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Table of Contents
Year : 2019  |  Volume : 2  |  Issue : 4  |  Page : 130-133

Laparoscopic round ligament preserving repair for groin hernia in women: A critical appraisal

1 Department of General Surgery, Oryol State University Clinic, Plesheevo Regional Hospital, Oryol, Russia
2 Department of General Surgery and Coloproctology, GMS Clinic and Hospitals, Centrosojuz Hospital, Moscow, Russia

Date of Submission27-Jun-2019
Date of Decision23-Jul-2019
Date of Acceptance29-Jul-2019
Date of Web Publication22-Oct-2019

Correspondence Address:
Dr. V Abolmasov Alexey
Oryol State University Clinic, Komsomolskaya Str. 95, Oryol 302026
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_23_19

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BACKGROUND: Our objective was to investigate the clinical characteristics of original laparoscopic round ligament-sparing repair technique for groin hernias in female patients.
METHODS: The clinical data of 48 female patients (58 hernias) who underwent laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair using original split mesh technique at Orel Regional Hospital (Russia) between March 2009 and January 2019 were analyzed retrospectively. The aim of the study was to provide an overview about female groin hernias, preferred surgical approach, and the management of round ligament of uterus.
RESULTS: There were 58 TAPP repairs in 48 patients. The average follow-up period was 43 months (min. – 3, max. – 122, Mo – 12, and Me – 43). Fifteen femoral hernias were noted in ten patients, of which two femoral hernias were incarcerated. Cysts on the round ligament of the uterus were found in four patients, and most of them underwent laparoscopic resection. Round ligaments of the uterus were preserved in all patients. An average operation time was 56 min (min. – 20, max. – 135, Mo – 40 min, and Me – 50 min). None of the cases was converted to laparotomy. All patients returned to normal activity soon and 1 (1.7%) recurrence was noted during follow-up.
CONCLUSION: Laparoscopic inguinal hernia repair is well adopted around the world, but still questions remain which are related to female patients, especially regarding the function and preserving the round ligament. Based on this study, it is possible to preserve the round ligament by using the original laparoscopic TAPP keyhole technique.

Keywords: Femoral hernia, groin hernias, laparoscopic repair, round ligament, transabdominal preperitoneal repairs

How to cite this article:
Alexey V A, Bashankaev B. Laparoscopic round ligament preserving repair for groin hernia in women: A critical appraisal. Int J Abdom Wall Hernia Surg 2019;2:130-3

How to cite this URL:
Alexey V A, Bashankaev B. Laparoscopic round ligament preserving repair for groin hernia in women: A critical appraisal. Int J Abdom Wall Hernia Surg [serial online] 2019 [cited 2023 Jun 9];2:130-3. Available from: http://www.herniasurgeryjournal.org/text.asp?2019/2/4/130/269726

  Introduction Top

There are few studies and systematic reviews focusing specifically on groin hernia in women.[1],[2]

Groin hernia repairs are conducted 8–10 fold more often in men than in women, but the proportion of groin hernia emergency procedures was five times higher in women than in men.[2],[3] In the Swedish Hernia Registry, the emergency procedure rate was 5.1% in men and 17.0% in women.[2],[4],[5]

Despite anatomical differences in groin anatomy (presence of cord structures and wider inguinal ring in men), the outcome appears to be less favorable in women.[6] Women have a higher risk of recurrence after an open inguinal hernia repair operation due to a higher occurrence of overlooked femoral hernia at primary operation.[7]

The authors believe that higher recurrence rates in females could be attributable to femoral hernias being overlooked during the primary operation.[8] Thanks to the laparoscopic operation, we know for sure that the incidence of femoral hernias has been as high as 23%–37% for women and 3% for men.[9],[10] A study from the USA identified a lower incidence of groin hernias in patients with a body mass index (BMI) of 30–34.9 and ≥35 compared with persons of normal weight (BMI <25) and overweight patients (BMI 25–29.9).[11] That relationship was confirmed once again by data from the Swedish Hernia Registry and by administrative data from the USA.[12],[13]

Personal opinions and knowledge on the function of the ligament and the importance of preserving it varied greatly among the surgeons. Transection of the round ligament of the uterus in laparoscopic groin hernia repair is common. The consequences of transecting the round ligament of the uterus are not well described, and opinions and knowledge on the issue vary widely among experienced hernia surgeons.

