Round Ligament of the Uterus: Radiological and Surgical Perspective

Abstract

The round ligaments of the uterus are a pair of fibromuscular cord-like structures derived from the gubernaculum and serve as a secondary support system for the uterus. The round ligaments have varied clinical and surgical implications. The involvement of round ligaments by pathological processes is underestimated. Advancements in imaging, visualization, and evaluation of round ligaments have widened our understanding of various developmental anomalies and diseases, resulting in better prognostication and management.

Keywords

round ligament - processus vaginalis - ultrasonography - magnetic resonance imaging - laparoscopy - canal of Nuck - leiomyoma - gubernaculum

Introduction

The round ligament forms the superior margin of the broad ligament and connects the uterine cornu to the mons pubis. They are a pair of fibromuscular cord-like structures derived from the gubernaculum and serve as a secondary support system for the uterus. The round ligaments have varied clinical and surgical implications. The involvement of round ligaments by pathological processes is underestimated. They are involved in spreading diseases, as sites for primary neoplasms, and serve as landmarks in differentiating lesions. Imaging modalities, especially magnetic resonance (MR) aid in visualization and evaluation of normal and abnormal round ligament, resulting in better prognostication and management of disease conditions. This article aims to provide a comprehensive review of anatomy, embryology of the round ligaments, its implications, and the role of imaging in related disorders.

Embryology and Anatomy of Round Ligaments and Related Structures

Round ligaments are a pair of 10- to 12-cm-long cord-like fibromuscular structures that connect the uterine cornu to the labia majora.[1] They are derived from the gubernaculum and represent the remnant of the same. The gubernaculum and processus vaginalis develop during the eighth week of fetus development ([Fig. 1]). The gubernaculum is attached to the inferior pole of the gonads. In males, it directs and creates a passage for the descent of the testis into the scrotum coursing through the inguinal canal. In females, mullerian development interferes with descent and the ovaries are fixed higher up by the ovarian ligament, a proximal gubernaculum derivative, while the distal portion remains as the round ligament merging with the labial soft tissue. This entire process is facilitated by the processus vaginalis, which is a ventral peritoneal outpouching that is attached to the gubernaculum. The processus vaginalis carries the parietal wall layers, forming the inguinal canal. It eventually gets obliterated in females ranging between the eighth month of gestation to the first year of life, the persistence of which manifests as patent canal of Nuck.[2] [3]

Fig. 1 The ovarian and round ligament are the gubernaculum derivatives. The round ligament connects the uterine cornu, enters the inguinal canal, and merges with the labia majora fat. On the right is the obliterated canal of Nuck, an ideal occurrence. On the left is the patent canal, which can predispose to hernias and hydrocele. F, fallopian tube; O, ovary.

The round ligament is covered by a fold of peritoneum forming the broad ligament ([Fig. 2]). The round ligament forms the superior margin of the broad ligament, which also contains the fallopian tubes, vessels, nerves, and loose connective tissue.[1] Two-thirds of the round ligament is intraperitoneal, and one-third is extraperitoneal in location. The portion distal to the deep inguinal ring, within the inguinal canal and beyond, is extraperitoneal. This division is important as diseases that spread via the round ligament once involve the extraperitoneal portion can require a change in the management or more extensive treatment strategies.[4] The blood supply is by the Sampsons artery, a branch of the inferior epigastric artery that runs along the round ligament and constitutes an anastomosis between the uterine and the ovarian artery. The venous drainage is by the uterine vein or the ovarian vein. The lymphatics drain through superficial inguinal nodes (extraperitoneal portion) and internal iliac lymph nodes (intraperitoneal portion)[1]

Fig. 2 Laparoscopic image of the pelvic cavity: *, uterus; F, fallopian tubes; O, ovaries, B, broad ligament; white arrows: round ligaments.

Imaging Appearances: Normal

The imaging appearance of the normal round ligament reflects the histology. The ligament is comprised of muscle fibers, fibrotic tissue, a few vessels, and nerves, and hence appears as a smooth, hypointense band on both T1 and T2, which is made prominent by the surrounding fat ([Fig. 3D–F]). From the uterine cornu on either side, they run anterior to the external iliac vessels, within the inguinal canal, and ramify with the subcutaneous fat in the mons pubis.[5] On computed tomography (CT), it appears isodense to the muscle surrounded by the fat. The presence of ascites identifies the ligament easily ([Fig. 3A–C]). Ultrasound appearances are variable from iso- to hyperechoic and difficult to delineate from adjacent fat unless accompanied by a patent canal that appears anechoic/hypoechoic.

