Round ligament forms covering of the sac in an inguinal hernia in female children. Should it be preserved or ligated / transfixed. What would be long term implications of cutting the round ligament since they lend some support (false support of uterus) in adult life?
Mohan - How does one preserve round ligament esp in a complete sac? Its so closely adhered!! It may be possible in incomplete hernia but in complete hernia there is a risk of not doing a complete herniotomy, isnt there?
We transected it together with hernial sac, and transfixed it on aponeurosis.
Divide the round ligament and transfix the entire sac as low as possible.
Interesting second question that also applies in adult hernia surgery:
Dividing the round ligament certainly simplifies the subsequent (mesh) repair (as compared to male hernias). Most gynecologists and surgeons I have discussed this issue with, agree that the ligament has no function of interest. However, some state that transection of the round ligament may lead to an (in the patient's view) esthetically concerning "prolapse" of the major labium.
Anyone here who has any solid base of knowledge on that?
I divide it, and it is included in my transfixation at the level of the internal ring. It is a question which we ask ourselves, but alas have little evidence to direct us.
Dear Roy - Do you transfix the distal end too? or do you just cauterize it and leave it. In doing above have you ever encountered a hydrocele / residual swelling or ever a hematoma in distal end?
Dear Zahoor, in girls I will excise the distal sac. I find the sac can be separated easily by blunt dissection from it's attachments. I never use diathermy during inguinal surgery in children. I also always check for an ovary/Fallopian tube in a girl by opening the sac.
Zahoor,
After getting underneath the hernia sac (intracanalicular) in a girl I find that traction on the distal end displays an avascular plane of separation. Like my colleague Roy Kimble I don't use diathermy for paediatric herniotomy, and I've not had any distal bleeding. Having dissected away the distal end of the sac I can then open it to check for the absence of a sliding component at the deep ring. Then I transfix it, with the round ligament, at the deep ring.
I'm not aware of any evidence of problems in later life from division of the round ligament - at either the uterine or the labial end.
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