Inguinal Surgery Research Articles

Identification and management of the ilio-inguinal and ilio-hypogastric nerves in open inguinal hernia repair: benefits of self-gripping mesh.

A large randomized, multicenter European study recently reported a reduction in early pain after open inguinal surgery when self-gripping mesh was used compared with sutured Lichtenstein repair. This secondary exploratory study is focused on the influence of nerve identification and handling on post-operative pain. Post-operative VAS pain data and Surgical Pain Scores (SPS) from 507 patients included in this study were analyzed according to whether inguinal nerves were preserved or resected during surgery to investigate whether identification and peri-operative nerve handling impact post-operative pain. Preservation of the ilio-hypogastric nerve during Lichtenstein mesh repair with suture fixation was associated with significantly more post-operative pain compared with resection at each follow-up (p≤0.003). This difference was not significant with self-gripping mesh repair. The decrease from baseline in post-operative VAS and SPS scores were significantly greater after self-gripping mesh repair compared to Lichtenstein repair at 1year, but only when the ilio-hypogastric nerve was preserved (VAS scores, p=0.009; SPS scores, p=0.015). No such difference was observed with the ilio-inguinal nerve. When self-gripping mesh was used, preservation of the ilio-hypogastric nerve was associated with significantly greater decreases in post-operative pain (change in VAS score from baseline) compared with Lichtenstein repair at each follow-up (p≤0.018). The ilio-hypogastric nerve is in danger of being traumatized during Lichtenstein mesh repair with suture fixation. The use of self-gripping mesh was shown to reduce the level of post-operative pain when the ilio-hypogastric nerve was preserved. Resection of the ilio-hypogastric nerve during Lichtenstein repair eliminates this difference.

Semen Parameters in Adolescents with Varicocele: Association with Testis Volume Differential and Total Testis Volume

We evaluated the relationship between testicular volume differential, total testis volume and total motile sperm count in adolescents with varicocele. Prior reports have been inconclusive regarding the association of testis volume with semen analysis parameters. We retrospectively reviewed a single institution database of Tanner 5 adolescents with nonoperated left varicocele with at least 1semen analysis available. Patients were included in analysis if they had clinical left varicocele, ultrasound measurement of testis volume and no prior inguinal or scrotal surgery. We analyzed the records of 100 patients. Mean ± SD age at presentation was 15.2 ± 3.5 years. The mean testicular volume differential was 8% ± 23% and 31 patients (31%) had a greater than 20% testicular volume differential. Mean total testis volume was 30.4 ± 13.3 cc. Varicocele was grade 3 in 39 patients, grade 2 in 50, grade 1 in 8 and ungraded in 3. Median total motile sperm count in the cohort was 42.0 (IQR 9.2, 105.8). ROC analysis with the Youden index indicated an optimal total testis volume cutoff of 30 cc to predict the total motile sperm count. In a multivariable logistic model accounting for age and varicocele grade a testicular volume differential of greater than 20% was associated with twice the odds of a total motile sperm count of less than 20 million per cc (OR 2.1, 95% CI 1.02-4.12, p = 0.04). Total testis volume less than 30 cc more than quadrupled the odds of a total motile sperm count of less than 20 million per cc (OR 4.2, 95% CI 1.8-9.7, p <0.001). Total testis volume and the testicular volume differential are associated with semen analysis outcomes in adolescents with varicocele. Atesticular volume differential of greater than 20% doubles the odds of a low total motile sperm count. A total testis volume of less than 30 cc quadruples the odds of a low total motile sperm count.

Controlled-Release Oxycodone Versus Naproxen at Home After Ambulatory Surgery: A Randomized Controlled Trial