Fig. 3 (A) Axial and (B, C) coronal computed tomography sections of the pelvis show round ligaments (white arrows) surrounded by fat, along the inguinal canal to merge with labial fat. Round white circles are inferior epigastric vessels. (D) Axial and (E) coronal T2 magnetic resonance imaging show hypointense smooth round ligaments (white arrows). (F) Coronal oblique postcontrast T1 with fat saturation shows homogenous and smooth enhancement of the round ligaments (white arrow).

The thickness is variable with age and since the development parallels the mullerian duct embryologically, the thickness probably corresponds to the size of the uterus. The postmenopausal atrophic uterus has thin sometimes nontraceable round ligaments. Any deviation from the normal hypointensity on MR should alert underlying pathology.

Clinical Implications of Round Ligament

The round ligament along with the broad ligament offers secondary support system for the uterus. The round ligament is implicated in maintaining the anteversion and anteflexion of the uterus.[6] In a pregnant uterus, there is undue stretching and hypertrophy of the round ligament, which can be symptomatic in some individuals, causing round ligament pain.

Plication of round ligaments or uterine ventrosuspension is indicated in retroverted retroflexed uteri to manage dysmenorrhea and deep dyspareunia[7] ([Fig. 4A]). It is routinely done in cases of isthmocele with a retroverted uterus as ventrofixation reduces the strain at the suture line and promotes better wound healing at the defected uterine scar site.

Fig. 4 (A) Intraoperative image depicting oophoropexy (O) to round ligament (RL) done in cases of recurrent ovarian torsion. (B) Combined ovarian ligament (OL) plication and round ligament oophoropexy. (C) Kakinuma method of vaginal vault fixation to the round ligament.

Combined utero-ovarian and round ligament oophoropexy is a novel oophoropexy procedure that may reduce the risk of recurrent torsion[8] ([Fig. 4B]).

The Kakinuma method involves suturing and fixation of round ligaments on both sides, effectively lifting the vaginal stump after laparoscopic hysterectomy[9] ([Fig. 4C]).

The round ligament can act as a route for the spread of diseases. Since it bridges the intraperitoneal space to the extraperitoneal space, pathologies such as endometriosis, infection, and malignant neoplasms can spread along the ligament and present as extraperitoneal lesions or masses. Spread along the round ligaments is more favored on the right side probably due to the direction of peritoneal fluid circulation and relative protection on the left by the sigmoid colon[4] [10]

Primary tumors of the round ligament are rare with leiomyoma and mesothelial cysts among the common lesions reported in the literature.[11] [12]

Persistence of the processus vaginalis beyond 1 year of life can result in congenital hernias where the herniation is almost always through the canal of Nuck into the inguinal canal lateral to the inferior epigastric vessels. Contents can be the intestine, genitalia, or both. The latter if it contains ovaries carries the risk of torsion or ischemia.[2]

Round Ligament as a Landmark

The round ligament serves as a surgical landmark to differentiate interstitial pregnancy from angular pregnancy. It is essential to understand the differences since the management and outcomes are different for each type of ectopic pregnancy.

Interstitial pregnancy is an ectopic pregnancy implanted in the interstitial part of the fallopian tube and close to the uterine musculature and implant lateral to the round ligament, whereas angular pregnancy (pregnancy in the normal cornual region of the uterus) implants medial to the round ligament, at the lateral angle of the endometrial/uterine cavity, and just medial to the uterotubal junction[13] ([Fig. 5]).

Fig. 5 (A) Laparoscopic image of interstitial pregnancy (*). (B) The relation of the gestational sac (*) to the round ligament (arrows) whose attachment is noted medial to the pregnancy differentiating from angular pregnancy.

