Open Jo urnal of Obstetr ics and Gynecology, 2011, 1, 136-138 OJOG
doi:10.4236 /ojog.2011.13025 Published Online September 2011 (
Published Online September 2011 in SciRes.
Intra-l i game ntous fibroid removed laparoscopically
Richard L. Heaton*, M. Sami Walid
Heart of Geor gi a Women’s Center, Warner Robins, USA.
E-mai l : *
Received 25 July 2011; revised 18 August 2011; accepted 25 August 2011.
In this paper, we report the case of a left round liga-
ment fibroid in a 24 year-old, gravida 0, female that
was successfully ma naged laparoscopically. Operativ e
findings also included severe adnexal adhesions bila-
terally, severe adhesions of the liver to the anterior
abdominal wall (Fitz-H ugh-Curtis syndrome), pig-
mented areas on the left tube, uterus and posterior
broad ligament (that proved to be endometriosis),
and low capacity bladder (450 cc at 70 cm water pre-
ssure) with florid glomerulations and Hunner’s ulcers
consistent with typical interstitial cystitis. Beside the
feasibility of laparoscopic management of intra-lig a -
mentous tu mors this c ase hi g hlight s the common mu l-
tifactorial nature of chronic pelvic pain and the fre-
quent association of endometriosis and interstitial
cysti tis.
Keywords: Intra-Ligamentous; Round Ligament;
Fibroid ; Leiomyoma; Pelvic Pain; Endo metrio sis;
Interstitial Cystitis
The round ligament of the uterus may rarely become the
site of oncologic formation, the most frequent histologic
type of which is leiomyoma [1]. Intra-round-ligament
fibro id may gro w at a ny po int a long the tra ck of t he li ga -
ment, from the uterine horns to the entry opening of the
inguinal canal, in the inguinal canal, or after exiting the
inguinal canal in the labia majora or mons pubis mimi-
cking therefore other mass lesions in the region such as
adenopathy or inguinal hernias [1-4]. Unlike other leio-
myomas, intra-ligamentous tumors can grow in already
hysterectomised patients [5]. In this paper, we report a
case of round ligament fibroid that was successfully
mana ged using a minimal i nvasive route.
A 24 year-old, gravida 0, 127 lb., 5 ft. 2 in., female
presented with complaints of chronic socially-co mp r o-
mising bleeding with right-sided pelvic pain. She had
elevated Pelvic Pain and Urgency/Frequency (PUF)
score of 10, positive potassium sensitivit y test (PST) and
positive anesthetic challenge test. On ultrasound, the left
ovary was normal but the right ovary appeared displaced
behind the uterus. There was slight endometrial hyper-
trophy (sounding to 8 cm).
The patient underwent diagnostic and operative lapa-
roscopy, hysteroscopy, and cystoscopy with hydrodisten-
sion. Operative findings were severe adnexal adhesions
bilaterally, severe adhesions of the liver to the anterior
abdominal wall (Fitz-Hugh-Curtis syndrome, Figure 1),
a tumor from the left round ligament (Figure 2), pig-
mented areas on the left tube, uterus and posterior broad
ligament, and low capacity bladder (450 cc at 70 cm
water pressure) with florid glomerulations and Hunner ’s
ulcers consistent with typical interstitial cystitis (Figu re 3).
Figure 1. Perihepatic adhesions consistent with Fitz-
Hugh-Curtis syndrome.
Figure 2. Leiomyoma at the anteriolateral left junction
of the round ligament with the peritoneum.
R. L. Heaton et al. / Open Journal of Obstetrics and Genecology 1 (2011) 136-138
Copyright © 2011 Sc iRes. OJOG
Fi gure 3 . Florid glomerulations and Hunner’s ulcers of
the bladder consistent with typical interstitial cystitis.
Extensive lysis of adhesions, biopsying of pigmented
areas and laparoscopic excision of the round ligament
tumor were performed. Hysteroscopically, both cornua
appeared to be normal and open; there was no evidence
of submucosal pigmentations consistent with adenomy-
osis. Pathologic report showed endometriosis and the
round ligament t umor proved to be a leiomyoma. Opera-
tive time was 65 minutes and blood loss was estimated at
100 cc.
The leiomyomatous tumor was located at the anterio-
lateral left ju nction o f the r ound ligame nt with t he per ito-
neum. Laparoscopic removal of interligementous fib-
roids is accomplished by traction counter traction with
either sharp or harmonic dissection taking care to coagu-
late any bleeding sites as encountered, to maintain a dry
field and optimal visualization to avoid injury to su-
rrounding structures. Removal of a tumor, if small, can
be done with an endopouch, and if large, morcellation is
Intra-ligamentous fibroids affecting the round ligament
are not common. During a busy gynsurgical career we
have seen intraligamentous fibroids involving the labia
majora, the lower third of the right lateral vaginal wall,
and the broad ligament of the uterus. It is important to
remember that a solid tumor any where in t he pelvi s ma y
be a fibroid. These misplaced tumors usually lead to
exploratory surgery to rule out more sinister lesions.
Since fibroids are hormone-sensitive they tend to grow
until menopause or until they outgrow their blood supply.
Therefore when seen during diagnostic laparoscopy it is
our recommendation to remove them and prevent a sub-
sequent exploratory surgery.
The other interesting aspect of this case is the coe-
xistent endometriosis and interstitial cystitis. We have
previously reported that in our retrospective series there
was a 60% comorbid state with endometriosis or adeno-
myosis when Interstitial cystitis (IC) is present [6]. We
are disturbed by the de-emphasis of the importance of
cystoscopy with hydrodistension in the evaluation of
possible IC. With such a high rate of comorbid disease, if
the patient is already under anesthesia for evaluation of
pelvic pain laparoscopically why would one pass up the
opportunity to diagnose a frequent comorbid disease and
get prognostic information based on anesthetic bladder
capacity? As it appears that prognosis for remission is
good with normal bladder capacity and progressively
worse ns with loss of bladder capacity [7]. Also since the
symptom complex for adenomyosis and endometriosis
overlap and adenomyosis can be confirmed but not ex-
cluded hysteroscopically it seems somewhat negligent
not to hysteroscope these patients. The senior author (Dr.
Heaton) in the past used a resectoscope to biopsy pig-
mented submucosal uterine lesions; the pathology unifor-
mally revealed ademomyosis. Endometriosis, adenomy-
osis and leio myomata develop in wome n of reprod uctive
age and regress after menopause or removal of ovaries,
indicating t hat they grow in an estrogen-dependent man-
ner. These diseases appear to have some co mmo n patho-
genetic pathways [8]. A recent study suggested that the
PVUII polymorphism of the ERalpha gene is associated
with the risk for end ometriosis, ade nomyosis, and leio m-
yomata [9].
We have reported previously on the common multi-
factorial nature of chronic pelvic pain [10]. This patient
is yet another example of this concept. It is our opinion
that if a patient has e no ugh cyclic pelvic pain to indicate
laparoscopy then hysteroscopy is warranted as well to
evaluate for possible adenomyosis. If endometriosis or
adenomyosis or an elevated PUF score is present it is
also our opinion that with the patient already asleep for
laparoscopy failing to take t he opportunity to confirm the
diagnosis of IC and obtain prognostic informatio n seems
to be less than optimal care especially with the patients
having a 50% chance of temporary relieve of IC sym-
ptoms for several mo nths after hydrodistension [7,11 ].
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