Deep Inguinal Ring Research Articles

Etiopathogenesis of oblique inguinal hernia, new concept of its surgical treatment, postoperative complications and their correction

Objective. To study the results of applying a new conceptual approach to the surgical treatment of oblique inguinal hernia in order to reduce the frequency of its recurrence and preserve the function of the male reproductive system. Materials and methods. The study is based on the results of topographic and anatomical examination of 50 unfixed male cadavers on the 1st day after death. As clinical material, 144 patients who were inpatients in the surgical department were involved in the study. Results. Patients of the main group (n=71) underwent hernioplasty according to the developed method. The control group included 73 patients operated on by the Lichtenstein method. The etiopathogenetic basis of oblique inguinal hernia and the causes of its recurrence, the frequency of which after open and laparoscopic use of mesh implants is 5 – 15%, were studied. It is after the use of these implants in the Lichtenstein operation that a complication no less important than recurrence occurs, which is a decrease or even loss of male reproductive function. Conceptually, the new approach is to eliminate the deep inguinal ring, move the spermatic cord under the transverse fascia, and create a new inguinal ring. Conclusions. The proposed method of hernioplasty has significant advantages over the Lichtenstein method of surgery, which are to prevent recurrence of the disease and preserve male reproductive function.

A rare case of transverse testicular ectopia associated with polyorchidism addressed by minimally invasive surgery: A case report.

This report describes the rare case of transverse testicular ectopia (TTE) associated with polyorchidism in a 16-month-old male, successfully managed through laparoscopic surgery. The patient presented with bilateral cryptorchidism, a palpable mass in the right inguinal canal and an absent left-side gonad. Ultrasound revealed three gonad-like structures. Laparoscopy identified duplicated and fused testes at the right deep inguinal ring, and a third testis in the right inguinal canal. Minimally invasive techniques positioned the duplicated testes in the right hemiscrotum and the single testis in the left hemiscrotum. Post-operative follow-up confirmed optimal scrotal positioning, with normal growth. This rare case underscores the efficacy of laparoscopy in diagnosing and managing rare paediatric conditions, providing valuable insights for surgeons facing cryptorchidism or scrotal masses.

CYSTIC INGUINAL LYNFHANGIOMA IN ADULT FEMALE

Abstract Background To present a clinical case of cystic inguinal lymphangioma in an adult female, an atypical site and age of presentation. Method A 42-year-old woman was referred for consultation due to persistent pain and swelling in the right inguinal region, with initial suspicion of inguinal hernia. A mobile, irreducible mass without protrusion during the Valsalva maneuver was identified. Faced with diagnostic uncertainty, inguinal ultrasound and magnetic resonance imaging were requested, revealing a cystic lesion indicative of cystic inguinal lymphangioma. Results Elective surgery was decided. A right inguinal incision revealed a cystic tumor extending along the inguinal canal from the labium majus to the preperitoneal space. Complete excision was performed, requiring section of the round ligament. Subsequently, closure of the deep inguinal ring was conducted, with the conjoint tendon approximated to the inguinal ligament using a continuous suture of slowly absorbable monofilament. Hernioplasty with self-adhesive polypropylene mesh was employed to repair the inguinal defect. The procedure was carried out in the ambulatory major surgery program. At the one-month post-surgery follow-up, the patient exhibited satisfactory recovery with no signs of clinical recurrence. Histopathological examination of the surgical specimen confirmed the diagnosis of cystic inguinal lymphangioma, with no additional pathological findings. Conclusion Cystic lymphangioma is a benign and uncommon malformation of the lymphatic system. It should be considered in cases of inguinal masses with progressive growth whose examination is not consistent with an inguinal hernia. Ultrasound is the imaging test of choice, with definitive diagnosis confirmed by histopathology. Surgery with complete resection is recommended due to the risk of recurrence.

Does the contralateral testicular volume decide the need for diagnostic laparoscopy in cases of unilateral impalpable undescended testis?

