Inguinal Exploration Research Articles

Long-term outcome of gender assignment in individuals with 46, XY DSD assigned female sex in multicultural society

The decision regarding sex rearing in patients with Disorders of Sex Development (DSD) is heavily connected to the shared decision-making model within multidisciplinary team. Some of these patients might develop gender dysphoria, when they become adults. We have aimed to evaluate the long-term outcomes of patients with XY DSD who underwent female gender assignment at our center. We have conducted a retrospective study of all 46, XY DSD patients who underwent female assignment in our institution over the last 30 years. we have found 25 46, XY patients who were raised as a female after birth. After excluding the Androgen insensitivity syndrome (AIS) patients we have identified 15 patients who have matched study criteria. The decision on gender rearing was made by the parents in 11(74%) and by the surgical team 2(13%) during hernia repair/inguinal exploration. In 2(13%) cases, the patients opted to continue identifying as women after learning about the pathology during adolescence. Nine (60%) out of 15 patients (age17.9±4.7 years (mean±SD)) agreed to answer questionnaires regarding sexual function and satisfaction from gender assignment. Mean follow up was 11.1±8.2 years (mean±SD). only one participant consented to respond to a questionnaire regarding sexual intercourse (homosexual). The overall FSFI score was 24 which included the scores 4, 4, 3, 4, 3, 2 in the categories desire, arousal, lubrication, orgasm, satisfaction, and pain respectively. Two patients regretted the decision of female gender assignment. The first with 5α-reductase deficiency, he made the decision for assignment himself as an adult and the other (3β-hydroxysteroid dehydrogenase) who underwent gonadectomy during inguinal exploration as a child. The rest of the patients were satisfied with the choice of gender, 2 need psychological support on the daily basis. In the study group, relationship and cohabitation were significantly later in life compared to the general population. Despite the sensitivity of the subject and cultural differences, most patients (78%) were satisfied with the decision to undergo female gender assignment. Over the years, patients require meticulous follow-up in order to consider additional interventions, and mental support if it is necessary. The two cases of later regret highlight the importance of proper education of patients, their families and medical providers upon decision on gender assignment.

(025) Laparoscopic Assisted Reservoir Removal of an Infected Inflatable Penile Prosthesis in a Patient with Ipsilateral Inguinal Hernia Mesh Implant

Abstract Introduction Infection is a devastating complication of penile prosthesis implantation ranging from 0.33 to 11.4%. 1 Although a salvage procedure is an option in case of infection, the rule of thumb is to remove all device components. 2 Special considerations and pre-operative planning are essential for better outcome in the management of such condition. We are presenting a video case presentation demonstrating the use of laparoscopic assisted approach to aid in the extraction of the reservoir of an infected penile prosthesis from a patient who had ipsilateral inguinal hernia mesh implant Objective To demonstrate the feasibility and efficacy laparoscopic assisted approach in the removal of difficult to extract inflatable penile prosthesis (IPP) reservoir. Methods A 72-year-old gentleman with past medical history of Diabetes and hypertension presented to our clinic 3 weeks after an IPP insertion that was done in another center. He was complaining of right inguinal bulge and scrotal pain. The bulge developed suddenly without any preceding event. Examination confirmed a prosthesis reservoir herniation in to the right groin. Plan CT abdomen& pelvis confirmed the diagnosis. In three days, the herniated reservoir was managed by inguinal exploration, repositioning of the same reservoir in the right Retzius space and posterior inguinal canal wall repair using a mesh. The patient was discharged on post-operative day 1 in a stable condition, but unfortunately, he developed persistent scrotal pain that progressed into an overt scrotal infection over the early follow up period. During the examination, a scrotal collection was observed, swap was taken from the draining pus and results showed moderate growth of pseudomonas aeruginosa. On the other hand, the inguinal scar showed good healing with no tenderness, indicating the presence of an intact and non-infected inguinal mesh. Therefore, the decision was made to remove all components of the prosthesis without removing the mesh. Considering the anticipated challenges associated with removing the reservoir of the IPP through a scrotal approach, a decision was made to incorporate an additional laparoscopic-assisted abdominal approach for reservoir removal. Results Removal of the IPP cylinders and pump was performed through a scrotal incision, then a laparoscopic assisted abdominal approach was used successfully to remove the reservoir. After the IPP explant procedure, patient had an uneventful smooth recovery at the two and four weeks follow up visits, he was advised to use Vacuum erection device (VED) to alleviate possible penile fibrosis/shortening. A penile prosthesis reimplantation procedure was planned in a 6 months period Conclusions Laparoscopic assisted approach for penile prosthesis reservoir extraction is a feasible and safe technique that can be used in anticipated cases of difficult reservoir extraction. Pre-operative assessment, planning and counselling are crucial in obtaining a favorable outcome in such complex cases. Disclosure No.