True broad ligament fibroids arise from the intraperitoneal portion of the round ligament or utero-ovarian ligament that contains smooth muscle cells. Distinction from false broad ligament fibroids, which arise from the lateral wall of the uterus corpus or cervix and bulge outward between the layers of broad ligament, is made by demonstrating a groove between the uterus and the fibroid on laparoscopy, with the round ligament inseparable from the mass[14] ([Fig. 6]). Additional demarcation is by demonstrating the relation of mass with the ureter, which is medially displaced in a true broad ligament fibroid.

Fig. 6 (A) Intraoperative images of the pseudo-broad ligament fibroid arising from the right lateral wall of the uterus. (B) True broad ligament fibroid arising in between the leaves of the broad ligament and lateral to the ureter.

Since round ligaments can be easily identified on imaging modalities such as CT and MR imaging (MRI), they can be used as landmarks to diagnose certain pathologies with confidence.

Accessory and cavitated uterine mass (ACUM) is a rare mullerian anomaly where there is a separate noncommunicating endometrium-lined cavity surrounded by myometrium-like smooth cells, separate from the normal endometrial cavity. Patients present with dysmenorrhea or postmenstrual pain.[15] This entity can be confused with cystic adenomyosis or red degeneration of the fibroid. Confident diagnosis can be made on MR as ACUM typically presents as a lateral myometrial mass below the round ligament attachment to the uterus[16] [17] ([Fig. 7]).

Fig. 7 (A) Coronal and (B) axial T2-weighted image shows a well-defined cavitary mass containing hemorrhage (*) indenting the normal endometrium (E) consistent with ACUM. White arrows point to the round ligament related superiorly to the mass. (C) Intraoperative image shows the relation of the cavity (*) to the round ligament (white arrow).

Mayer–Rokitansky–Kuster–Hauser (MRKH) syndrome is one of the causes of primary amenorrhea in adolescent girls who otherwise have normal secondary sexual characteristics. A variable spectrum of imaging findings are seen including absent or hypoplastic uterus with or without rudimentary horns. Rudimentary horns are common in MRKH in up to 92% of cases.[18] They are seen as nodular masses isointense to myometrium with or without an endometrium lining on either side consistently caudal to the corresponding ovary. The rudimentary horns are in line/attached to the round ligaments explaining its location caudal to the ovary. Interference in the nonunion of mullerian ducts probably leads to distal migration of the rudimentary horns along the round ligament ([Fig. 8]). In suspected cases of MRKH, a careful review of MR images focusing along the round ligaments is warranted to pick the rudimentary horns. [Table 1] summarizes the round ligament as a landmark and localizing tool.

Fig. 8 (A) Axial and (B) coronal T2-weighted magnetic resonance shows nodular isointense structures in the lateral pelvic wall bilaterally (dashed arrows) located caudal to the ovaries (circle) and seen attached to the round ligament (solid arrow). (C) Inset shows the laparoscopic image of rudimentary horns (dotted arrow) attached to the round ligament (solid arrow).

Table 1 Round ligament as a landmark and localizing tool

Sl. no.	Condition	Clue
1	Interstitial and angular pregnancy	Implantation in interstitial pregnancy is lateral to the round ligament
2	True and false broad ligament fibroid	Presence of a groove between the uterus and the broad ligament in true fibroid and may be inseparable from the round ligament if arising from the same
3	Accessory and cavitated uterine mass (ACUM)	Typically in the lateral myometrial wall below the curve of the round ligament separate from the normal endometrial cavity
4	Rudimentary horns in MRKH (Mayer–Rokitansky–Kuster–Hauser) syndrome	Horns are seen along and attached to the round ligament
5	Right iliac fossa abscess	Differentiate between an abscess of appendicular or tubo-ovarian origin based on whether the abscess is lateral or medial to the round ligament

Pathologies of Round Ligament: Role of Imaging

Ultrasonography (USG) is the preferred initial imaging modality for female pelvic pathologies. Although direct visualization of the intraperitoneal portion of the round ligament is not possible on USG, the inguinal component is easily accessed due to its superficial location. USG is especially reliable for the diagnosis of inguinal masses related to round ligament including canal of Nuck cyst/hydrocele, congenital hernias, lymphadenopathy, and tumors ([Fig. 9]).