BackgroundStrong opioids in the home setting after ambulatory surgery have rarely been studied for fear of hazardous adverse effects such as respiratory depression. ObjectivesWe compared the efficacy of paracetamol/controlled-release (CR) oxycodone and paracetamol/naproxen for treatment of acute postoperative pain at home after ambulatory surgery. Secondary outcomes were adverse effects of study medication, treatment satisfaction, and postoperative analgesic compliance. MethodsPatients undergoing ambulatory knee arthroscopy or inguinal hernia repair surgery (n = 105) were randomized into 3 groups: Group1 paracetamol/naproxen (n = 35), Group 2 paracetamol/CR oxycodone for 24 hours (n = 35), and Group 3 paracetamol/CR oxycodone for 48 hours (n = 35). Pain intensity at movement and at rest using a visual analog scale as well as satisfaction with postoperative analgesia and side effects were recorded for up to 48 hours postoperatively. Compliance with study medication was also assessed. ResultsFor pain at movement and at rest, no significant differences were found between the paracetamol/naproxen group and either the paracetamol/CR oxycodone for 24 hours group (β = 2.6 [4.9]; P = 0.597) or the paracetamol/CR oxycodone for 48 hours (β = –1.7 [5.1]; P = 0.736). No major adverse effects of study medication were registered and satisfaction with postoperative pain treatment was high in all groups. Compliance was comparable across the groups. Despite clear instructions, 8 patients with the lowest pain scores did not use any of the prescribed pain medication. ConclusionsParacetamol/CR oxycodone and paracetamol/naproxen are equally effective in treatment of acute postoperative pain at home after ambulatory surgery with comparable patient satisfaction level. We suggest paracetamol/CR oxycodone to be a valuable alternative for the current paracetamol/naproxen gold standard, particularly in patients with a contraindication for nonsteroidal anti-inflammatory drugs. ClinicalTrials.gov identifier: NCT02152592.

Safety of minimally invasive radical prostatectomy in patients with prior abdominopelvic or inguinal surgery.

Despite the widespread use of minimally invasive radical prostatectomy (MIRP), there remain concerns regarding its safety in patients with a history of prior abdominopelvic or inguinal surgery. A prospective database of 1165 MIRP procedures performed by a single surgeon at a high-volume tertiary care center from 2001 to 2013 was analyzed. After an initial period of transperitoneal MIRP (TP), an extraperitoneal (EP) approach was used preferentially beginning in 2005 (for both laparoscopic and robotic cases), and robotics were used preferentially beginning in 2010. Overall perioperative complications, major complications (Clavien-Dindo III or IV), and abdominal complications (e.g., ileus, bowel/organ injury, or vascular injury) were compared for patients with and without a prior surgical history. Uni- and multivariate logistic regression were used to control the impact of robotics, approach, operative time, estimated blood loss, case number, prostate weight, and primary Gleason on complications. Three hundred patients undergoing MIRP had prior abdominopelvic or inguinal surgery (25.8%). Of these, 102 (34%) underwent TP and 198 (66%) EP MIRP. Robotics was used in 286 cases (24.6%) and pure laparoscopy in 879 (75.4%). Complications occurred in 111 patients (9.5%) from the total cohort, with major complications in 32 (2.75%) and abdominal complications in 19 (1.63%). Prior surgery was not associated with overall, major, or abdominal complications. Of the controlling factors, only increasing operative time was associated with postoperative abdominal complications (most of which were ileus) on multivariate analysis. In this large single-surgeon series where both EP and TP approaches to MIRP are utilized, prior abdominopelvic or inguinal surgery was not associated with an increased risk of perioperative complications.

PS-067 Treatment Of Varicocele In Paediatric Patients With Contraindication For Open Surgery With Transfemoral Retrograde Sclero-embolization Under Local Anaesthesia

<h3>Background</h3> Varicocele treatment in paediatric age is still under discussion, the aim of this study is to present our experience with transfemoral retrograde sclero-embolization in paediatric patients and varicocele under local anaesthesia with contraindication for open surgery. <h3>Materials and methods</h3> Between December 2008 and December 2012 184 patients 10 to 14 years of age with left varicocele were treated. Study inclusion criteria were created: grade II or III left varicocele; previous inguinal surgeries and contraindications to general anaesthesia. Sclero-embolization included the following procedures: right femoral access under local sedation (carbocaine). Mean time of intervention, recurrence and persistence rates as well as early and late complications were also considered. <h3>Results</h3> During the study period 184 cases were treated with the radiological technique, 172 of which proved to be successful. In 10 cases a continent valve was found and it was therefore impossible to use this technique (5,4%); Two cases had rupture of the vein with consequent spillage of the contrast agent. Twelve cases (6,5%) showed recurrence No patient reported postoperative pain. <h3>Discussion</h3> This technique proved to be efficient and reliable. It can be performed under local sedation and it involves fewer complications than traditional techniques. The use of such technique allows preservation of the spermatic artery and is free from complications like testicular atrophy and hydrocele.

