, surgical condition, and the occurrence of postoperative related complications between the 2 groups.

RESULTS

The operative time for unilateral primary inguinal hernia was (129.2 ± 35.1) and (89.5 ± 42.6) minutes in the preservation and transection groups, respectively. There were no statistical differences between the two groups in terms of age, length of hospital stay, ASA, BMI, history of lower abdominal surgery, type and side of hernia, intraoperative bleeding, and time to surgery for primary bilateral hernia (P > 0.05). In addition, there was likewise no statistical difference in the occurrence of postoperative Clavien-Dindo classification, VAS, seroma, mesh infection, labia majora edema, chronic pain or abnormal sensation in the inguinal region, and hernia recurrence in the two groups as well (P > 0.05).

CONCLUSION

There is no evidence that the transection of the round ligament of the uterus during TAPP has an impact on postoperative complications in patients. However, given the important role of the uterine round ligament in the surgical management of patients with uterine prolapse and the high incidence of uterine prolapse in older women, hernia surgeons should also be aware of the need to protect the round ligament of uterus in older women.

New native tissue repair for pelvic organ prolapse: Medium-term outcomes of laparoscopic vaginal stump–round ligament fixation

BACKGROUND

Laparoscopic sacrocolpopexy for pelvic organ prolapse (POP) is a new and widely used approach; however, ever since the United States Food and Drug Administration warned against the use of surgical mesh, repairs performed using patients’ tissues [i.e. native tissue repair (NTR)] instead of mesh have attracted much attention. At our hospital, laparoscopic sacrocolpopexy (the Shull method) was introduced in 2017. However, patients with more severe POP who have a long vaginal canal and overextended uterosacral ligaments may not be candidates for this procedure.

AIM

To validate a new NTR treatment for POP, we examined patients undergoing laparoscopic vaginal stump–round ligament fixation (the Kakinuma method).

METHODS

The study patients were 30 individuals with POP who underwent surgery using the Kakinuma method between January 2020 and December 2021 and who were followed up for > 12 mo after surgery. We retrospectively examined surgical outcomes for surgery duration, blood loss, intraoperative complications, and incidence of recurrence. The Kakinuma method involves round ligament suturing and fixation on both sides, effectively lifting the vaginal stump after laparoscopic hysterectomy.

RESULTS

The patients’ mean age was 66.5 ± 9.1 (45-82) years, gravidity was 3.1 ± 1.4 (2-7), parity was 2.5 ± 0.6 (2-4) times, and body mass index was 24.5 ± 3.3 (20.9-32.8) kg/m². According to the POP quantification stage classification, there were 8 patients with stage II, 11 with stage III, and 11 with stage IV. The mean surgery duration was 113.4 ± 22.6 (88-148) min, and the mean blood loss was 26.5 ± 39.7 (10-150) mL. There were no perioperative complications. None of the patients exhibited reduced activities of daily living or cognitive impairment after hospital discharge. No cases of POP recurrence were observed 12 mo after the operation.

CONCLUSION

The Kakinuma method, similar to conventional NTR, may be an effective treatment for POP.

Identifying safe corridors for anterior pelvic percutaneous instrumentation using computed tomography-based anatomical relationships

INTRODUCTION

Percutaneous anterior pelvic ring instrumentation is performed for retrograde screw fixation of ramus fractures, as well as for repair of pubic symphysis diastasis. The anatomic relationships of critical structures around the anterior pelvic ring, such as the spermatic cord and round ligament, have been described in only a few studies regarding the risk of iatrogenic injury during surgery. Our goal is to further describe these relationships, as well as provide radiographic information on safe corridors for percutaneous fixation.

METHODS

Eighty (80) axial computed tomography scans of the abdomen, obtained for non traumatic diagnostic purposes and screened for prior abdominal trauma or procedures, were evaluated by 3 fellowship trained radiologists. Mid-symphyseal cuts were used to obtain several measurements relative to the spermatic cords (SC) or round ligaments (RL): inter-cord or inter-ligament distance, skin to cortex of symphysis distance (vertical), skin to cortex of symphysis distance (oblique), safe corridor distance (between SC/RL and femoral triangle), center safe angle (relative to bilateral ischia), maximal safe angle, and minimal safe angle.

RESULTS

There were 41 male and 39 female scans included in the final analysis. The average inter-cord distance was 50.2 mm, skin to cortex vertical distance of 43.0 mm, skin to cortex oblique distance of 83.5 mm, safe corridor distance 26.3 mm, center safe angle 19.3˚, maximal safe angle 32.3˚, and minimal safe angle 13.6˚. These were further broken down by range and gender in Table 1. Agreement between radiologists was high for these different measurements with the exception of the skin to cortex oblique distance in female patients and the maximal safe angle in female patients, due to absence of round ligament in a majority of the scans. The round ligament was only present at the mid-symphyseal level for our three reviewers in 37/39, 36/39, and 24/39 of female patient scans.

CONCLUSIONS

We have identified defined safe corridors for instrumentation of the anterior pelvic ring that can assist the surgeon in percutaneous application of fixation for fracture care.

Cyst of the canal of Nuck: an atypical course with cyclic changing of size

As the canal of Nuck normally obliterates before birth, a patent canal is a rare anatomic variant in adult women analogue to the patent processus vaginalis in men. In a patent canal of Nuck, pathologies such as hernias and cyst can build within time. Such cysts themselves are so uncommon that they are mostly described in case reports. Normally, cysts of the canal of Nuck present as a consistent, inguinal swelling with or without pain. Interestingly, in our case, the painful swelling was cyclic changing from the size of a plum to being clinically undetectable within the course of a day. To the best of our knowledge, this is the first description of such an unusual course. The cyst was removed operatively via an open approach. The spasms declined shortly after the operation. At 1 year postoperatively, the patient was still asymptomatic.

Embryonic developmental process and clinical anatomy of the preperitoneal fascia and its clinical significance

PURPOSE

Many researchers have different views on the origin and anatomy of the preperitoneal fascia. The purpose of this study is to review studies on the anatomy related to the preperitoneal fascia and to investigate the origin, structure, and clinical significance of the preperitoneal fascia in conjunction with previous anatomical findings of the genitourinary fascia, using the embryogenesis of the genitourinary system as a guide.

METHODS

Publications on the preperitoneal and genitourinary fascia are reviewed, with emphasis on the anatomy of the preperitoneal fascia and its relationship to the embryonic development of the genitourinary organs. We also describe previous anatomical studies of the genitourinary fascia in the inguinal region through the fixation of formalin-fixed cadavers.

RESULTS

Published literature on the origin, structure, and distribution of the preperitoneal fascia is sometimes inconsistent. However, studies on the urogenital fascia provide more than sufficient evidence that the formation of the preperitoneal fascia is closely related to the embryonic development of the urogenital fascia and its tegument. Combined with previous anatomical studies of the genitourinary fascia in the inguinal region of formalin-fixed cadavers showed that there is a complete fascial system. This fascial system moves from the retroperitoneum to the anterior peritoneum as the preperitoneal fascia.

CONCLUSIONS

We can assume that the preperitoneal fascia (PPF) is continuous with the retroperitoneal renal fascia, ureter and its accessory vessels, lymphatic vessels, peritoneum of the bladder, internal spermatic fascia, and other peritoneal and pelvic urogenital organ surfaces, which means that the urogenital fascia (UGF) is a complete fascial system, which migrates into PPF in the preperitoneal space and the internal spermatic fascia in the inguinal canal.