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Round ligament management during minimally invasive groin hernia repair in women: a systematic review and meta-analysis

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Abstract

Background

Female sex has been associated with worse outcomes after groin hernia repair (GHR), including a higher rate of chronic pain and recurrence. Most of the studies in GHR are performed in males, and the recommendations for females extrapolate from these studies, even though females have anatomy intricacies. The round ligament of the uterus (RLU) is associated with pelvic stabilization and plays a role in sensory function. Transection of the RLU during GHR is controversial as it can allow easier mesh placement but can favor genitourinary complications and chronic pain. As no previous meta-analysis compared preserving versus transecting the RLU during minimally invasive (MIS) GHR, we aim to perform a systematic review and meta-analysis evaluating surgical outcomes comparing the approaches.

Methods

Cochrane Central, Embase, and PubMed databases were systematically searched for studies comparing transection versus preservation of the RLU in MIS groin hernia surgeries. Outcomes assessed were operative time, bleeding, surgical site events, hospital stay, chronic pain, paresthesia, recurrence rates, and genital prolapse rates. Statistical analysis was performed using RevMan 5.4.1. Heterogeneity was assessed with I2 statistics. A review protocol for this meta-analysis was registered at PROSPERO (CRD 42023467146).

Results

1738 studies were screened. A total of six studies, comprising 1131 women, were included, of whom 652 (57.6%) had preservation of the RLU during MIS groin hernia repair. We found no statistical difference regarding chronic pain, paresthesia, recurrence rates, and postoperative complications. We found a longer operative time for the preservation group (MD 6.84 min; 95% CI 3.0–10.68; P = 0.0005; I2 = 74%).

Conclusion

Transecting the RLU reduces the operative time during MIS GHR with no difference regarding postoperative complication rates. Although transection appears safe, further prospective randomized studies with long-term follow-up and patient-reported outcomes are necessary to define the optimal management of RLU during MIS GHR.

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Authors and Affiliations

  1. Bahiana School of Medicine and Public Health, Rua Dom João VI, 275, Salvador, BA, 40290-000, Brazil

    C. A. B. Silveira, A. C. D. Rasador & M. G. Fernandez

  2. Cleveland Clinic, Cleveland, OH, USA

    S. Mazzola Poli de Figueiredo

  3. Beth Israel Deaconess Medical Center, Boston, MA, USA

    R. R. H. Martin

  4. Washington University in St. Louis, St. Louis, MO, USA

    Y. J. M. Dias

  5. University of Texas Medical Branch, Galveston, TX, USA

    R. Lu

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  1. C. A. B. Silveira
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  7. R. Lu
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Correspondence to C. A. B. Silveira.

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Disclosures

Dr. Richard Lu received payment from Intuitive Surgical for lectures unrelated to this work. Carlos Silveira, Dr. Sergio Mazzola Poli de Figueiredo, Ana Rasador, Miguel Fernandez, Dr. Rafael Martin, Dr. Yasmin Dias have no conflicts of interest or financial ties to disclose.

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Silveira, C.A.B., de Figueiredo, S.M.P., Rasador, A.C.D. et al. Round ligament management during minimally invasive groin hernia repair in women: a systematic review and meta-analysis. Surg Endosc 38, 1731–1739 (2024). https://doi.org/10.1007/s00464-024-10721-1

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