AB61. Advances of surgical treatment in male infertility

Approximately 15% of couples cannot conceive a child after 1 year of regular, unprotected intercourse. Male factor infertility is contributory in another 30% to 40%. Most causes of male infertility are treatable and the goal of many treatments is to restore the ability to conceive naturally. The dramatic recent improvements in the management of male infertility are largely contributable to improved surgical techniques and assisted reproductive technology (ART). Specifically in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) allow us to overcome even the most severe defects in spermatogenesis in which only a few are available.Varicocele repair may be considered as the primary treatment option when a man with a varicocele has suboptimal semen quality and the female partner is normal. varicocele repair can reverse a pathologic condition and halt further damage to testicular function, and improve spermatogenesis. Preferred approaches of most experts are microsurgical inguinal and subinguinal operations. Studies have shown that varicocele repair can improve semen parameters, testicular function and pregnancy rates in couples with male-factor infertility associated with varicocele. Also varicocele repair can result in sperm in the ejaculate of azoospermia men when severe hypospermatogenesis or maturation arrest spermatid stage is present.Obstructive azoospermia may result from epididymal, vasal or ejaculatory duct abnormalities. Microsurgical reconstruction remains the safest and most cost-effective treatment option for these patients (vasovasostomy, vasoepididymostomy). It is controversial that the technique of sperm retrieval (open or percutaneous) or the source of sperm (testicular, epididymal, vasal or seminal vesicular) affects pregnancy rate. Sperm extraction or aspiration for IVF via ICSI is needed in cure of surgically uncorrectable azoospermia or failed microsurgical reconstruction and the majority of patients with congenital bilateral absence of the vas deferens (CBAVD). Also sperm retrieval with IVF/ICSI is preferred to surgical treatment when the advanced female partner age, female infertility requiring IVF.Nonobstructive azoospermia (NOA) is the most challenging type, but no specific treatment was available previously. With advent of ICSI in conjunction with sperm retrieval via testicular sperm extraction (TESE), many of nonobstructive azoospermic patients are able to father own babies. However, 20-50% of NOA patients are not able to have sperm retrieved for ART. Microsurgical TESE is an advanced type of TESE that applies microsurgical techniques. This microsurgical TESE is an effective sperm retrieval from men with NOA for ICSI. The advantages of this technique are minimally invasive technique, removal of minimal amount of testicular tissue and minimalizing negative impact on testicular function. Microsurgical TESE is more effective in men with NOA than conventional TESE.Treatment strategies for male infertility have changed as dramatically over the past decade. These advances are largely contributable to microsurgical varicocele repair, microsurgical reconstructive techniques, and microsurgical techniques for surgical sperm retrieval and ART specifically ICSI.

English

Post-operative analgesia in children is a challenging task before the anesthesiologist. Caudal analgesia is an accepted and popular method of providing intraoperative and postoperative analgesia for genitourinary and inguinal surgeries in children. Because of short duration of action of Bupivacaine, various adjuncts have been tried by many anesthesiologists. Fentanyl and Clonidine are used along with local anesthetics to prolong duration of analgesia. Hence we are comparing 1 mcg/kg of Fentanyl and 1 mcg/kg of Clonidine as adjuvants to 0.25% bupivacaine at a volume of 0.75 ml/kg in children undergoing genitourinary and inguinal surgeries. AIMS AND OBJECTIVES: To compare the efficacy of Fentanyl and Clonidine as adjuncts to Bupivacaine for postoperative analgesia in pediatric patients and to evaluate the sequel and side effects of both. MATERIALS AND METHODS: Study design - Comparative randomized controlled study. Sample size: 120 children aged between 2-7 years posted for genitourinary and inguinal surgeries. Group I (B) received 0.75 ml/kg of 0.25% Bupivacaine alone caudally. Group II (BF) received 0.75 ml/kg of 0.25% Bupivacaine and 1 µg/kg Fentanyl caudally. Group III (BC) received 0.75 ml/kg of 0.25% Bupivacaine and 1 µg/kg Clonidine caudally. Postoperatively the duration of analgesia, motor blockade and sedation was assessed by Modified Objective Pain Scale, Ramsay Sedation Score and modified Bromage scale respectively. Side effects and complications, if present were recorded. Tests used for statistical analysis were Fishers exact test and student t test. RESULTS: The mean duration of analgesia in group BC (601.5 + 60.17 minutes) was much higher than group BF and B but with side effect of sedation. We observed that there was a statistically increased duration of analgesia in Clonidine group as compared to Fentanyl and plain Bupivacaine group with no difference in duration of motor blockade. There was increased sedation in group BC. Group BF had nausea and vomiting, shivering and pruritus as side effects. Hence we conclude that Clonidine is a better adjunct than Fentanyl in prolonging duration of analgesia of Bupivacaine in pediatric caudal block.

