Resection of an Inguinal Canal Fibroid With Concurrent Endometriosis in a Patient Status Post Hysterectomy

INTRODUCTION: Round ligament masses are rare, but one of the most common etiologies is leiomyoma. Due to their rarity, women are often misdiagnosed with hernias, malignant tumors, or mesothelial cysts. The majority of round ligament fibroids occur at the extraperitoneal end of the round ligament. Patients can present with lower abdominal pain or pressure and a palpable mass in the groin area. The most common treatment is surgical removal of the fibroid with closure of the defect in the deep inguinal ring. OBJECTIVE: The objective of this video is to review the anatomy of the inguinal canal and highlight techniques for safe and efficient excision of a round ligament fibroid with concurrent endometriotic lesions. METHODS: This case describes a 51-year-old G2P2 female with a history of chronic pelvic pain and severe dyspareunia presenting for evaluation of endometriosis. She had previously undergone a total abdominal hysterectomy for fibroids. Her preoperative imaging revealed a right ovarian cyst concerning for endometrioma. On entry, a round ligament fibroid and endometriosis were identified in the inguinal canal. RESULTS: This surgical video illustrates the robot-assisted excision of a round ligament fibroid and surrounding endometriotic lesions in the inguinal canal. Using blunt and sharp dissection, the peritoneum surrounding the mass is excised circumferentially. Short bursts of electrosurgery are utilized while applying adequate traction to ensure entry into the correct plane without injury to nearby structures. A robotic tenaculum effectively allows for counter traction, while the fibroid is shelled out from the inguinal canal. Care is taken to ensure complete excision of the fibroid. Endometriotic lesions are identified at the deep inguinal ring and are carefully excised. The peritoneal defect is then closed using a 2-0 delayed absorbable barbed suture. CONCLUSIONS: This video demonstrates important techniques that allow for safe and complete removal of a round ligament fibroid with concurrent endometriotic lesions from the inguinal canal.