An inguinal surprise: strangulated femoral hernia

Femoral hernias account for 2% to 4% of groin hernias, are more common in women, and are more appropriate to present with strangulation and require emergency surgery. This condition may lead to symptoms of bowel obstruction or strangulation and possible bowel resection-anastomosis. There are few reports of strangulated femoral hernia. Femoral hernias, often, are usually delegated to a secondary differential or if even rarer not considered at all during dubious presentations as groin swellings which are irreducible without the classical features which have usually been described in our surgical literatures, Inguinal being forefront for diagnosis. We herein present a 45-year-old female had come to the outpatient department at MVJ MC and RH with the complaints of swelling in the left groin for 5 years and pain for 8 days sudden onset with irreducibility, with no features of small bowel obstruction. She was diagnosed as having a left side obstructed inguinal hernia after appropriate radiological investigations and underwent inguinal exploration. Intraoperative diagnosis of left sided strangulated femoral hernia with omentum as its content was made. Omentectomy with herniorrhaphy was done and post-operative period was uneventful, and patient was discharged with regular follow up. Femoral hernias are more common in women and lead to a substantial over risk for an emergency operation, and consequently, a higher rate of bowel resection and mortality. Femoral hernias should be operated with high priority to avoid incarceration and be repaired with a mesh.

Abdominoscrotal Hydrocele - Considerations.

The aim of the study was to highlight the pathology, clinical spectrum, and approach considerations in abdominoscrotal hydrocele (ASH). Our study included eight children with ASH from 2015 to 2022. The demographics, clinical presentation, investigations, operative details, and postoperative outcome were collected retrospectively from case files. The age of presentation ranged from 11 months to 2½ years. Six lesions were on the right side and two were on the left side. One child presented with an acute scrotum and underwent emergency inguinal exploration, revealing hemorrhagic fluid after trauma. Others presented with tense inguinoscrotal swelling, which was fully reducible but refilled promptly after emptying. Preoperative ultrasound showed the abdominal component in 50%, while others were detected intraoperatively. All of them were approached inguinally, and the hydrocele sac was traced proximally to the abdominal component through the internal ring. This was drained and a partial excision of the extraperitoneal sac was done. An additional patent processus vaginalis (PPV) was identified in 87%, dissected up to the deep ring, and ligated. On follow-up, there was no recurrence. ASH is an uncommon condition that should be identified and dealt with appropriately. Physical examination and ultrasonography are usually sufficient for diagnosis. The inguinal approach is a safe, simple method and an extension of the standard operation for the hydrocele. One must keep in mind to explore for an additional narrow PPV to prevent the recurrence of hydrocele.