The use of TPA in combination with alcohol in the treatment of the recurrent complex hydrocele.

A hydrocele is an abnormal collection of serous fluid in the space between the parietal and visceral layers of the tunica vaginalis. Hydrocele is the most common cause of painless scrotal swelling which affects about 1% of men. Generally, adult hydroceles are idiopathic in origin; however, inguinal surgery, varicocelectomy, infection, trauma and a patent processus vaginalis are each associated with the subsequent development of a hydrocele. Surgical removal of hydroceles is the gold standard of care. However, multiple cases have reported high success rates (ranging from 85% to 96%) using a combination of aspiration and sclerotherapy. We present a case of a patient with recurring complex hydrocele and effective treatment utilizing a combination of thrombolytic therapy, catheter drainage and subsequent alcohol ablation.

Cyanoacrylate Skin Microsealant for Preventing Surgical Site Infection after Vascular Surgery: A Discontinued Randomized Clinical Trial

Surgical site infections (SSI) after vascular surgery are related to substantial morbidity. Restriction of bacterial access to the site of surgery with a cyanoacrylate sealant is a new concept. We performed a randomized clinical trial to assess the effect of the sealing of skin with a cyanoacrylate preparation at the site of surgery on the incidence of SSI after arterial reconstruction. Patients scheduled for vascular reconstruction in or distal to the groin were randomized into a treatment and a control group. Standard measures for preventing contamination of the surgical field were taken in the control group, whereas cyanoacrylate was used as a skin sealant at the surgical site in the patients in the treatment group. We hypothesized that the incidence of SSI with the use of cyanoacrylate would be two-thirds (67%) lower than that with standard preparation of the surgical site, and performed an interim analysis of 50 patients to assess this. Risk factors among the 50 patients in the study included smoking (28%), hypertension (77%), diabetes mellitus (36%), and hypercholesterolemia (74%). Indications for surgery were invalidating claudication (Fontaine IIb), pain at rest, or tissue necrosis. The overall incidence of SSI was 3/47 (6%), without differences between groups; 9% SSIs in the control group versus 4% SSIs in the intervention group. We could not confirm a reduction in the incidence of SSI after inguinal vascular surgery with the use of a cyanoacrylate skin sealant as compared with conventional means for preparing the surgical site.

Epidural administration of ketamine or fentanyl with bupivacaine for postoperative analgesia – A comparative study

The purpose of the study was to compare the analgesic effectiveness of epidural administration of ketamine mixed bupivacaine with fentanyl mixed bupivacaine in the management of postoperative pain. This prospective study was carried out in CMH, Bogra in one calendar year from July 2004 to June 2005. For postoperative pain management 100 patients of both sex, age ranging between 20 to 50 years, ASA physical status I and II scheduled for lower abdominal, pelvic and inguinal surgery were included in the study. All patients were divided into two groups. Epidural catheter was inserted in each patient through space between L3 to L2. Surgery was done under epidural anaesthesia in both groups. In group A (n=50) surgery was done with 0.5% bupivacaine and fentanyl (bupivacaine 1.5 ml/segment + fentanyl 2?g/ml). In group B (n=50) surgery was done with 0.5% bupivacaine and ketamine (bupivacaine 1.5ml/segment + ketamine 0.3mg/kg body weight). Epidural analgesia was continued in postoperative ward with 6 ml 0.25% bupivacaine + fentanyl 2?g/ml in group A and with 6 ml 0.25% bupivacaine + ketamine 0.3mg/kg bodyweight in group B, 4 hourly for 24 hours. The efficacy of analgesia was assessed by using Visual Analogue Scale (VAS) and Verbal Rating Scale (VRS). Mean VAS and mean VRS were less than 3 in both groups, which proved adequate postoperative analgesia. Differences of mean VAS and mean VRS between two groups were statistically not significant. Haemodynamic parameters, respiration and oxygenation were within normal range in both groups. Postoperative complications, like inadequate analgesia, post operative nausea and vomiting (PONV), headache and vertigo were less in both groups. It was observed that epidural administration of both bupivacaine mixed with ketamine and bupivacaine mixed with fentanyl found safe, effective and tolerable for postoperative pain management. DOI: http://dx.doi.org/10.3329/jbsa.v22i1.18097 Journal of BSA, 2009; 22(1): 21-25

