Inguinal Ring Research Articles

A novel anterior approach that involves Retzius space development between the umbilical ligaments is associated with a lower incidence of postoperative inguinal hernia in robotic radical prostatectomy

BackgroundTo facilitate robotic radical prostatectomy (RP), we developed a novel anterior approach that utilizes a peritoneal incision between the umbilical ligaments to develop the Retzius space without contacting the internal inguinal rings, followed by closure of this space prior to prostatectomy and vesicourethral anastomosis. This approach could decrease the incidence of postoperative inguinal hernia (IH), similar to a Retzius-sparing RP (RS-RP). We compared the incidence of IH following this novel approach with that following conventional anterior RP and RS-RP. MethodsWe retrospectively reviewed 532 patients who underwent robotic RP from September 2017 to August 2022. We compared the incidence of IH following novel anterior RP (n = 153) to that following conventional anterior RP (n = 284) and RS-RP (n = 95). We also assessed the independent factors associated with postoperative IH using Cox hazard models. ResultsThe 12- and 24-month cumulative incidences of postoperative IH following novel anterior RP were 1.3% and 1.3%, significantly lower than those associated with conventional anterior RP (8.0% and 12.6%, p = 0.009) but not significantly different from those following RS-RP (1.1% and 2.1%, p = 0.782). In multivariate analysis, use of the novel anterior RP approach, RS-RP, and body mass index were independent factors negatively associated with the occurrence of postoperative IH. ConclusionsThis novel anterior approach involves developing the Retzius space between the umbilical ligaments and closure of this space following prostatectomy and vesicourethral anastomosis. It can decrease the incidence of IH compared to the conventional anterior approach. Prospective comparative studies are necessary to confirm the benefits of this approach.

Ekstrarenalni Vilmsov tumor koji je imponovao kao funikulocela

Introduction/Objective: Extrarenal Wilms' tumor (ERWT) comprises 0.5% to 1% of all nephroblastoma cases. The most common locations of ERWT are the retroperitoneum, inguinal, lumbosacral and pelvic region, female genital organs, mediastinum and chest wall, spermatic cord and paratesticular region. ERWT most likely originates from the ectopic nephrogenic rest that undergoes a malignant transformation. The exclusion of primary renal tumor is necessary to establish the diagnosis of ERWT. Patient Review: A 15-month-old male was operated on because of a left-sided inguinal mass that clinically resembled a funicular hydrocele. The surgical exploration of the inguinal canal revealed a solid tumor located in the area of the external inguinal ring, measuring around 2cm in diameter, with no ingvinal hernia present. Complete surgical resection of the mass was performed. The histological structure of the tumor corresponded to non-anaplastic nephroblastoma (Wilms tumor), mixed type. After abdominal CT scan primary renal tumor was excluded and the diagnosis of ERWT was made. Because of microscopic tumor rests on the resection margin, the patient was treated according to the high-risk SIOP Wilms tumor protocol. The patient made a full recovery. During the 10-year follow-up, the boy has remained disease-free. Conclusion: ERWT is mostly diagnosed after the surgical removal of the specimen. The clinical resemblance of the ERWT located in the inguinal region to common benign inguinal conditions in children may lead to the omission of detailed preoperative work-up. Most children with ERWT in the inguinal region have an excellent prognosis, although most of them require adjuvant chemotherapy and/or radiotherapy after surgery.

Combination of High Ligation and Intraoperative Embolization using Polidocanol for Treatment of Varicoceles.

Varicoceles are dilated veins within the pampiniform plexus and are relatively common in the general male population. The spermatic vein has many branches in the scrotal segment and then gradually merges into 1-2 trunks after passing through the internal inguinal ring. The key to a successful varicocelectomy is to ligate all the spermatic veins while protecting the testicular arteries and spermatic lymphatic vessels from damage. The small veins, including the branches of spermatic veins and collateral veins, are easily missed for ligation during conventional high ligation of varicocele, which has been suggested as a major cause of postoperative recurrence. Although microsurgery effectively reduces the risk of missing ligation of the spermatic veins during surgery, it has several shortcomings, such as long operation time and a steep learning curve. More importantly, this technique is difficult to carry out in primary hospitals due to the requirement of specialized equipment. Therefore, an attempt to modify the traditional high ligation aiming to reduce the postoperative recurrence rate has been carried out here. The protocol here combines traditional high ligation with intraoperative embolization to seal off the branches of the spermatic vein and collateral veins. We rapidly injected foamed sclerosant into the internal spermatic vein under direct observation after separation of the spermatic vein and then ligated all the veins. The foamed sclerosant through the varicose vein hampers endothelial cell growth, promotes the growth of thrombus and fibrosis, and ultimately forms fibrous streaks that permanently fill the venous. The results showed a more satisfactory effect on reducing the postoperative recurrence rate compared with traditional high ligation. Since this protocol is simple to carry out and has better results in reducing the recurrence rate, this can be an alternative surgical method for the treatment of varicocele, especially in primary hospitals.

