Recurrent Inguinal Canal Endometrioma Excision

INTRODUCTION: Endometriosis is a gynecologic condition that occurs in 6–10% of women of reproductive age , commonly causing chronic pelvic pain and infertility. There are multiple proposed theories on the complex pathogenesis of endometriosis, the main being implantation of endometrial glands and stroma on the peritoneum from retrograde menstruation. Endometriotic lesions can manifest as intrapelvic and extrapelvic lesions. Extrapelvic endometriosis is a rare phenomenon where endometrial tissue can be seen in the abdominal wall, inguinal canal, urinary tract, gastrointestinal tract, thoracic cavity, skin, and nervous system. Cases of inguinal canal endometriosis have been identified, presenting as a tender palpable groin mass with catamenial symptoms such as cyclic pain, bleeding, and changes in mass size. The definitive treatment method for inguinal canal endometriosis is a wide local excision with goals of complete resection of the extraperitoneal portion of the round ligament as it runs through the inguinal canal. Recurrence of inguinal canal endometriosis can be up to 5%; therefore, ensuring negative margins is imperative. The following video highlights the relevant and anatomy and surgical techniques necessary for complete resection of inguinal canal endometriosis. OBJECTIVE: To highlight the anatomy of the inguinal canal in female patients from both abdominal and laparoscopic perspectives. To discuss surgical principles and techniques that are involved in complex extrapelvic endometriosis excision with the ultimate goal to prevent recurrence. METHODS: Video case review and surgical tutorial. RESULTS: 28-year-old G0 with a history of stage IV endometriosis and recurrent inguinal canal endometrioma. The patient reports cyclic dysmenorrhea and dyspareunia since she was a teenager and had trialed both medical and surgical treatments resulting in short-term symptom relief. Her medical treatments included NSAIDs, combined oral contraceptives, GnRH agonists, and GnRH antagonists. Her surgical history includes two laparoscopic lysis of adhesions and extensive endometriosis excision with an ultimate decision on definitive management with transabdominal hysterectomy and bilateral salpingo-oophrectomy. Unfortunately, her symptoms continued to reoccur; thus, she underwent additional endometriosis excisional procedures. She had presented to the clinic for evaluation of a tender 2- to 3-cm left groin mass that demonstrated cyclical pain. General surgery was consulted for surgical collaboration in the removal of this groin mass, given the recurrent nature of the lesions, complex inguinal anatomy, and to assist with possible hernia repair or prophylaxis, if needed. This surgical video illustrates a combined abdominal and laparoscopic approach. CONCLUSIONS: Multidisciplinary collaboration can be critical for excision of complex endometriosis, particularly in anatomic locations that are not routine areas of operation for gynecologists. It is essential to be aware of the many manifestations of extrapelvic endometriosis to achieve a prompt diagnosis and optimize patient outcomes and resolution of symptoms.