Male reproductive status after the classical inguinal hernia repair

Aim. To determine the male reproductive status 18-20 years after classic unilateral herniotomy performed in childhood. Methods. Newsletters were sent to 127 patients, of whom 12 (9.45 %) responded. Male patients were invited for examination, including physical examination spermography with mixed agglutination reaction (MAR)-test, scrotum Doppler ultrasonography, prostate ultrasonography. Complete list of abovementioned examinations was performed in 10 male patients, representing 7.87% of the total number of respondents. 10 volunteers who had no medical history of inguinal hernia surgery were tested as a comparison group. Results. Sclerotic changes manifesting as testicular calcification were found in 4 (3.15%) patients who underwent inguinal hernioplasty surgery. No such findings were registered in volunteers who had no inguinal hernia surgery. Besides, 4 patients developed unilateral testicular hypotrophy of the hernia side, accompanied by an increased resistance index of parenchymal vessels in 75% of cases, which indirectly explains the causes of pathological changes in sperm. Considering small number of examined patients, the study had not enough power to state that hernioplasty surgery had the negative impact on male reproductive function; hence, it should be noted that in 7 cases alterations in the semen analysis were found, and 3 patients were infertile. These changes are likely to be related to technical defects of classic inguinal hernioplasty surgery performed in childhood. Conclusion. It is necessary to revise the use of classic inguinal hernioplasty and herniorrhaphy surgery performed in male children.

Anestesia subaracnoidea y anestesia general en el tratamiento quirúrgico de la hernia inguinal en pacientes ambulatorios. Análisis comparativo de coste-efectividad

To compare the costs related to the clinical effectiveness of general anesthesia versus spinal anesthesia in inguinal hernioplasty ambulatory surgery. An observational, retrospective cohort study measurement and analysis of cost-effectiveness, in the ambulatory surgery unit of a general hospital. All patients over 18 years of age diagnosed with primary inguinal hernia and scheduled for unilateral hernioplasty between January 2010 and December 2011 were included. Duration of anesthetic induction, length of stay in both the operating room, and in the post-anesthesia care unit, the anesthetic effectiveness (the incidence of adverse effects and the patient's comfort level), and variable economic costs associated with the use of drugs, as well as the use of human resources, were compared. The final analysis included 218 patients, 87.2% male, with a mean age of 53 years (range: 18-85 years). Of these, 139 (63.76%) received subarachnoid anesthesia and 79,(36.2%) general anesthesia. The length of time a patient remained in the post-anesthesia care unit was 337.6±160.2min in the subarachnoid anesthesia group, and 210.0±97.5min for the general anesthesia group (P<.001). Costs of drugs for general anesthesia were higher than that for subarachnoid anesthesia (86.2±8.3 vs. 18.7±7.2). The total cost difference between the 2 techniques was €115.8 more for subarachnoid anesthesia (P<.001). Both techniques showed similar effectiveness. The overall costs for subarachnoid anesthesia were greater than for the general. The cost-effectiveness of general anesthesia is better for outpatient inguinal hernia repair surgery.