BackgroundThis study aimed the evaluation of the value of the calculated volume of a normal testis to predict the status of its contralateral impalpable side and hence decide the importance of laparoscopic exploration.MethodsPatients with unilateral impalpable undescended testis – as confirmed by clinical and sonographic examination- were enrolled in our prospective interventional study between November 2018 and August 2022 at Elshatby University Hospital, Faculty of Medicine, Alexandria University. The volume and three-dimensional diameter of the normal contralateral testis were measured by the pre-operative US using the formula: Volume = L x W x H x π/6, where L is the length, W is the width, H is the height, and was correlated with the intra-operative laparoscopic findings.ResultsSeventy-six patients were included in our study. The age of the studied patients ranged between 6 months and 4 years with a mean of 2.17 ± 1.30 years; most of them were between one and three years old. Forty-six patients (60.5%) have left-sided impalpable testis and 30 patients (39.5%) have right-sided impalpable testis. The calculated volume of the contralateral normal testis was significantly larger in those patients who had both blind ending vas and vessels (0.89 ± 0.16) and in those who had an atrophic testis passing through the deep inguinal ring (DIR) –which was excised through the inguinal region- (0.83 ± 0.20) than in those patients who had their testes intra-abdominal (0.53 ± 0.18) or passing through the DIR to the inguinal region (0.80 ± 0.19). (Kruskal Wallis test; p < 0.001*).ConclusionsThe calculated sonographic volume of a normal testis can predict the status of its contralateral impalpable side significantly with sensitivity & specificity of 75.0% & 88.89% respectively and a cut-off point of ≤ 0.674; hence, helps in parent counselling preoperatively.Trial registrationName of the registry: Clinicaltrials.gov PRS. Trial registration number: NCT05933811. Date of registration: 10-7-2023 (retrospectively registered). URL of trial registry record: https://clinicaltrials.gov.

Totally laparoscopic surgery for a hydrocele of the canal of Nuck extending from the abdominal cavity to the subcutaneous space: a case report

BackgroundHydrocele of the canal of Nuck (HCN) is a rare disease, and its indications for laparoscopic surgery are not well-established.Case presentationA 53-year-old woman was referred to our hospital due to an uncomfortable thumb-sized inguinal mass. Preoperative computed tomography scan and magnetic resonance imaging revealed a hydrocele extending from the abdominal cavity around the left deep inguinal ring via the inguinal canal to the subcutaneous space. The patient was diagnosed with HCN protruding into the abdominal cavity and extending to the subcutaneous space. Laparoscopy can easily access the hydrocele protruding into the abdominal cavity. Furthermore, laparoscopic hernioplasty can be superior to the anterior approach for females. Hence, laparoscopic surgery was performed. After transecting the round ligament of the uterus, a tense 3-cm hydrocele was dissected with it. In order to approach the hydrocele distal to the deep inguinal ring, the transversalis fascia was incised medially to the inferior epigastric vessels. The subcutaneously connected hydrocele was excised from the incision. Then, the enlarged deep inguinal ring was reinforced using a mesh with the laparoscopic transabdominal preperitoneal approach. The patient was discharged 2 days postoperatively. Laparoscopic resection can be more effective for a hydrocele protruding into the abdominal cavity as it facilitates an easy access to the hydrocele. Moreover, laparoscopic resection of a hydrocele extending from the inguinal canal to the subcutaneous space via a transversalis fascia incision can be safer, with low risk of injury to the inferior epigastric vessels. The incised transversalis fascia and the enlarged deep inguinal ring due to the HCN were simultaneously repaired with the laparoscopic transabdominal preperitoneal repair. There are two reports on laparoscopic resection via a transversalis fascia incision for HCNs located between the inguinal canal and the subcutaneous space, which does not require intraperitoneal hydrocelectomy. However, this is the first report on laparoscopic resection of large HCNs protruding into the abdominal cavity and extending beyond the inguinal canal into the subcutaneous space via intraperitoneal hydrocelectomy and a transversalis fascia incision.ConclusionsLaparoscopic surgery with transversalis fascia incision can be useful for HCNs extending from the abdominal cavity to the subcutaneous space.

