Round ligament varicosities mimicking inguinal hernias in a gravid patient

Surgical Rounds®, January 2008, Volume 0, Issue 0

Charles E. Copeland, Attending Surgeon, Department of Surgery; Christopher J. Myers, General Surgery Resident, Department of Surgery, The Mercy Hospital of Pittsburgh, Pittsburgh, PA

Charles E. Copeland, MD

Attending Surgeon

Department of Surgery

Christopher J. Myers, MD

General Surgery Resident

Department of Surgery

The Mercy Hospital

of Pittsburgh

Pittsburgh, PA

ABSTRACT

Introduction: Bilateral round ligament varicosities may be mistaken for inguinal hernias in gravid patients because these conditions have similar presentations. Distinguishing between varicosities and hernias is critical to avoid performing unnecessary surgery.

Results and discussion: The authors report a case of bilateral round ligament varicosities mimicking inguinal hernias. A patient in her fifth month of pregnancy presented with what were thought to be bilateral inguinal hernias. The authors conducted a literature search and were alerted to the possibility that their patient's condition could be round ligament varicosities. Ultrasonography and color duplex scanning confirmed this diagnosis and allowed a conservative approach.

Conclusion: Inguinal masses that are identified during pregnancy and resemble inguinal hernias must be examined with ultrasonography and color duplex scanning. If round ligament varicosities are observed, recommended treatment is conservative, with the expectation that the varicosities will resolve spontaneously during the postpartum period.

Round ligament varicosities can cause pain and have a similar presentation to inguinal hernias. We report a case of a pregnant woman with bilateral inguinal masses that were initially thought to be inguinal hernias. Various general surgery textbooks and obstetric and gynecology textbooks were consulted, but they offered no information on the differential diagnosis or management of inguinal masses during pregnancy. A subsequent literature search revealed that these masses could be varicose veins of the round ligament. Bilateral inguinal ultrasonography and color duplex scanning were performed and confirmed the diagnosis of round ligament varicosities, allowing unnecessary surgery to be avoided.

Case report

A 38-year-old African American woman in her fifth month of pregnancy was referred to the general surgery service for treatment of bilateral inguinal masses that were thought to be inguinal hernias. On erect physical examination, masses at both external inguinal rings were visible. These masses were soft and nontender to palpation. The patient reported experiencing vague bilateral inguinal pain, which she controlled with acetaminophen. The right inguinal mass was larger than the left, and both masses completely receded when the patient was in the supine position.

A textbook and journal literature search for the proper management of inguinal hernias during pregnancy alerted us to the possibility that the patient could have bilateral round ligament varicosities. She underwent bilateral inguinal ultrasonography and color duplex scanning, which showed multiple, large varicosities in the right inguinal area (Figure 1). Varicosities were also identified in the left inguinal area (Figure 2). Based on these findings, the patient's symptoms were controlled as needed with acetaminophen.

At term, the patient underwent an uncomplicated elective Caesarean section and delivered a healthy 7 lb 4 oz baby. The patient related that the varicosities began receding immediately after delivery and resolved almost completely after 16 days.

Discussion

We reviewed seven standard general surgery textbooks to determine how to manage inguinal hernias in pregnancy.1-7 None of the textbooks discussed a differential diagnosis; they only noted that pregnancy could be an etiology for inguinal hernias. In terms of treatment, the recommendation was to wait until the postpartum period for repair, but surgery could be un-dertaken during the second trimester if needed (presumably for pain). We also reviewed five obstetric and gynecology textbooks, which provided no additional differential diagnostic information or alternative recommendations for managing inguinal masses during pregnancy.8-12 A subsequent literature search uncovered three articles regarding round ligament varicosities mimicking inguinal hernias during pregnancy.13-15 An article was also found that discussed two gravid patients who were operated on for inguinal hernias and discovered instead to have large varicosities of the inguinal canal.16

Both round ligament varicosities and inguinal hernias can occur in the second trimester of pregnancy. Pelvic vein enlargement typically occurs during this time, which can sometimes extend to the round ligament in the inguinal canal, resulting in round ligament varicosities. Although inguinal hernias are uncommon in women, increased intra-abdominal pressure during pregnancy can lead to this condition. Distinguishing between round ligament varicosities and inguinal hernias can be challenging because of their similar presentations, with both presenting as nontender, soft masses that are more apparent when the patient stands erect and recede when the patient is supine. A correct diagnosis can be established using ultrasonography followed by color duplex scanning. Round ligament varicosities appear as large dilated spaces on ultrasonography, and color duplex scanning shows that these spaces contain blood.