Avoiding Injuries during Inguinal Canal Surgery Case Report

The anatomical localization of Inguinal region is important especially to pediatric surgeons and General Surgeons. A thorough understanding of groin anatomy is essential to successful inguinal hernia treatment. Conservative management of asymptomatic inguinal hernias is usually acceptable and Elective repair of inguinal hernias can be undertaken using a laparoscopic or open approach .Laparoscopic inguinal hernia repair results in less pain and faster recovery, yet requires specialized training and equipment. Without the knowledge of surgical anatomy surgeon can damage many vital structures in this region. The incidence of complications of inguinal hernia surgery is about 10 percent in United states and recent data from India suggests complication rates of order of 20-25 percent in Hospital settings which can increase to about 30-35 percent in District Hospitals will ill equipped theatres and lack of Full Expertise.

Is Postoperative Prophylactic Antibiotics Necessary for Pediatric Scrotal and Inguinal Outpatient Surgeries?

Purpose: Excess usage of antibiotics can cause complications of antibiotics and rise of antibiotic-resistant strains. However, guidelines for antibiotic prophylaxis differ between countries. We evaluated necessity of postoperative prophylactic antibiotics for pediatric patients who underwent scrotal and inguinal outpatient surgeries. Materials and Methods: From April 2011 to April 2014, 725 patients (mean age, 30.5±21.6 months) who underwent outpatient surgery (hydrocelectomy, orchiopexy, orchiectomy, and inguinal herniorrhaphy) were evaluated. In group 1 (556 cases), each patient had intravenous antibiotic prophylaxis only preoperatively. In group 2 (169 cases), each patient had intravenous antibiotic prophylaxis preand post-operatively. In group 1 and group 2, we analyzed postoperative complications including wound dehiscence, fever, skin erythema, pain, pus, and diarrhea with medical records. Results: In group 1 and group 2, mean age was 30.4±21.7 months (5.0-108.0 months) and 30.8±21.2 months (7.0-108.0 months), respectively. In group 1 and group 2, the mean operative time was 29.6±2.4 minutes and 29.7±2.5 minutes, respectively. The differences of mean age and mean operative time were not statistically significant (p=0.82 and p=0.77, respectively). Nine patients in group 1 and two patients in group 2 had postoperative complications. The difference between two groups was statistically insignificant (p=0.69). According to age and operation, the differences of postoperative complications were not statistically significant. However, in patients under 2 years old, more complications tended to occur in group 1 than in group 2. Conclusions: Postoperative prophylactic antibiotics may not be necessary for pediatric scrotal and inguinal outpatient surgeries.

Analgesic efficacy of transversus abdominis plane block in providing effective perioperative analgesia in patients undergoing total abdominal hysterectomy: A randomized controlled trial.

Background and Aims:Transversus abdominis plane (TAP) block has been shown to provide postoperative pain relief following various abdominal and inguinal surgeries, but few studies have evaluated its analgesic efficacy for intraoperative analgesia. We evaluated the efficacy of TAP block in providing effective perioperative analgesia in total abdominal hysterectomy in a randomized double-blind controlled clinical trial.Materials and Methods:A total of 90 adult female patients American Society of Anesthesiologists physical status I or II were randomized to Group B (n = 45) receiving TAP block with 0.25% bupivacaine and Group N (n = 45) with normal saline followed by general anesthesia. Hemodynamic responses to surgical incision and intraoperative fentanyl consumption were noted. Visual analog scale (VAS) scores were assessed on the emergence, at 1, 2, 3, 4, 5, 6 and 24 h. Time to first rescue analgesic (when VAS ≥4 cm or on demand), duration of postoperative analgesia, incidence of postoperative nausea-vomiting were also noted.Results:Pulse rate (95.9 ± 11.2 bpm vs. 102.9 ± 8.8 bpm, P = 0.001) systolic and diastolic BP were significantly higher in Group N. Median intraoperative fentanyl requirement was significantly higher in Group N (81 mcg vs. 114 mcg, P = 0.000). VAS scores on emergence at rest (median VAS 3 mm vs 27 mm), with activity (median 8 mm vs. 35 mm) were significantly lower in Group B. Median duration of analgesia was significantly higher in Group B (290 min vs. 16 min, P = 0.000). No complication or opioid related side effect attributed to TAP block were noted in any patient.Conclusion:Preincisional TAP block decreases intraoperative fentanyl requirements, prevents hemodynamic responses to surgical stimuli and provides effective postoperative analgesia.

A systematic review and meta-analysis of caudal block as compared to noncaudal regional techniques for inguinal surgeries in children.