Comparison of Laparoscopic Needle-Assisted Extra-Corporeal Inguinal Hernia Repair with Intracorporeal Inguinal Hernia Repair in Terms of Postoperative Recurrence

Objective: To compare laparoscopic needle-assisted extra-corporeal hernia repair regarding recurrence in children with intracorporeal repair. Study Design: Retrospective longitudinal study. Department of Paediatric Surgery, Pak Emirates Military Hospital, Rawalpindi Pakistan, from Jul 2019 to Dec 2020. Methodology: Retrospectively, all patients who underwent laparoscopic herniotomy were searched through hospital records.Ninety-seven patients matched the inclusion criteria out of 148 laparoscopic surgeries. All patients were diagnosed with inguinal hernia based on history and clinical examination. Fifty-one patients underwent laparoscopic needle-assisted repair (LNAR) with extra-corporeal knotting, whereas 46 underwent repair with intracorporeal knotting of the deep inguinal ring. Pneumoperitoneum was created in all cases by open method. All patients were followed up for six months outdoors for recurrence. Results: The age of patients ranged from 1-12 years; the mean age of study patients was 5.29±3.17 years. Regarding the inguinal hernia site, 45(46.4%) had a right-sided hernia, and 52(53.6%) had a left-sided hernia. All operations were completed laparoscopically. There were no intraoperative complications. A total of 2(3.53%) patients developed recurrence, one from each group, 2.17% in Group-A and 1.96% in Group-B, with no statistically significant difference between the two groups after six months of follow-up (p-value=0.942). Conclusion: Extra-corporeal knotting in children with inguinal hernia is an effective, quick and safe technique. It is comparable to the standard intracorporeal knotting technique in terms of recurrence.

Hydrocele of the Canal of Nuck: A report of five cases

Introduction and importanceCanal of Nuck hydrocele is a rare condition in females. Due to mild symptoms, it may be neglected, leading to complications, including infection and bleeding. The rarity of this condition, coupled with its potential for adverse outcomes, necessitates a high index of suspicion among treating surgeons to diagnose and promptly manage the case. We present five cases of the canal of Nuck hydrocele. Case presentationWe prospectively studied five cases of the canal of Nuck hydrocele admitted to our surgical department over two years. Three patients presented with painless, non-tender inguinal swelling, while two had tenderness. Three patients had a right-sided canal of Nuck hydrocele, one had a left-sided, and one had bilateral hydroceles. One patient had an associated indirect inguinal hernia. All patients were treated by carefully dissecting the hydrocele from the round ligament, followed by ligation of the canal of Nuck near the deep inguinal ring. The associated hernia was treated using herniotomy. All patients had an uneventful postoperative course with no recorded postoperative wound infection or recurrence. Clinical discussionThe hydrocele of the Canal of Nuck develops from the failure of complete obliteration of the processus vaginalis in female patients. Most cases are asymptomatic and are usually found incidentally as painless swelling in the inguinolabial region. Surgery is the treatment of choice, as there is an increased incidence of associated complications such as infection and bleeding, and it also helps to confirm the diagnosis. The surgical procedure involves resection of the hydrocele, ligation of the neck of the processus vaginalis, and repair of any associated hernia, if present. ConclusionThe canal of Nuck hydrocele is often overlooked in female pediatric patients with inguinolabial masses. Surgeons must maintain a high index of suspicion and perform prompt ultrasound examinations for an accurate diagnosis. Early surgical intervention is of utmost importance for preventing morbidity.