The human uterine teres ligament is to be judged a structure different from that of other, nonprimate, mammals. It is speculated that the unusual structure of the human teres ligament is related to one or more of the many unusual features of human uterine development; sas a single organ (uterus simplex), with a position deep in the abdominal cavity below the pelvic brim, and far away from the posterior abdominal wall. The unusual anatomical position may require an unusual construction of the uterine suspensory apparatus of which the teres ligament is one component.[14]

The steroid hormone receptors were localized in the smooth muscle cell nuclei of the round ligament, and these findings support the view that the round ligament is a target organ influenced by hormones, which has implications for the changes in the ligament during pregnancy and pre- and post-menopausally.[15],[16]

  Methods Top

All 48 women were operated using transabdominal preperitoneal (TAPP) approach. A total of 58 original round ligament-preserving techniques were conducted. We used 2–5 mm lateral and 1–10 mm umbilical ports. The peritoneum was open from the iliac spine level toward plica umbilicalis medialis. The pubic bone, urinary bladder, inferior epigastric vessels, hernia sac, and round uterus ligament were identified. The round uterus ligament was grasped and the space between ligament and iliac vessels was developed. The 10–15 cm to 12–16 cm mesh was formed in a sleeve fashion way [Figure 1]. Mesh incised parallel and 3 cm above its low edge up to 2/3 lengths. The lower sleeve was pushed under the round ligament. We used 2/0 prolene with 2-cm needle inserted directly through the skin after right 5-mm port removed. The hole between sleeves was closed taking the round ligament into the bite [Figure 2]. The peritoneum was closed using continuous absorbable suture.
Figure 1: Irregular mesh form

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Figure 2: Closing the gap between sleeves using round ligament as an anchor

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  Results Top


During 10 years study, since 2009 till 2019, 58 TAPP for inguinal hernia in 48 women were done. The mean age of patients was 51 ± 17.3 years (min. – 20, max. - 83, Mo – 63, and Me – 53). The mean BMI was 26.48 ± 4.6 kg/m2 (min. – 18 kg/m2, max – 42.7 kg/m2, Mo – 29.4 kg/m2, and Me – 26.4 kg/m2). Left side hernia was diagnosed in 13, right side in 25, and both sides in 10 patients. Direct hernia was found in 10 women, indirect in 33, and femoral hernia in 15.

A total of two 2 women underwent emergency femoral hernia hernioplasty without bowel resection. There were four women with recurrence from previous surgery: two after open Lichtenstein and two after TAPP. Chronic inguinal pain was an indication for surgery in two women. All patients were operated successfully and the mean operative time was 56 min. (max. – 135, min. – 20, Me – 50, and Mo – 40). There was no strong correlation between operative time and patient's BMI (Pearson's, r = 0.4), no strong correlation was noted between hernia's type and time of operation (left side to right side hernia Pearson's score was 0, 3, left side to both sides – 0.5, and right side to both sides – 0,4).

There was no conversion to open surgery. We used 10–15 cm to 12–16 cm polypropylene mesh 30 g/cm2 density. The mean follow-up period was 43 months (max. – 122, min. – 3, Mo – 12, and Me – 33). There were no intraoperative complications. All women were admitted to the hospital in the day of surgery and discharged the next day after the procedure. The 10-mm trocar's hernia with omentum incarceration was diagnosed on 7th postoperative day in one patient. The only recurrence was diagnosed in 20-year-old woman 1 year after previous surgery. She underwent TAPP reoperation with additional 5 cm–8 cm mesh, placed onto a hole between two sleeves near the round ligament (the knot's rupture was the reason of recurrence). Two patients were readmitted with preoperatively diagnosed recurrence hernia on 14th and 90th postoperative days. Relaparoscopy detected no recurrence. The round's ligament hematoma suspected for recurrence was evacuated.

Two women underwent TAPP surgery because of chronic pain in inguinal region.

There was complete release of pain after TAPP in one patient, and no effect was detected in a second case where an interstitial cystitis was diagnosed later on.

The combine surgery – laparoscopic TAPP and open omentum resection was done in one woman. All except one woman were satisfied with a procedure. Chronic postoperative pain (visual analog scores = 3) was diagnosed in one patient operated for complicated M3 recurrent hernia (operative time 125 min).

  Discussion Top

There are few studies and systematic reviews focusing specifically on groin hernia in women. One of the basic principles of successful laparoendoscopic hernia repair is the direct, flat positioning of a large mesh to the abdominal wall. However, indispensable preconditions for achieving this goal are: (1) complete reduction of the hernia sac and (2) taking down the adhesions between the peritoneum from all the extraperitoneal structures, inclusive the cord structures in men as well as the round ligament in woman, down to at least 4–5 cm below the inner inguinal ring. This operative step is called “parietalization” and is essential for avoiding a recurrence in the latter course. While in the male, the sac and the peritoneum can be readily dissected away from the cord, and in the female, it is often more difficult to separate the sac from the round ligament because of strong adhesions.

The anatomy and the close relationship between the sac and the round ligament were fully investigated by Koontz who described how many folds of the sac project around the ligament.[17]

These findings could explain why it may be very difficult to achieve an optimal parietalization but preserving the round ligament in TAPP or totally extraperitoneal. Cutting the ligament is the easier way; however, there is no proper knowledge about the function of the round ligament yet. Personal opinions and knowledge on the function of the ligament vary greatly among the surgeons, but there are no reliable data. Transection of the round ligament of the uterus in laparoscopic groin hernia repair is common, but the consequences of transecting the round ligament are not well described.