Laparoscopic inguinal hernia repair (LIHR): the benefit of the double stitch in the largest single-center experience

AimTo review our experience of laparoscopic inguinal hernia repair (LIHR) regarding complication rates, the practice of closing the asymptomatic patent processes vaginalis (PPV), and comparison of complication rates between pre-term (< 37 week gestation) and term infants.MethodsRetrospective review of LIHR performed between 2009 and 2021. Repair was performed by intracorporal single or double purse string/purse string + Z-stitch using a non-absorbable suture. Data were analyzed using Chi-squared/Mann–Whitney and are quoted as median (range).Results1855 inguinal rings were closed in 1195 patients (943 (79%) male). 1378 rings (74%) were symptomatic. 492 (41%) patients were pre-term. Corrected gestational age at surgery was 55 weeks (31 weeks–14.6 years) and weight 5.9 kg (1–65.5). Closure of contralateral PPV was higher in the premature group (210/397 [53%] vs. 265/613 [43%] p = 0.003). There were 23 recurrences in 20 patients, of whom 10 had been born prematurely. The only factor significantly associated with a lower recurrence was use of a second stitch (p = 0.011).ConclusionThis is the largest single-center reported series of LIHR. LIHR is safe at any age, the risk of recurrence is low, and can be corrected by re-laparoscopy. Use of a Z-stitch or second purse string is associated with a significantly lower rate of recurrence.

Оцінка виразності післяопераційного набряку мошонки в дітей з патологією вагінального відростка очеревини при різних методах лікування

Congenital malformations, the cause of which is a disturbance of the obliteration of the vaginal process of the peritoneum, such as an inguinal hernia, hydrocele testis, occupy one of the leading places among childhood diseases. This explains the continuation of scientific observations and the analysis of various methods of treatment of patients with lesions of the vaginal process of the peritoneum. Researchers note the possibility of certain complications among male patients, such as swelling of the scrotum, postoperative hydrocele testis, iatrogenic retraction of the testicle (acquired cryptorchidism). This became the reason for additional study of such a complication as postoperative swelling of the scrotum. Purpose - to analyze the severity of postoperative swelling of the scrotum depending on the methods of surgical correction of the pathology in patients with nonoblitereted vaginal process of the peritoneum. Materials and methods. 91 children who underwent surgical correction of the pathology of nonobliterated vaginal process of the peritoneum (inguinal hernias, hydrocele testis) participated in the conducted scientific study. Patients were assessed for postoperative swelling of the scrotum depending on the method of surgical correction of the pathology. Results. The degree of postoperative swelling of the scrotum in patients with pathology of the vaginal process of the peritoneum is directly proportional to the severity of tissue injury during surgical correction in patients with nonoblitereted vaginal process of the peritoneum. Conclusions. Any surgical intervention entails certain consequences that are associated with a violation of the integrity of the body. And although these complications are temporary, a qualitative assessment of their severity can become the basis for choosing a particular method of surgical treatment. The obtained data show the severity of postoperative swelling of the scrotum and the dynamics of its changes depending on access for surgical manipulation. The less soft tissue is injured to access the internal inguinal ring, the smaller the postoperative swelling and the better its dynamics. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors.

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.

Surgical tricks of handling a needle and grasping forceps during laparoscopic percutaneous extraperitoneal closure (LPEC) for pediatric inguinal hernia.

Laparoscopic percutaneous extraperitoneal closure (LPEC) is an alternative to open repair for pediatric inguinal hernias; however, its application for boys remains controversial. In this study, we developed a technique to enhance the safety and feasibility of LPEC. In our technique, forceps are used to pull up the peritoneum ahead on the route, creating a space between the peritoneum and structures, including gonadal vessels and vas deferens. This potentially decreases the risk of perioperative injury of these structures. This technique also allows the needle to pass on the shortest course around the inguinal ring without crossing the vas deferens, possibly lowering the likelihood of injury and preventing excessively high ligation of the vaginalis process. Our technique diversifies the LPEC methods, thereby augmenting the feasibility and safety of the procedure.