Splenogonadal fusion: a case report

BackgroundAccessory splenic tissue is a commonly encountered phenomenon in medical literature. Typically, these accessory spleens are found in close proximity to the main spleen, either in the hilum or within the surrounding ligaments. Nevertheless, it is noteworthy that they can also be located in unusual sites such as the jejunum wall, mesentery, pelvis, and, exceptionally rarely, the scrotum. The first documented case of accessory splenic tissue in the scrotum was reported by Sneath in 1913 and is associated with a rare congenital anomaly called splenogonadal fusion. This report describes an infant who presented with a scrotal mass noted by his mother and after examination, investigations, and surgical exploration, it was revealed to be splenogonadal fusion.Case descriptionAn 8-month-old Caucasian male patient presented with a mass in the left testicle and bluish discoloration of the scrotum, which had been incidentally noticed in the previous 2 months. The general physical examination was unremarkable. Other than a palpable scrotal mass that was related to the upper pole of the testis, the rest of examination was unremarkable. Imaging revealed that this mass originated from the tail of the epididymis without infiltrating the testis and tumor markers were normal. On inguinal exploration, a reddish brown 2 × 2 cm mass was found attached to the upper pole and was completely excised without causing any harm to the testis, vessels, or epididymis. Histopathological evaluation confirmed the presence of intratesticular ectopic splenic tissue.ConclusionAlthough uncommon, splenogonadal fusion can be included in the differential diagnosis of a testicular swelling. Accurate diagnosis allows for appropriate treatment planning which helps to avoid unnecessary radical orchiectomy, which can have a significant impact on the patient’s reproductive and psychological wellbeing.

V-022 POSTOPERATIVE INGUINODYNIA: LAPAROSCOPIC NEURECTOMY AND MESH REMOVAL

Abstract Aim Chronic groin pain following a hernioplasty is a complication with an incidence of 10–12%. A multidisciplinary approach, including pain management services, interventional radiology and surgery, has proven the best outcomes. Persistence of symptoms and lack of efficacy of non-surgical treatments make surgical treatment with prosthetic removal and neurectomies an appropriate alternative. Material & Methods We present the clinical case of a 35-year-old male with a history of bilateral laparoscopic groin hernioplasty performed at another institution 10 years ago. After the surgery, he developed chronic groin pain, predominantly on the left side, and underwent multiple interventions. He complained that the pain was severe and incapacitating, affecting his quality of life. Dermatome mapping evidenced compromise of the three inguinal nerves (ilioinguinal, iliohypogastric and inguinal branch of genitofemoral). A multidisciplinary approach including NSAIDs, pregabalin, tricyclic antidepressants and periradicular blocks followed by radiofrequency ablation was established, without success. A laparoscopic left inguinal exploration with mesh removal and triple neurectomy was then decided. Results The patient had an adequate postoperative course. He returned to daily activities including sports practice, and no recurrence was observed after 1 year of follow up. Conclusions A multidisciplinary approach is suggested for the treatment of postoperative inguinodynia. Neurectomy and mesh removal is a safe and effective strategy, and must be considered for the management of severe postoperative groin pain in which non-operative approaches failed. Surgery entails a great challenge and therefore should be performed in specialized centers.

Paratesticular epithelioid sarcoma: A rare case

Primary soft-tissue sarcomas of the paratesticular region are uncommon tumors comprising 1% of all adult sarcomas. Paratesticular epithelioid sarcoma (ES) is a rare subtype. Here, we report the case of a 68-years-old male with scrotal swelling who underwent high inguinal exploration and right orchidectomy. Histopathology and immunohistochemistry revealed paratesticular ES. Very few cases of paratesticular ES have been reported so far in the literature. Clinical presentation, investigations, treatment interventions, and prognosis have been discussed. As it can be confused with other benign and malignant conditions, diagnosis is often made on histopathological evaluation.

Management of bilateral nubbin testis, past and present controversies: a case report

Introduction: Testicular nubbin is the most common case of impalpable testis found by pediatric urologists. Diagnostic and surgical management, including long-term follow-up, is still a debate, especially in cases of bilateral testicular nubbin. Case presentation: A 5-year-old boy with bilateral impalpable testis was brought to a hospital. A diagnostic laparoscopy was performed, and both internal inguinal rings were closed with testicular blood vessels, and the vas deferens had entered the inguinal canal. We found bilateral testicular nubbin on inguinal exploration and subsequently performed only right orchidopexy because it was larger than the left testis. Conclusion: Evidence-based medicine, comprehensive management, and consultation between doctor and patient are needed in bilateral management of testicular nubbin for a good patient outcome.