Fig. 9 Ultrasonography of the left inguinal region in a female shows an elongated cystic lesion (*) with thin septations, suggestive of canal of Nuck hydrocele.

CT poses radiation risk and offers relatively poor contrast for pelvic organ assessment. Gross pathologies like mass, cyst, varices, or lymphadenopathy can be picked up ([Fig. 10]) and whenever feasible should be evaluated by MRI for better lesion characterization.

Fig. 10 (A) Axial, (B) sagittal, and (C) coronal contrast-enhanced computed tomography sections of the pelvis in a female with inguinal swelling shows an elongated cystic lesion in the right inguinal region with a “cyst in cyst” appearance (solid arrow) consistent with type 1 canal of Nuck hydrocele.

MRI is the preferred modality for the evaluation of round ligament–related pathologies as it offers the best contrast resolution and lesion characterization. Basic sequences along with susceptibility-weighted imaging (SWI), diffusion-weighted imaging, and post-contrast-enhanced sequences with subtraction should be done ideally or tailored according to the clinical suspicion ([Fig. 11]).

Fig. 11 (A) T2 axial section of the pelvis in a known case of endometriosis shows thickening of the left round ligament (white arrows) suggesting possible involvement. (B) Susceptibility-weighted imaging confirms the presence of hemorrhagic foci (endometriotic deposits) along the left round ligament (black arrow).

[Table 2] summarizes various round ligament–related pathologies.

Table 2 Various round ligament related pathologies

Infection

Endometriosis

Varices

Benign tumors: leiomyoma, mesothelial cyst, lipoma, dermoid, serous cystadenoma

Malignant Primary: leiomyosarcoma, PEComa (perivascular epithelioid cell tumor) Secondary: endometrial carcinoma, cervical carcinoma, ovarian epithelial carcinoma, gastric adenocarcinoma, and gallbladder carcinoma

Canal of Nuck related: hernia, cyst/hydrocele

Infection

Uterine and adnexal infection (pelvic inflammatory disease) can spread along the round ligament in similar means to tumor spread and can cause inguinal lymphadenopathy.[19] Involvement of the round ligament by the infectious process manifests as thickening and enhancement of the ligament in contiguity with the primary disease process ([Fig. 12]). In the case of a right iliac fossa abscess of uncertain origin, displacement of the round ligament can aid in differentiating a tubo-ovarian abscess from an appendicular abscess in addition to other imaging features.[19] Knowledge about the extent of infection can help in management decisions and better outcomes.

Fig. 12 (A, B) Axial and (C) coronal postcontrast T1 images show an infective collection in the right adnexa (circle) with contiguous extension along the right round ligament that appears thickened with enhancement (solid arrows) till its insertion to the mons. Dashed arrows indicate normal round ligaments on the left side.

Endometriosis

Deep infiltrating endometriosis predominantly affects the posterior structures such as the torus uteri and uterosacral ligaments. Involvement of round ligaments has a variable prevalence of 0.3 to 14%.[4] Since it is an atypical site of involvement with no specific clinical symptoms or signs, round ligament involvement is often overlooked, resulting in incomplete surgical clearance of the disease. In patients with coexisting endometriosis, dissemination of endometrial cells along the round ligament from the abdominal cavity is the more acceptable theory, and deposits are usually seen in the proximal part of the round ligament and the inguinal canal.[20] Isolated involvement of the inguinal portion by endometriosis advocates for the mullerianosis theory in patients without coexisting pelvic endometriosis.[21]

MR is the best modality for detecting round ligament involvement by endometriosis ([Fig. 13]). Common imaging findings are thickening, irregularity, and shortening of the ligament. T1 hyperintense foci, blooming of SWI, or just hypointense thickening can be seen.[22] [23] Surgical findings such as shortening, deviation, or thickening of the round ligaments have high positive predictive values for the diagnosis of endometriosis.[24] It is important to describe the endometriotic involvement of round ligaments in radiology reports to facilitate better surgical outcomes.[25]

Fig. 13 (A) Axial T1, (B) axial T2, and (C) coronal T2 images show significant thickening, irregularity, and tethering of the left round ligament (solid arrow) in a case of deep endometriosis. “*” refers to left ovarian endometrioma. (D) Axial T1 with fat saturation shows the presence of T1 hyperintense foci along the round ligament (dashed arrow) consistent with endometriotic deposits. (E) Intraoperative image showing endometriotic deposits involving the round ligament (solid arrows).