Reference value of testicular temperature measured by finite element analysis after first staged inguinal orchidopexy in children with abdominal testis and short spermatic cord.

This study aims to build a 3D reconstruction computed simulation model and to establish a regression equation for detecting the testis's temperature by its location after first staged open orchidopexy in children with abdominal undescended testis (UDT) and short spermatic cords. In this cross-sectional study, we enrolled 31 children with abdominal UDT and short spermatic cords who underwent first staged orchiopexy between 2017 and 2020. Using ultrasonography to obtain the testis's location distance from the skin surface (X1), external iliac vessel (X2), and internal inguinal ring (X3), we input the data into a 3D reconstruction computed simulation along with COMSOL to calculate the testicular temperature. We also used multivariate regression to establish the testicular temperature regression equation from the gathered data. The mean age of the participants was 4.47 ± 1.21 years. The mean size of the operated testis was 0.39 ± 0.13 cc. The mean distance of the testis from X1, X2, and X3 was 3.27 ± 1.25 mm, 21.06 ± 6.42 mm, and 27.19 ± 10.09 mm, respectively. The testicular temperature regression equation derived from testis location was calculated by the formula: 34.57 + 0.0236 X12 - 0.0105 X2 - 0.0018 X3. The concordance for testis temperature calculated via the computational method and regression equation was 83%. The current study provided a reference value for the testicular temperature of children with abdominal UDT and short spermatic cords after the first stage of orchiopexy. A testicular temperature regression equation can be established based on the testis location, which will provide relevant information for the testicular development assessment, disease diagnosis, and follow-up, and possibly determination of the time of the second stage of orchiopexy.

Preperitoneal vas deferens infiltration in high-risk prostate cancer.

The objective of this study is to evaluate the prevalence and the importance of preperitoneal vas deferens (VD) infiltration in high-risk prostate cancer (PCa). In this prospectively designed study, we included 332 high-risk PCa patients with a Briganti score >5%, who were treated by robot-assisted radical prostatectomy between July 2017 and February 2022 at the Urology Department, SLK Kliniken Heilbronn. In addition to the standard histological analysis of the distal VD, which was attached to the prostate specimen, we analysed the infiltration status of preperitoneal VD in this cohort. The preperitoneal VD, which represents the middle part of ductus deferens and extends between the internal inguinal ring and obturator fossa, was resected during extended pelvic lymphadenectomy. Distal and preperitoneal VD status was registered together with preoperative and postoperative disease characteristics. Descriptive analysis methods and logistic regression analysis were used. Briganti score of the target cohort had a median value of 19%, while 235 patients (70.8%) of the group demonstrated a locally advanced disease. The Grade Group at prostatectomy specimen was at least 3 for 286 patients (86.1%). Distal VD infiltration was found in 20 patients (6%) and preperitoneal VD infiltration in two patients (0.6%). Distal VD infiltration was not associated with an increased possibility for positive surgical margins or nodal status among pT3b patients, while both patients with preperitoneal VD infiltration were characterized by highly aggressive disease in locally advanced stage and bilateral distal VD infiltration. PCa extension along VD may reach a more proximal point of VD than the reported from the existing data infiltration of VD adjacent to seminal vesicles. This rare manifestation of PCa local extension may be the intermediate step to the rare cases of recurrence in the testicles. However, more robust data are needed to confirm the aforementioned hypothesis. Distal VD infiltration seems to have no additional prognostic value among patients with infiltrated seminal vesicles.