Femoral Hernia in Children as a Rare Pathology: A Retrospective Case Series

Abstract Background: Femoral hernias are uncommon groin pathology among children. The rarity of the pathology results in increased complications, delayed diagnosis and inappropriate inguinal exploration. In this study, we review our experience with this surgical entity over a 10-year period. Materials and Methods: The medical records of seven children who underwent femoral hernia repair between January 2010 and January 2021 at a single tertiary centre were retrospectively analysed. Reviewed data included demographics, pre-operative diagnosis, operative technique, complications and follow-up. Results: Seven children (5 females [71%] and 2 males [29%]) were operated due to femoral hernia. Median age was 8 years (range: 3–16 years). Four (57%) patients had right-sided femoral hernia and three (43%) were on the left side. The correct pre-operative diagnosis was obtained in three (42%) cases. The remaining four misdiagnosed cases were diagnosed as femoral hernia at the surgery. In all cases, the initial presentation was swelling; two (28%) had inguinal pain and three patients (42%) required emergency inguinal exploration due to suspected incarceration. All patients had repair of their hernia by open technique; the femoral canal was closed by mesh plug or Vicryl sutures. All patients were discharged without complications. No recurrence was detected and the median post-operative follow-up period was 24 months (range: 8–48 months). Conclusion: Femoral hernia is a challenging pathology and correct diagnosis requires a high index of clinical suspicion. In equivocal cases, ultrasonography and laparoscopy may be useful. Appropriate pre-operative diagnosis evades complications and delays in treatment. Regardless of the surgical approach recurrences and complications are very rare in children.

Pattern and Diagnosis of Solid Testicular Swellings and it’s Management Outcome

Objective: To determine the frequency of the clinical pattern and diagnosis of various types of solid testicular swellings and its management outcomes. Materials and methods: This prospective cross-sectional study was done at the surgery department of Muhammad Medical College, Mirpur Khas. Cases with different presentations raising suspicion about the disease were admitted to the hospital from OPD after recording the detailed history and clinical examination. All the patients presenting with solid testicular swellings underwent inguinal exploration through an incision above the inguinal ligament, regardless of age, were included. After taking verbal informed consent, all the cases underwent testicular biopsies, and specimens were sent to the diagnostic laboratory for histopathological diagnosis. Patients having neoplastic testicular changes were referred, and patients with non-neoplastic testicular swellings lesions were treated conservatively or surgically as per indications. The data and records of all the patients were taken and maintained by the study proforma. Results: A total of 50 cases of solid testicular swellings were studied; their mean age was 48.45+7.23 years. Painless enlargement was present in 70% of cases, enlargement was usually gradual with a feeling of heaviness, followed by painful enlargement in 10.0% of cases. 20(40%) patients were diagnosed as neoplastic testicular swellings, and 30(60%) patients had non-neoplastic swellings. Among 30 cases of testicular swellings, 40.0% had orchitis, 8.0% had trauma, Epididymo-orchitis 12.0%, testicular tuberculosis was in 4.0%, and 1 (2%) had mumps orchitis. All the non-neoplastic lesions were treated successfully and neoplastic lesions cases were referred for further treatment. Conclusion: As per the study conclusion, painless enlargement (usually gradual with the feeling of heaviness) was observed to be the most common clinical feature. However, orchitis, epididymo-orchitis, and tuberculosis of the testis seemed to be the most common diagnoses among non-neoplastic cases. Neoplastic lesions were frequently high. Keywords: Testicles, swelling, features, diagnosis