Round Ligament Varices

Round ligament varices are exclusively seen in pregnancy, especially beyond the second trimester due to hormonal influence and pressure on the pelvic veins. They typically present with painless or painful inguinal swelling, which may be clinically mistaken for hernia, lymphadenopathy, or abscess. USG is the imaging modality of choice and shows the classical “bag of worms” appearance composed of multiple dilated veins along the inguinal canal ([Fig. 14]). This can be confirmed by Doppler with augmentation by the Valsalva maneuver.[26] [27]

Fig. 14 (A) Grayscale ultrasonography and (B) Doppler of the right groin in a second-trimester pregnant woman who presented with palpable swelling show a clump of vessels with venous flow likely attributed to round ligament varices.

Benign Tumors

Leiomyomas and mesothelial cysts ([Fig. 15]) are commonly reported benign masses from round ligaments. Leiomyomas are very rare tumors of the round ligament that have a predilection for the right side extraperitoneal location.[11] [12] Clinically they present with inguinal or vulval masses and hence are mistaken for incarcerated hernia. They most often show hydropic degeneration.[28] MR can depict an elongated mass along the round ligament within the inguinal canal of in the vulva ([Fig. 16]). Heterogenous enhancement is often seen due to underlying degeneration. Surgical excision is the treatment of choice.

Fig. 15 T2-weighted (A) sagittal, (B) coronal, and (C) axial sections show a uniloculated cystic lesion (*) with thin septations in the supravesical region related to the left round ligament (arrows) and separate from ovaries—proven mesothelial cyst of the left round ligament.

Fig. 16 (A, B) Ultrasonography of the left inguinal region shows a heteroechoic elongated lesion in the region of the inguinal canal (solid arrow in a) with a deep component (dotted arrow in B). (C) Coronal postcontrast maximum intensity projection image shows the origin of the mass from the round ligament (bent arrow), which was subsequently confirmed on surgery as a round ligament fibroid with hydropic degeneration * refers to coexisting uterine intramural fibroid. Sagittal sections: (D) T1, (E) T2, and (F) T1 post-contrast show a dumbbell-shaped mass with partial enhancement of the hypointense areas.

Other rare benign tumors reported in the literature include lipoma, dermoid, and serous cystadenoma.[29] [30]

Malignant Tumors

A PubMed search for primary malignant round ligament tumors revealed two cases of leiomyosarcoma[31] [32] and two cases of malignant perivascular epithelioid cell tumor (PEComa)[33] [34] accounting for its extreme rarity. These are pathological diagnoses and imaging features grossly overlap those of benign leiomyomas.

Secondary involvement/spread to the round ligament is known and is through one of the pathways of uterine and ovarian lymphatic drainage along the round ligaments to the inguinal and femoral nodes[35] [36] ([Fig. 17]).

Fig. 17 (A) Axial, (B, C) coronal, and (D) sagittal T2-weighted images show a malignant lesion of the uterus (*) with involvement of the bilateral round ligaments (white arrows) with right inguinal lymphadenopathy (black arrow).

Case reports of the spread of endometrial, cervical, ovarian, gastric, and gallbladder carcinomas along the round ligament presenting with inguinal nodes are reported in the literature requiring special attention to such occurrences that need a change in management options and a more vigilant approach ([Fig. 18]).[37] [38] [39]

Fig. 18 (A, B) Contrast-enhanced computed tomography in axial section in a case of carcinoma stomach (circle in B) with peritoneal carcinomatosis (black arrow in B) shows thickening and enhancement of bilateral round ligaments (white arrows in A) suggestive of a malignant spread.

Canal of Nuck Pathologies

The processus vaginalis gets obliterated between the eighth month of gestation and 1 year of life in the craniocaudal direction. The portion that persists within the inguinal canal is called the “canal of Nuck.” It is related to the round ligament anteromedially within the inguinal canal.[2]

The patent canal of Nuck can be seen as a physiological finding in infants but poses a risk for herniation of abdominal contents. Both genital and intestinal herniation can occur, and like any other hernia, there is a risk of obstruction or incarceration, resulting in ischemia of the organ.