V-049 THE IMPORTANCE OF PROCTORING- MISSING THE “TEN GOLDEN RULES” OF TAPP

Abstract Claus in 2020 published the “Ten golden Rules” for a minimally Invasive safe approach to the Myopectineal Orifice. During the first proctoring session of a TAPP procedure for the repair of a left side inguinal hernia we revised the application of the rules by the trainee. The proctor invited the trainee to study the paper before the session of surgery. The first and the last 3 rules were followed by the trainee but there was a lack of the 4-5-6-7 rules. The knowledge of the anatomy of the inguinal region allows the surgeon to create a preperitoneal box for a mesh at least 15×15cm covering all the possible origins for hernia. In particular we focused our attention to the rule 7. The trainee was missing to check the emptiness of the deep inguinal ring that was covered, in the iliopubic tract, by fat sliding to the scrotal region. After dissection a big cord lipoma was reduced in the abdomen. Missing this rule should be a problem because the patient could feel,after the inguinal hernia repair, a bulging and discomfort in the inguinal region. The imaging could not be helpful and the clinical visit could report a “false Positive” for the presence of bulging without a real hernia. In a similar case we reoperate a man after a TAPP procedures for a bulging in inguinal region, pain and discomfort miming a recurrence but we only found a large cord lipoma that we resected.

Towards automatic verification of the critical view of the myopectineal orifice with artificial intelligence.

Visualization of key anatomical landmarks is required during surgical Trans Abdominal Pre Peritoneal repair (TAPP)of inguinal hernia. The Critical View of the MyoPectineal Orifice (CVMPO) was proposed to ensure correct dissection. An artificial intelligence (AI) system that automatically validates the presence of key and marks during the procedure is a critical step towards automatic dissection quality assessment and video-based competency evaluation. The aim of this study was to develop an AI system that automatically recognizes the TAPP key CVMPO landmarks in hernia repair videos. Surgical videos of 160TAPP procedures were used in this single-center study. A deep neural network-based object detector was developed to automatically recognize the pubic symphysis, direct hernia orifice, Cooper's ligament, the iliac vein, triangle of Doom, deep inguinal ring, and iliopsoas muscle. The system was trained using 130 videos, annotated and verified by two board-certified surgeons. Performance was evaluated in 30 videos of new patients excluded from the training data. Performance was validated in 2 ways: first, single-image validation where the AI model detected landmarks in a single laparoscopic image (mean average precision (MAP) of 51.2%). The second validation is video evaluation where the model detected landmarks throughout the myopectineal orifice visual inspection phase (mean accuracy and F-score of 77.1 and 75.4% respectively). Annotation objectivity was assessed between 2 surgeons in video evaluation, showing a high agreement of 88.3%. This study establishes the first AI-based automated recognition of critical structures in TAPP surgical videos, and a major step towards automatic CVMPO validation with AI. Strong performance was achieved in the video evaluation. The high inter-rater agreement confirms annotation quality and task objectivity.

An unusual association of type II Mayer-Rokitansky-Kuster-Hauser syndrome, turner mosaic syndrome and tubo-ovarian inguinal hernia– case report and review of literature

BackgroundHerniation of ovaries and Mullerian structures into inguinal canal is usually reported in infants and is rare among adults. We are presenting a rare case of Mullerian agenesis and Turner mosaic syndrome with tubo-ovarian inguinal hernia.Case presentationA 17-year-old girl presented with complaints of primary amenorrhea, phenotypical features of Turner syndrome with left inguinal hernia and severe hypertension. Baseline hormonal analysis was normal. Karyotype revealed Turner mosaic with 46XX (85%); 45XO (15%). MRI showed Mullerian agenesis with normally located right ovary in pelvis and left ovary prolapsed through deep inguinal ring into the canal of Nuck. Anti-hypertensives were started and patient optimized for surgery. Laparoscopic hernia repair and repositioning of left ovary into the pelvis was done. Patient had uneventful post-operative course and was discharged in stable condition on anti-hypertensive medication. Future reproductive issues and need of passive vaginal dilatation or vaginoplasty before marriage were explained to the patient and family.ConclusionThis is the first ever reported case with unusual association of atypical MRKH, Turner mosaic syndrome and tubo-ovarian hernia into the inguinal canal. The case emphasizes the need and importance of complete work up of these atypical cases as patients may have more than one cause of primary amenorrhea and complete evaluation is must before any medical or surgical intervention.

