CASE REPORT A laparoscopic approach to Nuck’s duct endometriosis Jesus S. Jimenez, M.D.,a Patricia Barbero, M.D.,b Alvaro Tejerizo, M.D.,a Carmen Guillen, M.D.,a and Carol Strate, M.D.b a
Department of Gynecological Endoscopic Surgery, and b Department of Obstetrics and Gynecology, Hospital 12 de Octubre, Madrid, Spain
Objective: To report a case of uncommon endometriosis located in the Nuck’s duct and its laparoscopic resolution. Design: Case report. Setting: Gynecologic department at 12 de Octubre University Hospital, Madrid. Patient(s): A 35-year-old woman, gravida 1 para 1, presented with an inguinal right mass. She had a right nephrectomy because of acute pyelonephritis. Computed tomography showed a cystic lesion that was suggestive of a Nuck’s duct cyst. Fine-needle aspiration cytology was performed, and endometriosis was determined. Intervention(s): Cyst removal and closure of the internal inguinal ring’s defect by the laparoscopic approach. Main Outcome Measure(s): Disease free. Result(s): The intervention was successfully performed by laparoscopic approach. The postoperative evolution was good, and the patient was discharged 2 days after surgery. Conclusion(s): Inguinal or Nuck’s duct are both uncommon locations for endometriosis; therefore, it is difficult to suspect in patients without a surgical history. Once identified, the treatment involves removal of the endometrioma and repair of the internal inguinal ring. A laparoscopic approach should be considered when possible. (Fertil Steril 2011;-:-–-. 2011 by American Society for Reproductive Medicine.) Key Words: Endometriosis, uncommon location, Nuck’s duct, inguinal, laparoscopic
Endometriosis is a chronic estrogen-dependent condition, which has an incidence of around 8%–15% in fertile women (1). The ectopic endometrial tissue can be placed anywhere in the body, but implants are usually located in the pelvis. Several theories have been proposed to explain the pathogenesis of endometriosis. The implantation theory and the direct transplantation theory can explain pelvis-located endometriosis. Retrograde menstruation is the most accepted theory. Immunological factors, such as alteration in the function of peritoneal macrophages, lymphocytes, and natural killers, explain the adhesion and proliferation of endometrial tissue (2). However, the etiopathogenetic basis of extrapelvic locations is not clear. The dissemination theory (through lymphatic and blood vessels) and the coelomic metaplasia theory can explain these rare locations (1, 3). The most frequent symptoms associated with endometriosis are chronic pelvic pain, dysmenorrhea, dyspareunia, dyschezia, and subfertility. The physical findings are of minor importance and include tenderness when palpating the posterior fornix, palpable tender nodules, thickening and induration of uterosacral ligaments, and tender and enlarged adnexal masses when ovarian endometriosis is present (4). Received March 18, 2011; revised May 20, 2011; accepted May 25, 2011. J.S.J. has nothing to disclose. P.B. has nothing to disclose. A.T. has nothing to disclose. C.G. has nothing to disclose. C.S. has nothing to disclose. nez, M.D., Servicio de Ginecologıa y Obs S. Jime Reprint requests: Jesu stetricia, Hospital Universitario ‘‘12 de Octubre,’’ Avda. Andalucıa s/n. 28041 Madrid, Spain (E-mail:
[email protected]).
0015-0282/$36.00 doi:10.1016/j.fertnstert.2011.05.083
The Nuck’s duct is the portion of the processus vaginalis within the inguinal canal in women. Failure to eliminate the processus vaginalis results in a direct or an indirect inguinal hernia. Rarely, a hydrocele forms if a sac of serous fluid is retained. A hydrocele of the canal of Nuck is equivalent to an encysted hydrocele of the cord in men (5).
CASE REPORT The patient was a 35-year-old woman, gravida 1 para 1. In 2003, she had a right nephrectomy because of acute pyelonephritis and secondary hypertrophy of her left kidney developed. There was no other surgical or medical history. She noticed a tender mass of 3 cm in her right groin. She first noticed it 1 year earlier when the tumor was present only during menstruation. It turned into a constant mass, which grew and became painful when she menstruated. She had no other symptoms such as dysmenorrhea, dyspareunia, or pelvic pain, and she menstruated regularly. She was transferred to our clinic with the suspected diagnosis of inguinal endometriosis. Computed tomography (CT; Fig. 1) showed a simple cystic lesion in the right inguinal area, which measured around 6 cm in its largest axis. The lesion was connected in its base with the round ligament and the parietal peritoneum, with the most probable diagnosis being a Nuck’s duct cyst. Fine-needle aspiration cytology was also performed, which showed endometriosis. Magnetic resonance imaging (MRI) was also performed to better evaluate the structures involved and to search for other pelvic or extrapelvic
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FIGURE 1 CT performed with intravenous portal contrast. A cystic lesion, which measures 55 mm at its larger axis, is shown. The lesion is located in the upper area of the right groin. The CT image suggests a Nuck’s duct cyst, but other cystic lesions such as lymphangioma cannot be excluded. Parietal peritoneum defect above the internal inguinal ring. This is an indirect hernia form, which courses parallel to the round ligament and develops toward the labia majora.
