Round Ligament's Cyst Passing Through Ingunal Canal

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 1Picture 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)90116-92- 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.202823- 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.2004.23.3.4294- 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.2010.11.3.3646- 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 aftergonadotropin stimulation for in vitro fertilization. Fertility and Sterility, 82(4):944-946. doi: https://doi.org/10.1016/j.fertnstert.2004.03.0428- 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