CAUSES OF INGUINAL HERNIAS RECURRENCE DURING THE LIECHTENSTEIN OPERATION

Numerous methods of plastic surgery of inguinal hernias with own tissues, which were developed by surgeons, gave relapses up to 35%. A large number of relapses in the treatment of inguinal hernias with tension methods forced surgeons to look for new ways to solve this problem.&#x0D; Without pathological changes in the deep inguinal ring, a hernia cannot occur, and this leads to the conclusion that all existing methods, which are aimed at strengthening only the front wall of the inguinal canal, are pathogenetically unfounded and often a recurrence of the hernia can be expected.&#x0D; Therefore, a justified operation for various types of inguinal hernia is the strengthening of the deep ring and the back wall of the inguinal canal.&#x0D; Changing the concept of the approach to the treatment of inguinal hernias should be aimed at minimizing trauma and take into account the pathogenetic features of the development of hernias.&#x0D; The reason for the development of inguinal hernias is expansion, destruction, functional insufficiency of deep inguinal openings: medial and lateral.&#x0D; The back wall of the inguinal canal does not have a protective function when intraperitoneal pressure increases and cannot resist hernia formation. At the same time, its weakening, destruction can contribute to the increase of the internal inguinal opening. Although we did not come across any publication that gave an example of a hernia exiting directly through the back wall of the inguinal canal.&#x0D; Based on our own clinical experience, as well as the processing of a large number of literary sources, we offer a modified type of Lichtenstein's operation in the following interpretation: a typical incision of the skin and subcutaneous tissue with the opening of the aponeurosis of the external oblique abdominal muscle; mobilization of the spermatic cord; mobilization of the hernia sac, its opening, stitching at the base and removal. With a direct inguinal hernia, if the bag is small, there is no need to remove it. Revision of the internal inguinal ring in case of an oblique hernia and, if necessary, sewing it to the required size (the tip of the little finger should pass between the cord and the ring).&#x0D; Revision of the medial deep ring in direct inguinal hernia and its suturing "tightly" over the hernial protrusion.&#x0D; Prepare a mesh implant so that its dimensions cover both deep holes, dissect it according to our proposed method. Fix the net to the deep ring using the described method. Sew the lower part of the mesh with an overlap of 1-1.5 cm to the pubic bone, fix the lateral edge of the implant to the pubic ligament with a wrapping suture or knotted single sutures.&#x0D; Above the spermatic cord, the legs of the dissected implant are sewn together and sewn to the aponeurosis of the external oblique muscle of the abdomen from below.&#x0D; The medial edge of the mesh is sewn to the internal oblique muscle and to the aponeurosis of the external oblique muscle in the manner described above.&#x0D; The middle part of the mesh is fixed to the sewn medial deep inguinal ring and to the middle of the inguinal canal with separate knotted stitches. We lay the spermatic cord on the mesh, over which we sew the aponeurosis of the external oblique muscle of the abdomen, subcutaneous tissue and skin.&#x0D; In our opinion, the method of surgery proposed by us for direct and oblique inguinal hernias is the most optimal, minimally traumatic, which best meets the modern requirements of the pathogenesis of the disease. But even this method of plastic inguinal hernias is not ideal and needs constant improvement.

Paediatric laparoscopic inguinal hernia repair: Level of disconnection of peritoneal cuff - An observational study.

Inguinal hernia is a common surgical condition in children. Conventionally, the open approach for inguinal hernia repair has been considered the gold standard. However, in the past two decades, laparoscopic inguinal hernia repair has gained popularity among paediatric surgeons as an alternative to the open approach. Apart from good cosmesis and shorter stay at hospital, laparoscopy offers clear-cut advantages of visualising contralateral site and simultaneous repair if it is patent. Many techniques for laparoscopic inguinal hernia repair have been proposed. In this retrospective observational study, we are comparing outcomes between proximal and distal disconnection of hernia sac. Ninety-five patients with inguinal hernia were studied in two groups. Group A included 50 patients in which hernia sac was disconnected from the peritoneal cuff proximal to deep inguinal ring (DIR). Group B included 45 patients in which hernia sac was disconnected distal to DIR. Various sociodemographic parameters and intraoperative findings were compared. Outcomes were analysed in terms of post-operative pain, duration of stay at the hospital and recurrences. In group A, there were 46 males and four females with mean age of 4.01 years with standard deviation (SD) of 2.96. Group B included 37 males and eight females with mean age of 5.09 years with SD of 3.56. Excess post-operative pain was observed in 33 patients in Group A with proximal disconnection of hernia sac whereas it was seen in only three patients in Group B with distal disconnection of sac. The P was 0.001 which was highly significant. The duration of stay in the hospital was more in Group A (2.36 ± 1.22 days) as compared to Group B (1.8 ± 0.66 days) with a P of 0.0076 which was significant. Hernia recurrence was seen in four out of 50 patients in Group A (8%) as compared to no recurrence in Group B. However, the difference was not significant. The disconnection of hernia sac distal to DIR is associated with less post-operative pain and shorter duration of hospital stay. There is less recurrence seen in distal disconnection of hernia sac as compared to proximal disconnection; however, to achieve the level of significance, a large cohort study is required.