Jimenez. Nuck’s duct endometriosis. Fertil Steril 2011.
endometriosis implants (6) to plan the most suitable approach for the surgery. Transvaginal ultrasound was performed to evaluate the internal genital structures and showed a regular uterus, a normal left ovary, and a 2-cm cyst in the right ovary with the ultrasound appearance of a typical endometrioma.
The intervention was executed by the laparoscopic approach. An open-access technique with a Hasson trocar was performed owing to the left kidney hypertrophy. Three accessory trocars were needed, one in each iliac fossa and another in the paraumbilical location. The uterus and adnexa were normal, and no endometrial implants were found. A defect of the parietal peritoneum
FIGURE 2 Cystic structure beginning in the inguinal duct through a defect of the parietal peritoneum in the inguinal internal ring area. Dissection of the internal inguinal ring was performed with bipolar grasper and scissors. Once the duct was opened, the cyst was removed and placed in an extraction bag for its extraction through the hole of the principal trocar (umbilicus level). The extraction is usually performed at the end of the surgery after verification of hemostasis.
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(Fig. 3). The postoperative period was normal, and the patient was discharged 2 days later in good health.
FIGURE 3 After dissection and identification of the abdominal wall structures, the defect of the parietal peritoneum was repaired and a polyurethane mesh placed to reinforce the inguinal internal ring area. The mesh was fixed to the abdominal wall by intracorporeal suturing.
Jimenez. Nuck’s duct endometriosis. Fertil Steril 2011.
(Fig. 1) at the inguinal canal was detected, with a saccular structure inside (Fig. 2). The cyst was removed (Fig. 2), and the defect of the internal inguinal ring was repaired and reinforced with mesh
DISCUSSION Extrapelvic endometriosis is a rare condition, and its diagnosis remains a challenge for gynecologists. An umbilical or scar location (like in a cesarean delivery or episiotomy) may be suspected in patients with a previous surgical history, but, as in this case, the clinical findings may not suggest this condition. The processus vaginalis has its embryological origin in the parietal peritoneum of the anterior abdominal wall. The coelomic metaplasia theory suggests that coelomic epithelium-related tissues and M€ ullerian-derived epithelia of the adult have a shared embryological origin. The tissues derived from the coelomic epithelium have the potential to differentiate into M€ ullerian epithelium or stroma (2, 3, 4). MRI and CT (6, 7) can help with the diagnosis, but it is also easy to confuse inguinal endometriosis with a complicated inguinal hernia or a lymphangioma. In a patient without a history of endometriosis, the gynecologist should consider endometriosis in the differential diagnosis when clinical symptoms, such as sporadic and recurrent pain that coincides with the menstrual period or growth of the mass during menstruation, are present. The recommended treatment is excision of the cyst and closure of the ring defect, which is usually performed through a small access in the skin (5). In this case, a laparoscopic approach was successfully executed with the advantage of a shorter recovery period; therefore, this minimally invasive procedure should be considered when treating inguinal endometriosis (8, 9).
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5. Li Destri G, Iraci M, Latino R, Carastro D, Li Destri M, Di Cataldo A. [Intestinal obstruction from undiagnosed rectal and ileal endometriosis. Two clinical cases and review of the most recent literature]. Ann Ital Chir 2010;81:383–8. 6. Chin-Jung W, An-Shine Ch, Tzu-Hao W, Chun-Te W, Angel Chao, Chyong-Huey L. Challenge in the management of endometriosis in the canal of Nuck: case report. Fertil Steril 2009;91:936.e9–11.
7. Sharma JB, Karmakar D, Hari S, Singh N, Singh SP, Kumar S, et al. Magnetic resonance imaging findings among women with tubercular tubo-ovarian masses. Int J Gynaecol Obstet 2011;113:76–80. 8. Kr€uger K, Behrendt K, Balzer M, H€ohn S, Ebert AD. Relevance of MRI for endometriosis diagnosis. Fortschr R€ontgenstr 2011;183:423–31. 9. Yen CF, Wang CJ, Chang PC, Lee CL, Soong YK. Concomitant closure of patent canal of Nuck during laparoscopic surgery: case report. Hum Reprod 2001;16:357–9.
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