Canal of Nuck hydrocele is due to partial or complete obliteration of the processus vaginalis and classified into three types[40] based on shape and communication ([Fig. 19]). Type 1 is common and is shaped like a sausage, round or comma shaped, or has a “cyst in cyst” appearance. A sudden increase in size may be secondary to inflammation and clinically present like an irreducible hernia ([Fig. 10]). Type 2 is communicating and changes in size on straining or Valsalva maneuver. USG is the preferred modality to demonstrate the patent processus vaginalis ([Fig. 20]). Type 3 is uncommon, hourglass shaped due to compression in the center within the inguinal canal ([Fig. 21]).

Fig. 19 Illustration of the types of canal of Nuck cysts. (A) Type 1: sausage, round, and comma shaped. (B) Type 2: tubular and cystic communicating. (C) Type 3: hourglass shaped.

Fig. 20 (A, B) Ultrasonography of the right groin in a female with intermittent swelling at different intervals shows collapsed (arrows in A) and fluid-filled (arrows in B) elongated lesion suggestive of communicating type (type 2) of canal of Nuck hydrocele.

Fig. 21 (A) Ultrasound right inguinal region shows an elongated cystic lesion with thin septation within. T2 weighted magnetic resonance imaging in (B) sagittal and (C) axial planes show an elongated cystic lesion with a central waist (hourglass) in the inguinal canal (dotted arrow) suggestive of type 3 canal of Nuck hydrocele.

Hernia into the patent processus vaginalis can manifest in infancy or later age. The hernial sac can contain the genitalia such as ovaries, fallopian tubes, and uterus or intestines. The former is seen in infants. Isolated ovarian herniation is associated with the MRKH syndrome ([Fig. 22]). Mullerian anomaly in the MRKH syndrome probably interferes with normal obliteration of the processus vaginalis, resulting in ovarian descent into the inguinal canal. Herniated ovaries can undergo torsion and ischemic infarct.[41] [42] [43]

Fig. 22 (A) Ultrasonography of the inguinal region shows the ovary with follicles within the inguinal canal (white arrows) conforming to the shape of the canal. (B) Coronal computed tomography image shows bilateral ovaries within the inguinal canals. (C, D) Magnetic resonance in axial and sagittal planes show bilateral ovaries in the inguinal canal with an absent uterus (circle) consistent with MRKH (Mayer–Rokitansky–Kuster–Hauser) syndrome.

Conclusion

Round ligament and related pathologies are often overlooked. With the advent of cross-sectional imaging, especially MRI, details pertaining to the round ligament involvement by various pathologies aid in better management and outcomes.

Conflict of Interest

None declared.

Note

The round ligaments are a pair of fibromuscular cords that act as a secondary support to the uterus. Imaging plays an important role in the evaluation of pathologies of the round ligaments.