635 Giant Paratesticular Liposarcoma Imitating a Recurrent Right Inguinoscrotal Hernia

Abstract Case 48-year-old male presented for elective open recurrent right inguinal hernia (RIH) repair due to ongoing right inguinoscrotal swelling; and an ultrasound suggestive of a large indirect inguinal hernia containing peritoneal fat and extending into the scrotum with displacement of the right testis. Previous open RIH repair with mesh completed 12mths prior found a moderate direct inguinal hernia; and during a post-op phone review (given the COVID pandemic) noted he was healing well. No urinary/obstructive or systemic symptoms identified. Other history included alpha thalassemia trait, ex-smoker and non-English speaking background (NESB). Intraoperatively there was no evidence of recurrent hernia, and the mesh was intact; however a large right scrotal mass was identified as the cause. An 18x8cm soft lipomatous mass surrounded the right testicle and extended up towards the cord structures at the superficial inguinal ring. Given the concern for malignancy, a right orchidectomy and excision of scrotal mass was performed. Histology confirmed a well differentiated grade 1 liposarcoma. He recovered well and is undergoing close MRI surveillance - with no sign of recurrence. Discussion Liposarcoma is an important differential for scrotal masses and can imitate an inguinoscrotal hernia on ultrasound, MRI is the gold standard investigation. The above case highlights the importance of physical post-operative examination and barriers to care during the COVID pandemic, particularly in those with NESB. Informed consent was imperative, we could safely proceed with the appropriate surgery as the patient had been explicitly consented for testicular loss due to recurrent nature of the operation.

Effect of Dexmedetomidine as an Adjuvant to Bupivacaine in Ultrasound Guided Transversus Abdominis Plane Block versus Caudal Block for Postoperative Analgesia in Children Undergoing Congenital Inguinal Hernia Repair

Abstract Background Inguinal hernia is the most common lower abdominal surgery of childhood. It results from a small sac that comes through the inguinal ring that is normally open during fetal life and closes around the time of birth. For reasons we don't understand, it does not close in some infants. This sac then makes a pathway for abdominal organs to come through the inguinal ring into the groin. Analgesic techniques in pediatric patients having surgery are often delayed by the inherent difficulties of conducting a large randomized clinical trial in those patients. TAP block and caudal epidural block are two anesthetic techniques that are commonly used in pediatric age group for lower abdominal surgeries. Aim of the Work Compares the efficacy of Dexmedetomidine as an adjuvant to Bupivacaine in Ultrasound Guided Transversus Abdominis Plane Block versus Caudal Block for postoperative analgesia in children undergoing congenital inguinal hernia repair especially to provide prolonged post-operative analgesia and decrease opioid consumption. Patients and Methods We conducted a prospective, randomized, controlled and comparative study in Ain shams university hospitals in a period of 6 months including 50 patients divided on 2 groups; group A 25 of them received ultrasound guided transversus abdominis plane block with 0.3 ml/kg of 0.25% Bupivacaine with 1 µg/kg dexmedetomidine with age ranged from 2.5-8 years and they were 6 females (24%) and 19 were males (76.0%) and group B 25 patients received caudal epidural block with 0.6 ml/kg of 0.25% Bupivacaine with 1 µg/kg dexmedetomidine with age ranged from 3 – 9 years and they were also 4 females (16%) and 21 were males (84.0%). Results In the present study there was statistically significant increase in pain at 1 hr, 2 hrs and 4 hrs in caudal block group and increase in pain score at 12 hrs in tap block group but there was no statistically significant difference found between them at 6 hrs, 18 hrs and 24 hrs. There was statistically significant increase in rescue analgesia in caudal block group at 4 hr with p-value &amp;lt;0.001; also there was statistically significant increase in rescue analgesia in tap block than caudal block at 12 hr with p-value = 0.009 while no statistically significant difference found between both groups at the other times of follow up. Conclusion TAP block was superior to caudal epidural anesthesia in terms of early postoperative pain, less need for rescue analgesia and need for less potent analgesia e.g. Paracetamol and NSAID. Addition of dexmedetomidine to conventional regional anesthetic protocol showed significant reduction of postoperative pain and the need for rescue analgesia.