There is some general agreement that it may make sense to preserve the ligament, especially in the young women, whereas in the elderly, it could be severed to make parietalization easier.

On the other hand, insufficiently done parietalization of the round ligament could lead to an elevation of the mesh with the result of mesh's dislocation and recurrence in the later course. Moreover, in some patients, it is not possible to perform full parietalization and provide smooth mesh position due to anatomical reasons (short round ligament, uterus fibroids, uterus position, etc).

There are not so many ligaments' preserving techniques described in the literature. One of them is to facilitate complete parietalization by incision of the peritoneum immediately bilateral to the ligament and leaving a peritoneal patch to the ligament,[18] the resulting hole is closed by suture at the end of the operation. This technique is promising but not so easy to perform.

We prefer the so-called mesh keyhole technique, which was in the beginning of laparoscopic surgery in 1992 the standard [19] for mesh placement. In this technique, the mesh is incised up to the middle region and then the upper and the lower sleeve is placed round the ligament (or cord in man) to create a new inner inguinal ring like in the Lichtenstein operation.

But according to the International Endohernia Hernia Society (IEHS) guidelines, cutting a slit in the mesh to allow the structures of the funicle to pass through, may destroy the integrity of the mesh and therefore may be a risk factor for recurrence.[7] Indeed, to incise the mesh for creation of a new inner inguinal ring means also to create a weak point in the mesh, which may promote a recurrence.[20] This point of view is also supported by our study, the only recurrence was seen at the new inner inguinal ring despite it had been closed by suture.

On the other hand, there are some studies showing a low recurrence rate when using the slitted mesh technique.[21],[22],[23],[24] However, precondition for a successful application of this technique is that the slit must safely be closed.

There are several techniques to close the gap and to fix both of the sleeves to each other, staplers, sutures, or glue may be utilized. Moreover, an additional second piece of mesh in front of the firstly implanted mesh may be used for the central reinforcement of the region of the inner inguinal ring (double buttress technique).[25] Furthermore, whereas in male, the cord structured should be touched as less as possible, and in female, like in our technique, the round ligament could be used for proper closure of the gap. Besides, newly special formed meshes provide adequate sleeve overlap in the lateral zone.

In summary, our ligament-preserving TAPP technique, which was applied in 48 female patients, has proven to be safe and effective. However, for a definite recommendation, larger studies on comparative basis are necessary.

  Conclusion Top

Our study confirmed that original round ligament-preserving technique by using a slitted mesh could safely and effectively be applied for inguinal hernia repair in women.

Further randomized control trials should be performed to confirm these findings.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Koch A, Edwards A, Haapaniemi S, Nordin P, Kald A. Prospective evaluation of 6895 groin hernia repairs in women. Br J Surg 2005;92:1553-8.  Back to cited text no. 4
Nilsson H, Stylianidis G, Haapamäki M, Nilsson E, Nordin P. Mortality after groin hernia surgery. Ann Surg 2007;245:656-60.  Back to cited text no. 5
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Zendejas B, Hernandez-Irizarry R, Ramirez T, Lohse CM, Grossardt BR, Farley DR. Relationship between body mass index and the incidence of inguinal hernia repairs: A population-based study in Olmsted county, MN. Hernia 2014;18:283-8.  Back to cited text no. 11
Rosemar A, Angerås U, Rosengren A, Nordin P. Effect of body mass index on groin hernia surgery. Ann Surg 2010;252:397-401.  Back to cited text no. 12
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van der Schoot P. Human (and some other primates') uterine teres ligament represents a mammalian developmental novelty. Anat Rec 1996;244:402-15.  Back to cited text no. 14
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Tarján G, Bognár Z. The round ligament: A target organ for steroid hormones. Gynecol Endocrinol 1993;7:97-100.  Back to cited text no. 16
Koontz AR. Hernia. New York: Appleton-Century-Crofts; 1963. p. 80.  Back to cited text no. 17
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Arregui ME, Davis CJ, Yucel O, Nagan RF. Laparoscopic mesh repair of inguinal hernia using a preperitoneal approach: A preliminary report. Surg Laparosc Endosc 1992;2:53-8.  Back to cited text no. 19
Bittner R, Schmedt CG, Schwarz J, Kraft K, Leibl BJ. Laparoscopic transperitoneal procedure for routine repair of groin hernia. Br J Surg 2002;89:1062-6.  Back to cited text no. 20
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Celik AS, Memmi N, Celebi F, Guzey D, Celik A, Kaplan R, et al. Impact of slit and Nonslit mesh technique on testicular perfusion and volume in the early and late postoperative period of the totally extraperitoneal preperitoneal technique in patients with inguinal hernia. Am J Surg 2009;198:287-91.  Back to cited text no. 22
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