Practice

Point

Varicosities of the round ligament should be managed conservatively, with the expectation that they will resolve spontaneously during the postpartum period.

Management of round ligament varicosities differs greatly from that of inguinal hernias, and it is imperative to diagnose the patient's condition accurately. Symptomatic inguinal hernias in pregnant women should be surgically repaired during the second trimester; if the patient is asymptomatic, repair can be delayed until the postpartum period. In contrast, varicosities of the round ligament should be managed conservatively, with the expectation that they will resolve spontaneously during the postpartum period. If there is progressive enlargement and increased discomfort, analgesics that are safe to use during pregnancy can be prescribed for pain control.

Conclusion

The usual diagnosis of a soft, reducible inguinal mass in pregnant women is inguinal hernia, but round ligament varicosities also must be considered. The observation that round ligament varicosities in pregnancy can mimic inguinal hernias has yet to arise in general surgery or obstetric and gynecology textbooks. As the four articles we found and our case illustrate, inguinal masses that arise during pregnancy and are characteristic of inguinal hernias must be evaluated with ultrasonography and color duplex scanning to establish a definitive diagnosis. In the event that the gravid patient's condition is identified as round ligament varicosities, which are managed conservatively, unnecessary surgery and its attendant risks can be avoided.

Disclosure

The authors have no relationship with any commercial entity that might represent a conflict of interest with the content of this article and attest that the data meet the requirements for informed consent and for the Institutional Review Boards.

References

  1. Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz's Principles of Surgery. 8th ed. New York, NY: McGraw-Hill; 2005:1129, 1353-1392.
  2. Townsend Jr CM, Beauchamp RD, Evers BM, et al. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 17th ed. Philadelphia, PA: Elsevier Saunders; 2004:1199-1217, 1236, 2233-2267, 2269-2280.
  3. Mulholland MW, Lillemoe KD, Doherty GM, et al. Greenfield's Surgery: Scientific Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:1172-1207, 2116-2131.
  4. Cameron JL. Current Surgical Therapy. 8th ed. Philadelphia, PA: Elsevier Mosby; 2004:545-552.
  5. Norton JA, Bollinger RR, Chang AE, et al. Surgery, Basic Science and Clinical Evidence. New York, NY: Springer-Verlag; 2001:426, 787-819, 1085.
  6. Doherty GM, Way LW. Current Surgical Diagnosis & Treatment. 12th ed. New York, NY: Lange Medical Books/McGraw-Hill; 2006:65-68, 765-777, 1065-1096.
  7. Morris PJ, Wood WC. Oxford Textbook of Surgery. 2nd ed. New York, NY: Oxford University Press; 2000:998, 1867-1876, 1891-1984.
  8. Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics. 22nd ed. New York, NY: McGraw-Hill; 2005:224-225, 1111-1120.
  9. Scott JR, Gibbs RS, Karlan BY, et al. Danforth's Obstetrics and Gynecology. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:1-20, 273-309.
  10. Gabbe SG, Niebyl JR, Simpson JL. Obstetrics, Normal and Problem Pregnancies. 4th ed. Philadelphia, PA: Churchill Livingstone; 2002:139-158, 607-645.
  11. Creasy RK, Resnik R, Iams JD. Maternal-Fetal Medicine. 5th ed. Philadelphia, PA: Saunders; 2004:1109-1122, 1202.
  12. James DK, Steer PJ, Weiner CP, et al. High Risk Pregnancy, Management Options. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2006:1032-1056, 1138-1139, 1231-1246.
  13. Cheng D, Lam H, Lam C. Round ligament varices in pregnancy mimicking inguinal hernia: an ultrasound diagnosis. Ultrasound Obstet Gynecol. 1997;9(3):198-199.
  14. Chi C, Taylor A, Munjuluri N, et al. A diagnostic dilemma: round ligament varicosities in pregnancy. Acta Obstet Gynecol Scand. 2005;84(11):1126-1127.
  15. Guillem P, Bounoua F, Duval G. Round ligament varicosities mimicking inguinal hernia: a diagnostic challenge during pregnancy. Acta Chir Belg. 2001;101(6):310-311.
  16. Huang A, Tweedie JH. Reducible inguinal swelling presenting during pregnancy-not always a hernia. J Obstet Gynaecol. 1998;18(3):284.