• References

• 1 Chaudhry SR, Chaudhry K. Anatomy, Abdomen and Pelvis: Uterus Round Ligament. Treasure Island, FL: StatPearls Publishing; 2024
• 2 Saguintaah M, Eulliot J, Bertrand M. et al. Canal of Nuck abnormalities in pediatric female patients. Radiographics 2022; 42 (02) 541-558
• 3 Brainwood M, Beirne G, Fenech M. Persistence of the processus vaginalis and its related disorders. Australas J Ultrasound Med 2020; 23 (01) 22-29
• 4 Gui B, Valentini AL, Ninivaggi V, Marino M, Iacobucci M, Bonomo L. Deep pelvic endometriosis: don't forget round ligaments. Review of anatomy, clinical characteristics, and MR imaging features. Abdom Imaging 2014; 39 (03) 622-632
• 5 Kaniewska M, Gołofit P, Heubner M, Maake C, Kubik-Huch RA. Suspensory ligaments of the female genital organs: MRI evaluation with intraoperative correlation. Radiographics 2018; 38 (07) 2195-2211
• 6 Craig ME, Sudanagunta S, Billow M. Anatomy, Abdomen and Pelvis: Broad Ligaments. Treasure Island, FL: StatPearls Publishing; 2024
• 7 Moawad NS. Laparoscopic Uterine Ventrosuspension. J Minim Invasive Gynecol 2018; 25 (07) S214
• 8 Smorgick N, Mor M, Dovev MN, Eisenberg N, Vaknin Z. Combined utero-ovarian and round ligament oophoropexy for recurrent torsion of normal adnexa: a case series. J Pediatr Adolesc Gynecol 2023; 36 (05) 484-487
• 9 Kakinuma T, Kaneko A, Kakinuma K, Imai K, Takeshima N, Ohwada M. New native tissue repair for pelvic organ prolapse: medium-term outcomes of laparoscopic vaginal stump-round ligament fixation. World J Clin Cases 2023; 11 (15) 3457-3463
• 10 Mashfiqul MA, Tan YM, Chintana CW. Endometriosis of the inguinal canal mimicking a hernia. Singapore Med J 2007; 48 (06) e157-e159
• 11 Ali SM, Malik KA, Al-Qadhi H, Shafiq M. Leiomyoma of the round ligament of the uterus: case report and review of literature. Sultan Qaboos Univ Med J 2012; 12 (03) 357-359
• 12 Wei L, Qin T, Chu J, Chong X, Wang W, Li P. A large leiomyoma of the round ligament: a case description and literature analysis. Quant Imaging Med Surg 2023; 13 (03) 1994-2000
• 13 Dhanju G, Goubran A, Zimolag L, Chartrand R, Matthew F, Breddam A. Distinguishing between cornual, angular and interstitial ectopic pregnancy: a case report and a brief literature review. Radiol Case Rep 2023; 18 (07) 2531-2544
• 14 Rajanna DK, Pandey V, Janardhan S, Datti SN. Broad ligament fibroid mimicking as ovarian tumor on ultrasonography and computed tomography scan. J Clin Imaging Sci 2013; 3: 8
• 15 Gupta S, Manchanda S, Vyas S, Malhotra N, Mathur SR, Kulshrestha V. Imaging features of accessory cavitated uterine mass (ACUM): a peculiar yet correctable cause of dysmenorrhea. Abdom Radiol (NY) 2023; 48 (03) 1100-1106
• 16 Jain N, Verma R. Imaging diagnosis of accessory and cavitated uterine mass, a rare mullerian anomaly. Indian J Radiol Imaging 2014; 24 (02) 178-181
• 17 Putta T, John R, Simon B, Sathyakumar K, Chandramohan A, Eapen A. Imaging manifestations of accessory cavitated uterine mass: a rare mullerian anomaly. Indian J Radiol Imaging 2021; 31 (03) 545-550
• 18 Hall-Craggs MA, Williams CE, Pattison SH, Kirkham AP, Creighton SM. Mayer-Rokitansky-Kuster-Hauser syndrome: diagnosis with MR imaging. Radiology 2013; 269 (03) 787-792
• 19 Revzin MV, Mathur M, Dave HB, Macer ML, Spektor M. Pelvic inflammatory disease: multimodality imaging approach with clinical-pathologic correlation. Radiographics 2016; 36 (05) 1579-1596
• 20 Li S-H, Sun H-Z, Li W-H, Wang S-Z. Inguinal endometriosis: ten case reports and review of literature. World J Clin Cases 2021; 9 (36) 11406-11418
• 21 Haghgoo A, Faegh A, Mostafavi SRS, Zamani HR, Ghahremani M. Inguinal endometriosis: a case series and review of the literature. J Med Case Rep 2024; 18 (01) 83