Clinical study of management of un-descended testes in pediatric age group

Background: The mode of un-descended testes (UDT), treatment remains controversial; however surgery is the treatment of choice. Method: 40 children < 2 to 12 years of age clinically evaluated and subjected USG. The patients with palpable tests planned for orchiopexy. Non palpable abdominal tests were planned for diagnostic laparoscopy. During inguinal exploration if cord structures or testicular remnants were found they are removed. Results: 8 (20%0 were < 2 years, 12 (30%) 2-4 years, 12 (30%) 5-9 years, 8 (20%) 10-12 years of age. The levels of UDT was 14 (35%) canalicular, 16 (40%) external ring, 5 (12.5%) internal ring, 5 (12.5%) abdominal. Conclusion: Orchiopexy is the ideal treatment for UDT and laparoscopic treatment is for abdominal testes, but boys with retractile and acquired testes usually don’t need medical or surgical treatment but require close follow up until puberty.

Testicular, Epididymal and Vasal Anomalies in Pediatric Patients with Cryptorchid Testes and Testes with Communicating Hydrocele.

The goal of this study was to determine the prevalence of the testicular, epididymal, and vasal anomalies (TEVA) in cryptorchid and communicating hydrocele pediatric patients. Six hundred and ninety-one prepubertal boys underwent inguinal exploration for 741 undescended (UDT) or hydrocele testes. Two hundred and fifty-five TEVA were detected in 154 UDT boys, compared to 32 defects in 24 hydrocele patients (p < 0.001). The TEVA were more frequent in bilateral UDT (p = 0.009). Multiple defects were observed more frequently in the intra-abdominal testicles (p = 0.028). A correlation was found between the testicular atrophy index (TAI) and the incidence and number of TEVA in the UDT boys (p < 0.001). The smaller the testis (higher TAI), the more the defects that appeared in it and the higher the frequency of their appearance. Another correlation was established between testis position and the incidence and number of TEVA (p < 0.001). The higher the testis position, the more the defects that appeared in it and the higher the frequency of their appearance. A correlation was established between the position and the volume of the affected testis (p < 0.001). The higher the gonad position, the more severe the atrophy observed in it. The TEVA were more frequent in the UDT boys than in the hydrocele patients. We revealed that the risk of abnormal fusion between the testis, epididymis, and vas deferens is connected with the testis position (intra-abdominal testes) and bilateral non-descent.

Liposarcoma of Spermatic CordEncountered While Operating the Inguinoscrotal Hernia

Liposarcomas in the spermatic cord are rare and difficult to diagnose preoperatively, since they present as inguinal or scrotal masses which are frequently evaluated only by ultrasonogram, and other imaging modalities. This case report is about a 48-yearold male, who presented with a painless swelling in the right inguinal region extending to the scrotum, since two years. Upon inguinal exploration, a single irregular fatty mass, arising from the cord, was found in addition to a small inguinal hernia. En-bloc resection of the mass with inguinal orchidectomy was done and histopathology proved it to be a well-differentiated liposarcoma. A rare malignancy with a deceptive presentation must be taken into account while evaluating scrotal masses, particularly in patients with suspected recurrent hernias of the inguinal region.

Üçüncü basamak bir çocuk cerrahisi merkezinde çocuklarda palpe edilemeyen testislerin laparoskopik tedavisinin klinik sonuçları