Абдоминальный крипторхизм на фоне полной диссоциации яичка и семявыносящего протока, имитирующей синдром тестикулярной регрессии.

Introduction. Complete separation of the deferent duct from the epididymis with the testicle in abdominal cryptorchidism cases is an extremely rare variation of abnormal development of genitals in boys. Available sources mention just 3 clinical cases similar to our observations. The unique anatomic details of the abnormality and extreme rarity of its exposure pave the way for a failure to reveal an intra-abdominal testis, and determine the need for particular attention during diagnostic laparoscopy. Materials and methods. Two patients with non-palpable left-sided cryptorchidism underwent a diagnostic laparoscopy, which revealed an intra-abdominal testis with epididymis on testicular vessels that was completely separated from the deferent duct. The difference between the described clinical cases was in the distance between the deep inguinal ring and the crossing of testicular vessels from the retroperitoneal location to the intraperitoneal position, which was approximately 3- 4 cm in the first patient and 4-5 mm in the second one. The second difference was in the "closed" deep inguinal ring found on the left side in the first case while the second patient had a patent processus vaginalis case. In both cases an incision was made in the left inguinal area, the inguinal canal was opened, and exploration thereof revealed blind-ended deferent ducts. The testicle in both cases was brought down through the inguinal canal and attached in the scrotum. Results. No complications occurred during the early postoperative care period, the check-up examination in 6 months following the surgery revealed no signs of testis atrophy or malposition in both patients. Conclusion. In diagnostic laparoscopy for abdominal cryptorchidism, it is important to consider the possibility of complete separation of the testicle and vas deferens. Detection of the deferent duct passing through the «closed» deep inguinal ring together with hypoplastic vessels does not rule out the chances for an ipsolateral intra-abdominal testis; therefore, a careful examination of the abdominal cavity along the embryological testicular migration path is necessary.

8995 Laparoscopic Hernia Repair in a Patient with Mayer-Rokitansky-Kuster-Hauser Syndrome, Turner Mosaic Syndrome and Tubo-Ovarian Hernia

<h3>Study Objective</h3> To report a rare case of Mullerian agenesis and Turner mosaic syndrome with tubo-ovarian inguinal hernia <h3>Design</h3> Case report. <h3>Setting</h3> Department of Obstetrics & Gynecology of a tertiary care referral center. <h3>Patients or Participants</h3> A 17-year-old girl presented with complaints of primary amenorrhea, phenotypical features of Turner syndrome with left inguinal hernia and severe hypertension. <h3>Interventions</h3> Baseline hormonal analysis was normal. Karyotype revealed Turner mosaic with 46XX (85%); 45XO (15%). MRI showed Mullerian agenesis with normally located right ovary in pelvis and left ovary prolapsed through deep inguinal ring into the canal of Nuck. Anti-hypertensives were started, and patient optimized for surgery. Laparoscopic hernia repair and repositioning of left ovary into the pelvis was done. <h3>Measurements and Main Results</h3> Patient had uneventful post-operative course and was discharged in stable condition on anti-hypertensive medication. Future reproductive issues and need of passive vaginal dilatation or vaginoplasty before marriage were explained to the patient and family. <h3>Conclusion</h3> This is the first ever reported case with unusual association of atypical MRKH, Turner mosaic syndrome and tubo-ovarian hernia into the inguinal canal.