• 22 Piccolo CL, Cea L, Sbarra M. et al. Magnetic resonance roadmap in detecting and staging endometriosis: usual and unusual localizations. Appl Sci (Basel) 2023; 13 (18) 10509
• 23 Choudhary S, Fasih N, Papadatos D, Surabhi VR. Unusual imaging appearances of endometriosis. AJR Am J Roentgenol 2009; 192 (06) 1632-1644
• 24 Crispi CP, de Souza CA, Oliveira MA. et al. Endometriosis of the round ligament of the uterus. J Minim Invasive Gynecol 2012; 19 (01) 46-51
• 25 Rousset P, Florin M, Bharwani N. et al. Deep pelvic infiltrating endometriosis: MRI consensus lexicon and compartment-based approach from the ENDOVALIRM group. Diagn Interv Imag 2023; 104 (03) 95-112
• 26 García-Paredes LF, Torres-Ayala SC, Rivera-Hernández W, Rodriguez Mojica W. A case of round ligament varices presenting in pregnancy. Am J Case Rep 2017; 18: 1194-1197
• 27 Naik SS, Balasubramanian P. Round ligament varices mimicking inguinal hernia during pregnancy. Radiol Case Rep 2019; 14 (08) 1036-1038
• 28 Christodoulou IM, Angelopoulos A, Siaperas P. et al. Leiomyoma of the round ligament of the uterus mimicking inguinal hernia. Case Rep Surg 2018; 2018: 6702494
• 29 Açmaz G, Aksoy H, Aksoy Ü, Özyurt S, Esin E, Gökahmetoğlu G. An unusual abdominal cystic mass in the round ligament of the uterus: a case report. J Pediatr Adolesc Gynecol 2014; 27 (05) e101-e102
• 30 Genetzakis M, Lagoudianakis EE, Papadima A. et al. Inguinal dermoid cyst of the round ligament. A case report and review of the literature. Clin Exp Obstet Gynecol 2006; 33 (04) 249-251
• 31 Kaba M, Tokmak A, Timur H, Özdal B, Şirvan L, Güngör T. A rare case of leiomyosarcoma originating from the left round ligament of the uterus. J Exp Ther Oncol 2016; 11 (03) 237-240
• 32 Kirkham JC, Nero CJ, Tambouret RH, Yoon SS. Leiomyoma and leiomyosarcoma arising from the round ligament of the uterus. J Am Coll Surg 2008; 207 (03) 452
• 33 Badlaeva A, Tregubova A, Kruglyak D, Luzhina I, Asaturova A. Perivascular epithelioid cell tumor with uncertain malignant potential arising in the round ligament. Diagnostics (Basel) 2024; 14 (06) 616
• 34 Pattamapaspong N, Khunamornpong S, Phongnarisorn C, Pojchamarnwiputh S. Malignant perivascular epithelioid cell tumour of the round ligament mimics leiomyoma on computed tomography. Singapore Med J 2009; 50 (07) e239-e242
• 35 Soliman PT, Lu KH. Malignant diseases of the uterus: endometrial hyperplasia, endometrial carcinoma, sarcoma—diagnosis and management. Comprehensive Gynecology 2021; 32: 691-706
• 36 Plentl AA, Friedman EA. Lymphatic system of the female genitalia. The morphologic basis of oncologic diagnosis and therapy. Major Probl Obstet Gynecol 1971; 2: 1-223
• 37 Togami S, Kato T, Oi T. et al. A rare case of recurrent ovarian cancer presenting as a round ligament metastasis. World J Surg Oncol 2011; 9: 144
• 38 Ruiz-Casado A, Miliani C, López C, López M, Martin T, Pereira F. Round ligament metastatic gastric cancer as a finding in an inguinal surgery. Gastrointest Cancer Res 2012; 5 (04) 137-138
• 39 Giri S, Shah SH, Batra K. et al. Presentation and management of inguinal lymphadenopathy in ovarian cancer. Indian J Surg Oncol 2016; 7 (04) 436-440
• 40 Counseller VS, Black BM. Hydrocele of the canal of Nuck: report of seventeen cases. Ann Surg 1941; 113 (04) 625-630
• 41 Saini R, Bains L, Kaur T. et al. Ovarian inguinal hernia: a possibility in MURCS syndrome. J Ovarian Res 2021; 14 (01) 114
• 42 Kumar A, Kumar A, Anwer M, Kumar D. Case of mullerian agenesis presenting as bilateral inguinal hernia with left sided irreducibility in a 21 years old female: a rare case report. Int J Surg Case Rep 2023; 103: 107895
• 43 Mohanty HS, Shirodkar K, Patil AR, Rojed N, Mallarajapatna G, Nandikoor S. A rare case of adult ovarian hernia in MRKH syndrome. BJR Case Rep 2017; 3 (03) 20160080

Publication History

Article published online:
03 February 2025