Aim: Non-palpable testis is defined as the absence of the testis in the inguinal canal and scrotum in a male patient. It is important to define the condition and location of the non-palpable testis, to prevent the risks of infertility and malignant transformation of the testis in patients. We aimed to evaluate the results of the laparoscopic approach we applied in the treatment of pediatric patients with non-palpable testes.Methods: Patients with non-palpable testes, diagnosed and treated by the laparoscopic approach in a tertiary pediatric surgery center, were evaluated retrospectively. In the treatment protocol, laparoscopic abdominal exploration, two-stage Fowler-Stephens laparoscopic orchiopexy, primary laparoscopic orchiopexy and inguinal exploration surgical approaches were applied according to the case characteristics.Results: Data from 54 testes in 45 pediatric patients were evaluated. Intra-abdominal testis was detected in 46.2% of the cases, with 88% of them at the entrance of the internal inguinal ring. After laparoscopic abdominal exploration, two-stage Fowler-Stephens in 7 (28%), primary laparoscopic orchiopexy in 18 (72%) were applied of testes. Inguinal exploration was performed in 27 (50%) whom no testis could not found. Seventeen (73.9%) of 23 testes that were descended into the scrotum remained viable, while atrophy occurred in 6 (26%) of them. Viable testis cells were not detected in the histopathology of 27 excised nubbins.Conclusion: The laparoscopic approach is a reliable and effective method in the diagnosis and treatment of non-palpable testis. Localization of intra-abdominal testes may support consideration of the inguinal exploration approach as the primary surgical intervention.

A Case Giving Proof of Pathogenesis of Abdominoscrotal Hydrocele: A Case Report

An abdominoscrotal hydrocele (ASH) is an uncommon condition characterized by cystic mass that occupies the scrotum and abdomen. The characteristic aspect is the presence of two hydrocele sacs in the abdominal cavity and the scrotum, and compression of one side causes enlargement of the other side, thereby connecting the two sacs. There are several hypotheses regarding the occurrence of ASH. However, the evidence of the hypotheses is lacking. The patient was a 52-year-old male. During observation of the right inguinoscrotal hydrocele, the patient complained of a palpable mass lesion on the right lower quadrant of the abdomen. Physical examination revealed ASH that occurred with the growth of the inguinoscrotal hydrocele. This was further confirmed by sequential imaging test thereby proposing the verification of cephalad extension of hydrocele. The surgical excision was recommended and inguinal exploration was performed under general anesthesia. No evidence of relapse was observed during the 2-year follow-up period after surgery. The present case proves the cephalad extension of hydrocele among other hypotheses on the etiology of ASH.

Migration of a Ventriculo-peritoneal Shunt into the Scrotum

Ventriculoperitoneal (VP) shunting has been a suitable therapeutic method for hydrocephalus. Nonetheless, it could be accompanied by several problems and devastating outcomes. Shunt migration is an uncommon occurrence in one out of 1000 individuals who undergo a shunt procedure. We report an 8-months-old infant known case of previous VP shunting who presented with the enlargement of the left inguinoscrotal area. According to a radiology scan, the peritoneal catheter had slipped into the left scrotum. The patient underwent left inguinal exploration under general anesthesia. The bowel content and VP catheter were retrieved to the peritoneal cavity and the sac was ligated. There was no recurrence or complications after surgery.

Preliminary Investigation on the Involvement of Cytoskeleton-Related Proteins, DAAM1 and PREP, in Human Testicular Disorders.

Herein, for the first time, the potential relationships between the cytoskeleton-associated proteins DAAM1 and PREP with different testicular disorders, such as classic seminoma (CS), Leydig cell tumor (LCT), and Sertoli cell-only syndrome (SOS), were evaluated. Six CS, two LCT, and two SOS tissue samples were obtained during inguinal exploration in patients with a suspect testis tumor based on clinical examination and ultrasonography. DAAM1 and PREP protein levels and immunofluorescent localization were analyzed. An increased DAAM1 protein level in CS and SOS as compared to non-pathological (NP) tissue was observed, while LCT showed no significant differences. Conversely, PREP protein level increased in LCT, while it decreased in CS and SOS compared to NP tissue. These results were strongly supported by the immunofluorescence staining, revealing an altered localization and signal intensity of DAAM1 and PREP in the analyzed samples, highlighting a perturbed cytoarchitecture. Interestingly, in LCT spermatogonia, a specific DAAM1 nuclear localization was found, probably due to an enhanced testosterone production, as confirmed by the increased protein levels of steroidogenic enzymes. Finally, although further studies are needed to verify the involvement of other formins and microtubule-associated proteins, this report raised the opportunity to indicate DAAM1 and PREP as new potential markers, supporting the cytoskeleton dynamics changes occurring during normal and/or pathological cell differentiation.