Bladder injury in an incarcerated inguinal hernia in a pediatric patient

Bladder injury is a relatively uncommon side effect of inguinal hernia surgery. One of the causes is bladder ears, i.e. , protrusions of the urinary bladder across the deep inguinal ring. Here, we presented a case of bladder injury during inguinal hernia surgery that was found intraoperative and successfully repaired without any sequelae for long-term follow up after surgery. A 10-month-old male came to the emergency department with a chief complaint of swelling and pain on the groin and profuse vomiting. Fluid resuscitation and manual reduction was performed but failed. Therefore, we decided to perform emergency surgery. We accidently opened the bladder during the surgery since mimicking the hernia sac. Fortunately, this injury was found intraoperatively. Subsequently, we repaired the bladder injury, followed by hernia repair. The patient was discharged uneventfully on a post-operative day 7. The patient was regularly followed up for approximately two years after surgery. No sequelae were noted. In conclusions, bladder injury is a rare case that might be occurred during an incarcerated inguinal hernia repair. Surgeons, particularly young surgeons or trainees should be aware of the possibility of bladder ears that might mimic the hernia sac and injured during the hernia repair. • Bladder injury is a rare case that might be occurred during an incarcerated inguinal hernia repair. • Bladder ears might be mistaken as a hernia sac during treatment for inguinal hernias, resulting in bladder injury. • Surgeons, particularly young surgeons or trainees should be aware of the possibility of bladder ears that might mimic the hernia sac and injured during the hernia repair.

Novel modification of Marcy operation for indirect inguinal hernia reconstituting deep inguinal ring shutter action.

The two most frequent and significant complications after inguinal hernia repair are hernia recurrence and post-herniorrhaphy chronic pain. To add anatomic and physiologic strength to the tissue repair, especially in indirect inguinal herniorrhaphy, we devised a modification of Marcy operation that can reconstitute inguinal shutter action more efficiently by changing the direction of the sutures vertical to horizontal. During 36months from 1st Jan. 2019, 148cases of 140 patients were operated for Indirect inguinal hernia or Pantaloon hernia (11 cases). 145 indirect inguinal herniorrhaphy were performed exclusively with author's modification of Marcy operation. Hernia recurrence during the follow-up period (3months-36months), and postoperative chronic pain at 3months after herniorrhaphy were analyzed. 104 cases among the 145 indirect inguinal hernia (71.7%) were operated with only deep inguinal ring (DIR) reconstruction as author modified. In 41 cases (28.3%), posterior wall reconstruction was done simultaneously. There was no recurrence or reoperation case during the follow-up period. The incidence of postoperative chronic pain at postoperative 3months of VAS greater than 3.0 was 2.2% (3 cases). Author's modification of Marcy operation was feasible anatomically in all indirect inguinal hernia repair, which is theoretically superior to classic Marcy operation in that repositioning the DIR more laterally and securing the obliquity and shutter action of the DIR. Result is at least not inferior in the aspect of short-term recurrence and chronic post-herniorrhaphy pain.

A patent processus vaginalis is a requirement for a laparoscopic orthotopic staged spermatic vessel-sparing procedure for intra-abdominal undescended testis

PurposeLaparoscopic orthotopic traction orchidopexy is a modification of the Shehata orchidopexy approach. Spermatic cord length is achieved by passing the testis through the inguinal canal, under tension, and securing the testis to the ipsilateral scrotal base. Spermatic vessels are not divided. Following intra-operative review of this technique, we present practical considerations.MethodsWe attempted the laparoscopic orthotopic traction approach in a 2-year-old boy presenting with bilateral undescended testes.ResultsIn the presence of a closed deep inguinal ring, traction of testis into the scrotum is necessarily non-orthotopic and increases risks associated with the procedure.ConclusionA closed ring should be considered a contra-indication to performing laparoscopic orthotopic traction orchidopexy.

