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Management of Hernias in Pregnancy
LETTERS
Management of Hernias in Pregnancy Frank FA IJpma, MD, Kristien M Boddeus, MD, Harm H de Haan, MD, PhD, Dick van Geldere, MD, PhD Zwolle, The Netherlands We compliment Dr Buch and colleagues for their well written paper: “Management of hernias in pregnancy.”1 But some remarks about the differential diagnosis of an inguinal swelling during pregnancy are required, because it contributes to the therapeutic management. Round ligament varicosities (RLV) during pregnancy can easily be mistaken for an inguinal hernia because they share the same clinical appearance.2 RLV may emerge during pregnancy as swelling and tenderness in the groin provoked by increased intraabdominal pressure. Progesteronemediated venous smooth muscle relaxation, a raised cardiac output causing increased venous return from the limbs and leading to engorgement of venous tributaries, and most important, pelvic venous obstruction by the gravid uterus, contributes to RLV formation during pregnancy. The incidence is unknown, but it is probably an underdiagnosed phenomenon. RLV can be diagnosed by duplex sonography, showing a prominent venous plexus with accompanying dilated draining veins in the inguinal canal, with dilatation and flow augmentation during Valsalva maneuver (Fig. 1). A wait-and-see policy is justified in case of an asymptomatic reducible groin mass based on RLV. After delivery, when pelvic venous obstruction by the gravid uterus is relieved, spontaneous resolution will occur in most patients. In case of a symptomatic reducible groin mass, duplex sonography is recommended, because it can help in differentiating RLV from other causes of groin swelling in pregnancy, so unnecessary surgical exploration may be avoided. Depending on the severity of symptoms and the additional diagnostic information from duplex sonography, the optimal treatment of either a wait-and-see policy or surgical excision and ligation of the RLV should be considered. Although RLV is frequently a self-limiting condition, immediate surgical exploration and excision of the varicose veins are sometimes necessary. Infrequently, rupture or thrombosis of the varicose round ligament may occur and produce an intensely painful groin swelling, which is clinically indistinguishable from a strangulated
© 2009 by the American College of Surgeons Published by Elsevier Inc.
Figure 1. Duplex sonography showing the characteristic ultrasound appearance of round ligament varicosities during pregnancy.
inguinal hernia. Emergency surgery is indicated to alleviate pain and to exclude a strangulated hernia, with its potential devastating effect on pregnancy. The authors advocate “watchful waiting” and postpartum herniorrhaphy for an inguinal swelling emerging during pregnancy. But before herniorrhaphy is undertaken, they should consider RLV, which may occur especially during pregnancy and is frequently a self-limiting condition, as a potential cause of inguinal swelling during pregnancy. By increasing the attention on RLV and by highlighting the advantage of duplex sonography, we hope RLV will be recognized and unnecessary operation will be avoided.
REFERENCES 1. Buch KE, Tabrizian P, Divino CM. Management of hernias in pregnancy. J Am Coll Surg 2008;207:539–542. 2. IJpma FF, Boddeus KM, de Haan HH, et al. Bilateral round ligament varicosities mimicking inguinal hernia during pregnancy. Hernia 2008;Jul 2. [Epub ahead of print].
Reply Kerri Buch, RN, FNP, Parissa Tabrizian, MD, Celia M Divino, MD, FACS New York, NY We appreciate Drs IJpma, Andriessen, and their colleagues’ interest and comments on our recent article, “Management of hernias in pregnancy.”1 Drs IJpma and Andriessen would like to emphasize the importance of round ligament varicosities (RLV) in the differential diagnosis of a reducible groin mass in pregnant women. Although RLV may mimic an inguinal hernia, it is an exceedingly rare phenomenon. A thorough literature search revealed only 15 cases
320
ISSN 1072-7515/09/$36.00 doi:10.1016/j.jamcollsurg.2008.11.002
Management of Hernias in Pregnancy Frank FA IJpma, MD, Kristien M Boddeus, MD, Harm H de Haan, MD, PhD, Dick van Geldere, MD, PhD Zwolle, The Netherlands We compliment Dr Buch and colleagues for their well written paper: “Management of hernias in pregnancy.”1 But some remarks about the differential diagnosis of an inguinal swelling during pregnancy are required, because it contributes to the therapeutic management. Round ligament varicosities (RLV) during pregnancy can easily be mistaken for an inguinal hernia because they share the same clinical appearance.2 RLV may emerge during pregnancy as swelling and tenderness in the groin provoked by increased intraabdominal pressure. Progesteronemediated venous smooth muscle relaxation, a raised cardiac output causing increased venous return from the limbs and leading to engorgement of venous tributaries, and most important, pelvic venous obstruction by the gravid uterus, contributes to RLV formation during pregnancy. The incidence is unknown, but it is probably an underdiagnosed phenomenon. RLV can be diagnosed by duplex sonography, showing a prominent venous plexus with accompanying dilated draining veins in the inguinal canal, with dilatation and flow augmentation during Valsalva maneuver (Fig. 1). A wait-and-see policy is justified in case of an asymptomatic reducible groin mass based on RLV. After delivery, when pelvic venous obstruction by the gravid uterus is relieved, spontaneous resolution will occur in most patients. In case of a symptomatic reducible groin mass, duplex sonography is recommended, because it can help in differentiating RLV from other causes of groin swelling in pregnancy, so unnecessary surgical exploration may be avoided. Depending on the severity of symptoms and the additional diagnostic information from duplex sonography, the optimal treatment of either a wait-and-see policy or surgical excision and ligation of the RLV should be considered. Although RLV is frequently a self-limiting condition, immediate surgical exploration and excision of the varicose veins are sometimes necessary. Infrequently, rupture or thrombosis of the varicose round ligament may occur and produce an intensely painful groin swelling, which is clinically indistinguishable from a strangulated
© 2009 by the American College of Surgeons Published by Elsevier Inc.
Figure 1. Duplex sonography showing the characteristic ultrasound appearance of round ligament varicosities during pregnancy.
inguinal hernia. Emergency surgery is indicated to alleviate pain and to exclude a strangulated hernia, with its potential devastating effect on pregnancy. The authors advocate “watchful waiting” and postpartum herniorrhaphy for an inguinal swelling emerging during pregnancy. But before herniorrhaphy is undertaken, they should consider RLV, which may occur especially during pregnancy and is frequently a self-limiting condition, as a potential cause of inguinal swelling during pregnancy. By increasing the attention on RLV and by highlighting the advantage of duplex sonography, we hope RLV will be recognized and unnecessary operation will be avoided.
REFERENCES 1. Buch KE, Tabrizian P, Divino CM. Management of hernias in pregnancy. J Am Coll Surg 2008;207:539–542. 2. IJpma FF, Boddeus KM, de Haan HH, et al. Bilateral round ligament varicosities mimicking inguinal hernia during pregnancy. Hernia 2008;Jul 2. [Epub ahead of print].
Reply Kerri Buch, RN, FNP, Parissa Tabrizian, MD, Celia M Divino, MD, FACS New York, NY We appreciate Drs IJpma, Andriessen, and their colleagues’ interest and comments on our recent article, “Management of hernias in pregnancy.”1 Drs IJpma and Andriessen would like to emphasize the importance of round ligament varicosities (RLV) in the differential diagnosis of a reducible groin mass in pregnant women. Although RLV may mimic an inguinal hernia, it is an exceedingly rare phenomenon. A thorough literature search revealed only 15 cases
320
ISSN 1072-7515/09/$36.00 doi:10.1016/j.jamcollsurg.2008.11.002