A rare case of bilateral Vanishing Testicle Syndrome

Vanishing testicle syndrome (VTS) is due to regression of already formed testes. This could occur at any stage during or after testicular descent due any insult resulting in testicular atrophy. VTS is estimated to affect 1:1250 males. We present a rare case of a 12-year-old boy presenting with absent secondary sexual characteristics and short stature found to have bilateral vanishing testicle syndrome. His testes were impalpable at neonatal examination. At the age of 1.5 years an ultrasound scan detected the right testis in the inguinal ring, measuring 1.5 x 1 cm with features suggestive of ischaemia with likely acute or subacute torsion. The left testes was seen in the inguinal canal already atrophied by that time. Subsequently, on surgical exploration the right testis was found atrophied in the inguinal canal, and was replaced in the right sub-dartose pouch, but left testis could not be identified. Surprisingly, 4 months later laparoscopic exploration failed to identify either of the testes except for bilateral atrophied gubernaculum, indicating testicular regression. At the age of 7 years, magnetic resonance imaging confirmed the absence of either of the testes, with no remnants. On examination his height was 146.5cm, which was between the 25th and 50th percentile for that age, and below his mid-parental height range. He had no androgenic hair growth, testes were impalpable and had a prepubertal penis accounting to tanner stage of 1. He had hypergonadotrophic hypogonadism. Pubertal induction was done with testosterone injections which resulted in height gain and development of secondary sexual characteristics.Introduction: The entity Vanishing testicle syndrome (VTS) was coined by Abryaratne et al. in 1969, and is also referred to as "Testicular regression syndrome" [1][2]. The two essential diagnostic criteria are; visualizing the blind-ending spermatic vessels within the retro-peritoneum or spermatic vessels and vas deferens exiting a closed internal inguinal ring, and Testis not palpated during examination under anaesthesia[2][3]. A small fibrotic nodule or nubbin with dystrophic calcification and haemosiderin deposition is usually found at the end of the spermatic cord, with or without identifiable testicular or para-testicular structures [2][3]. Cryptorchidism is reported in 1 -4.6% full term and 1.1 -45.3% pre-mature male infants [4]. This prevalence of cryptorchidism decreases to 1 % by the age of 1 year [5]. Testes are non-palpable in 10 -20% cases of cryptorchidism, and of these VTS accounts for 35 - 60% [6] VTS occurs in &lt; 5% cases of cryptorchidism [7]. VTS is estimated to affect 1:1250 males [8]. We present a rare case of bilateral VTS in a 12 year old boy who presented with short stature and absent secondary sexual characteristics with unpalpable testes.

(334) Robotic Transabdominal Vasovasostomy Following Laparoscopic Vasectomy: A Case Series

Abstract Introduction A small subset of men undergoing laparoscopic hernia repair will request concomitant vasectomy, which is typically performed via resection of a segment of the intra-abdominal vas deferens near the inguinal ring. Some of these men will ultimately desire vasectomy reversal to restore fertility or alleviate post-vasectomy pain syndrome. Traditional scrotal or inguinal microsurgical techniques are clearly not feasible in this situation, and open surgical repair carries significant morbidity. The use of a robotic approach may offer an attractive alternative to improve visualization and facilitate a patent intra-abdominal anastomosis. Objective To demonstrate technical feasibility and report institutional outcomes of robotic-assisted laparoscopic transabdominal vasectomy repair Methods IRB approval was obtained. A retrospective chart review of our institutional experience with this operation was performed. Preoperative, operative, and postoperative data was collected. Results Three cases were identified with a mean patient age of 43 and mean interval of 6 years (range 3-10 years) between vasectomy and reversal attempt. Two men desired restoration of fertility, and one man desired reversal for testicular pain. All patients had previously fathered children, and mean partner age was 30 years. Port placement was similar to standard W-configuration used for robotic prostatectomy. Mean operative time was 319 minutes and estimated blood loss was 27mL. Two men required a modified Prentiss maneuver to re-route the vas deferens to obtain additional length. Indocyanine green was used in one case to confirm vasal perfusion. Bilateral vasovasostomy was completed in all cases with either a modified one-layer anastomosis using 8-0 nylon or a two-layer anastomosis using 10-0 and 9-0 nylon. Both men undergoing fertility restoration had return of sperm in the ejaculate with a mean concentration of 62 million sperm/mL, and the solitary patient with pain had subjective resolution of his pain. Conclusions Robotic transabdominal vasectomy reversal is technically challenging but feasible with an experienced team including a robotic surgeon and andrologist. Outcomes appear to be satisfactory. This technique may be considered for men who have undergone abdominal vasectomy and desire restoration of fertility or treatment of post-vasectomy pain syndrome. Disclosure No

P-031 TREATMENT OF A VOLUMINOUS INGUINOSCROTAL HERNIA AFTER A PREOPERATIVE PNEUMOPERITONEUM PREPARATION

Abstract Voluminous inguinoscrotal hernias that have lost their “right of domain”, are usually hard to repair, and need preoperative preparations to reduce the risk of complications after the treatment, such as compartment syndrome, intestinal ischemia, and respiratory problems. In this e-poster, we present a case report of a patient who had a voluminous inguinoscrotal hernia containing most of the small intestine and the entire right colon, which we treated after a preoperative pneumoperitoneum preparation (PPP). The preparation was conducted 20 days before the surgery and the pneumoperitoneum was created through a percutaneous catheter that we inserted in the epigastric region after a radiologic control. We injected 1000 ml of air per day, and the dose was adapted to the clinical tolerance of the patient. We performed a reintegration of the hernia's volume, a resection of the hernial sac, and a reduction of the size othe profound inguinal ring via a Raphia, no intestinal resections were made, and the postoperative course was uneventful. We plan a second intervention that consists of a hernia repair by a mesh insertion and a resection of the extra skin developed as a result of the voluminous hernia. PPP is an interesting way to prepare the abdominal cavity to receive the component of a voluminous hernia after its reduction. The patient should be closely monitored during the preparation and after the surgery in order. Sometimes a second operation is necessary for definitive cure or aesthetic needs.