Enterocutaneous fistula from a perforated incarcerated Littre inguinal hernia in an infant

Inguinal hernia is a common surgical condition encountered of pediatric age group. Inguinal hernia may get incarcerated and if strangulated, it requires prompt intervention. Rarely incarcerated bowel can perforate leading to formation of entero-cutaneous fistula. Littre's hernia is the protrusion of a Meckel diverticulum through a potential abdominal opening. A one and half months old infant presented with an irreducible right inguino-scrotal swelling and faecal discharge from the scrotum for a month. Patient was passing stools from normal anal opening as well. Patient underwent exploratory laparotomy which revealed an incarcerated right inguinal hernia containing long ruptured Meckel's diverticulum of size 8 cm passing from deep inguinal ring to right hemiscrotum. Diverticulectomy with ileo-ileal end to end anastomosis with right herniotomy was done. The main complication of inguinal hernia is incarceration, which may result in bowel obstruction. Spontaneous intestinal-cutaneous fistula from incarcerated inguinal hernia with Meckel's diverticulum as content in neonates and infants is a rare occurrence and hitherto only one such case has been reported in the world literature. Prompt and early seeking of medical facility of patients with incarcerated inguinal hernias is necessary to reduce their morbidity and mortality.

Revisiting the surgical anatomy of the triangle of doom and the triangle of pain.

Better understanding of the surgical anatomy of the triangle of doom and the triangle of pain with fixed bony landmarks like the anterior superior iliac spine (ASIS) and the pubic symphysis (PS) can help in defining a safe location for trocar placement during laparoscopic surgeries and minimize neurovascular complications. Ten cadavers were dissected bilaterally to explore the surgical anatomy of both the triangles. ASIS and PS were evaluated in relation to the deep inguinal ring, external iliac artery, femoral nerve, and inferior epigastric artery. The deep inguinal ring was located at a depth of ~3 cm, about 4.9 ± 0.56 cm along the y-axis and 6.2 ± 0.94 cm along the x-axis, from the ASIS. The external iliac artery was located ~4.33 ± 0.6cm along the y-axis and 7.29 ± 0.76 along the x-axis from the ASIS. The inferior epigastric artery was at ~4.31 ± 0.38 cm from the midline at the level of ASIS. This knowledge can help in the surface localization of both the triangles and prevent injury to the various neurovascular structures in relation to these triangles. In the current study, cranial to the ASIS lying at a distance of >5cm from the midline was observed to be a safe zone for accessory trocar placement. The umbilical port has been observed to be safe for trocar placement. The mean angle between ductus deferens and testicular vessels was observed to be 43.5° ± 4.79°, which could help in determining their relative locations during various surgical procedures.

Rare case of inguinal ureteral hernia in a child diagnosed by drip infusion pyelography-computed tomography.

Introduction and importanceInguinal hernias are the most commonly experienced disease in pediatric surgery. However, it is rare for the organs of the urinary system to prolapse as the contents of the hernia.Case presentationWe report a case of a 14-year-old boy with congenital paraperitoneal inguinal herniation of the ureter. Intraoperatively, we found an unfamiliar tubular loop structure arising from the deep inguinal ring in the left inguinal canal. The tubular structure, which may have been part of the ureter, was left in the inguinal canal to avoid damage. Postoperative drip infusion pyelography-computed tomography showed anatomical irregularity of the ureter in the inguinal canal. Follow-up in the 5th postoperative year showed no recurrence of hydrocele and complications associated with ureteral obstruction.Clinical discussionInguinal ureteral hernias are rarely reported in children. Paraperitoneal inguinal hernias are reported to be associated with vesicoureteral reflux and posterior urethral valve. Patients rarely present with symptoms like those observed in our case report. Whilst general surgical treatment is to return the ureter to the retroperitoneal space, we opted to leave the ureter in the inguinal canal to avoid unnecessary damage. However, this intraoperative management resulted in slight hematuria. The ureter should be placed back where it belongs, and postoperative monitoring using computed tomography may be important.ConclusionThis case provides valuable insight into preoperative diagnostic difficulties and intra- and postoperative management of an inguinal ureteral hernia in children, highlighting the importance of accurate diagnosis and appropriate surgical intervention in the treatment of this disease.