Is Testicular Torsion a Real Problem in Pediatric Patients With Cryptorchidism?

Purpose: To present management and outcomes of patients with cryptorchidism suffering from testicular torsion.Methods: This is a retrospective review of pediatric patients with torsion of undescended testes, who were treated between 2009 and 2019. We recorded: the age, symptoms, duration of torsion, results of physical examination, surgery findings, and additional treatment. Additionally, an extensive online literature search, from 2015–2020, was performed to identify other similar case series.Results: We identified 9 boys with torsion of the undescended gonad, which represented 4.7% of all 192 boys with testicular torsion. The mean age of boys with torsion of undescended testis was 8.7 years. The mean duration of symptoms in our study group was long and it was up to 28.5 h. All patients had inguinal canal exploration. In eight cases, testicular necrosis and primary orchidectomy was performed. Furthermore, 45 cases were identified in the literature and reviewed.Conclusion: According to clinical experience and available studies, torsion of male undescended gonads is a comparatively rare condition. Nevertheless, diagnosis is still delayed and connected with inevitable orchidectomy.

Testis-sparing Surgery: A Single Institution Experience

ObjectiveTo demonstrate the safety and efficacy of testis-sparing surgery (TSS) in 2 specific circumstances: small, nonpalpable masses suspected to be benign and masses suspicious for germ cell tumor in a solitary or functionally solitary testicle or bilateral disease. MethodsOur institutional review board-approved testicular cancer registry was reviewed for men who underwent inguinal exploration with intent for TSS (2013-2020). The attempted TSS and completed TSS groups were evaluated for differences using Student's t test for normally-distributed variables, chi-squared and Fisher's exact tests for proportions, and Wilcoxon rank-sum test for nonparametric variables. ResultsTSS was attempted in 28 patients and completed in 14. TSS was completed only if intraoperative frozen section demonstrated benign disease, except for 1 patient with stage I seminoma and solitary testicle. Sensitivity and specificity of frozen section analysis was 100% and 93%, respectively. There were no significant differences in demographics between attempted vs completed TSS cohorts. Median tumor size was significantly smaller in the completed TSS cohort (1.0 cm vs 1.7 cm, P = .03). In patients with unilateral masses without history of testis cancer, the testis was successfully spared in 9 of 22 cases (41%). In patients with bilateral disease or germ cell tumor in solitary testis, the testis was spared in 5 of 6 cases (83%). At a median follow up of 12.2 months, all patients were alive, and 27 of 28 had no evidence of disease (96%). ConclusionTSS is safe and effective for small, benign masses and in the setting of bilateral disease or tumor in a solitary testis.

Case report: Amyand hernia reincarnate and the utility of computed tomography

BackgroundAn Amyand hernia is a rare condition in which the vermiform appendix follows the bowel as it bulges through the inguinal canal. Originally described by Claudius Amyand in 1735 in an 11-year-old boy who had a pin in the appendix (Philos Trans R Soc Lond. 1735;39:329–36), we describe here the first case with CT depicting all components of Dr. Amyand’s original case.Case presentationA 10-year-old boy presented with right lower quadrant and groin pain. CT imaging revealed a retained metallic foreign body perforating the appendix, acute appendicitis, and an Amyand hernia. A laparoscopic attempt at reduction failed due to tethering by the needle and inflammation of the hernia sac, requiring an open inguinal exploration and excision of the hernia sac. The patient was discharged on postoperative day 2 with plans for delayed hernia repair.ConclusionsCT is a crucial diagnostic test for surgical decision-making in Amyand hernias. In this case, it accurately classified the hernia and led to anticipation of unsuccessful laparoscopic hernia reduction. Management in the setting of foreign body and perforation includes appendectomy and tissue herniorrhaphy with delayed formal inguinal hernia repair after inflammation has subsided.