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.

Laparoscopic Multiport Inguinal Hernia Repair in a Male Infant

Inguinal hernias in infants and children may be treated with open surgery or laparoscopy. First performed in 1993 more and more pediatric surgeons in western countries use the laparoscopic technique, at least in older children. Laparoscopic repair may be performed by either intra- or extra corporeal closure of the open processus vaginalis. The intra-corporeal method uses an intracorporeal suture with the help of three ports while the extra-corporeal closure uses a suture that is passed over two needles and the knot is tied manually outside the patient without the need for an additional port. We hereby describe step by step the laparoscopic multiport inguinal hernia repair in a male infant. This includes positioning of patient and trocars, incision of the peritoneum and placement of a non-absorbable braided purse-string suture at the inner inguinal ring, and intracorporal knot tying using the laparoscopic sliding knot. Minimally invasive hernia surgery in children is a common and technically demanding operation that lends itself well to teaching residents.

MP62-07 ECTOPIC LOW SUBMUSCULAR RESERVOIR PLACEMENT WITH TRANSFASCIAL FIXATION FOR INFLATABLE PENILE PROSTHESIS

You have accessJournal of UrologyCME1 Apr 2023MP62-07 ECTOPIC LOW SUBMUSCULAR RESERVOIR PLACEMENT WITH TRANSFASCIAL FIXATION FOR INFLATABLE PENILE PROSTHESIS Nikola Rakic, Amelia Khoei, Utsav Bansal, and Mohit Khera Nikola RakicNikola Rakic More articles by this author , Amelia KhoeiAmelia Khoei More articles by this author , Utsav BansalUtsav Bansal More articles by this author , and Mohit KheraMohit Khera More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003320.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The objective of this study is to build upon work demonstrating novel low submuscular (LSM) reservoir placement with transfacial fixation (TFF) for inflatable penile prostheses (IPP). Several techniques have been described for placement of IPP reservoirs, with variable results. Our aim is to further demonstrate a novel approach to reservoir concealment with patient reported satisfaction outcomes as a suitable alternative. METHODS: A retrospective review was conducted on patients who underwent an IPP placement using the LSM with TFF technique between 6/2019 and 7/2022 by a single surgeon at a tertiary medical center. Preoperative patient characteristics were collected, and we conducted a telephone interview with a questionnaire to assess satisfaction with the IPP and reservoir concealment. Technique Once the IPP has been placed via a transverse scrotal incision, the external inguinal ring is identified. An S-retractor is placed in the external ring and the fascia is elevated. Ring forceps are used to develop a space inside the ring below the rectus muscle and above the transversalis fascia. An Allis clamp is employed to grasp the lateral aspect of the inguinal ring and a right angle is passed in an out-to-in fashion through the fascia. The reservoir tubing is grasped and brought through the fascia and the reservoir is then placed underneath the rectus muscle. RESULTS: A total of 36 patients underwent low submuscular reservoir placement with TFF of which 28 completed the questionnaire (77.7%). The average age of patients was 69.3 years, and 57.1% of patients had undergone a radical prostatectomy. Overall satisfaction with the penile implant was 4.1 (out of 5). Eight patients (28.6%) were able to palpate the reservoir, and four patients (14.3%) were able to visualize the reservoir below the abdominal skin. However, overall satisfaction with reservoir concealment was 4.5 (out of 5) (Table 1). No surgical revisions were required and there were no complications such as bowel obstruction, herniations, bladder erosion, or vascular injuries. CONCLUSIONS: The low submuscular placement with TFF of the IPP reservoir remains an optimal approach for reservoir placement with a high degree of patient satisfaction and significant ease of placement compared to alternative methods. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e864 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nikola Rakic More articles by this author Amelia Khoei More articles by this author Utsav Bansal More articles by this author Mohit Khera More articles by this author Expand All Advertisement PDF downloadLoading ...

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.