This systematic review and meta-analysis were designed to compare the analgesic effectiveness and adverse effects with the use of caudal analgesia as compared to noncaudal regional analgesia techniques in children undergoing inguinal surgeries. MEDLINE, EMBASE, and CENTRAL (Cochrane) databases were searched for randomized control trials published in English language from 1946 up to 2013. Use of rescue analgesia and adverse effects were considered as primary and secondary outcomes, respectively. Outcomes were pooled using random effects model and reported as risk ratio (RR) with 95% CI. Out of 3240 hits and 24 reports for final selection, 17 were included in this review. Caudal analgesia was found to be better in both early (RR = 0.81 [0.66, 0.99], P = 0.04) and late (RR = 0.81 [0.69, 0.96], P = 0.01) periods, but with a significant risk of motor block and urinary retention. According to GRADE, the quality of evidence was moderate. Although potentially superior, caudal analgesia increases the chance of motor block and urinary retention. There are limited studies to demonstrate that the technical superiority using ultrasound translates into better clinical success with the inguinal nerve blocks.

Aberrant Adrenocortical Tissue Associated with Resected Lipoma of Spermatic Cord in an Adult

Aberrant adrenocortical tissue in spermatic cord is rare in adult population. We report an unusual case of a 52-year-old male patient with an aberrant adrenocortical tissue which is incidentally resected within lipoma of spermatic cord and identified on microscopic examination. Although he was diagnosed with right inguinal hernia, there was no significant hernia orifice intraoperatively. When the 2nd operation by anterior open approach was undergone, there was a fat-like tissue adhered to the spermatic cord. It was removed and the histopathological finding first revealed aberrant adrenocortical tissue in the resected lipoma of spermatic cord (Figure 1). This abnormal tissue is usually found incidentally during inguinal operation. In general, most of the aberrant adrenal tissue becomes atrophic by adult life. Moreover, it is not clinically significant and also not associated with endocrine abnormalities.

Superiorly based perforator plus flap for inguinal defects

Aim: Inguinal block dissections for metastasis to inguinal lymph nodes and occasionally trauma are always associated with soft tissue loss over the groin region. A clinical study was undertaken to demonstrate the ability to utilize a superiorly-based perforator flap with reliable vascularity and less donor site morbidity to cover defects in the inguinal region. Methods: A prospective study was performed on 7 patients with inguinal soft tissue defects managed in our institution from January 2013 to September 2013. During the study period, a superiorly-based perforator plus flap was used for soft tissue coverage over the femoral vessels in the inguinal region. Hyperbaric oxygen therapy was administered postoperatively. The postoperative period, hospital course, and follow-up after radiotherapy was documented in patients with inguinal block dissection. Results: Seven patients presented with soft tissue defects in the inguinal region. Five of the defects were secondary to prior surgery, and 2 were secondary to trauma. A superiorly-based perforator plus flap was performed in all patients. The defect sizes ranged from 9 cm Χ 4 cm to 17 cm Χ 8 cm. The flap dimensions ranged from 12 cm Χ 5 cm to 20 cm Χ 10 cm. No secondary procedures were necessary following surgery. Postoperatively, there was no evidence of partial or total flap loss. No flap revisions were required, and no complications were experienced at either the donor or recipient site following radiotherapy. Patients were followed-up for 10-18 months. Conclusion: Inguinal defects require stable soft tissue coverage to withstand radiotherapy following inguinal block dissection surgery, and are susceptible to wound complications. The superiorly-based perforator plus flap technique is simple, requires little operative time, and is a reliable flap for coverage of the femoral vessels and inguinal region with improved tolerance to postoperative radiotherapy.

Lithiasis in spermatic veins

Calculi in spermatic veins is a very uncommon clinical entity reported only one case as “varicolithiasis”’in the literature. Here we present our second case as “lithiasis in spermatic veins” that was diagnosed during an inguinal herniography operation.

The Effects of 2 μG and 4 μG Doses of Dexmedetomidine in Combination with Intrathecal Hyperbaric Bupivacaine on Spinal Anesthesia and its Postoperative Analgesic Characteristics

To compare the postoperative analgesic characteristics and side effects of two different doses of intrathecal dexmedetomidine in combination with hyperbaric bupivacaine, and to evaluate the effects of these combinations on spinal anesthesia. After obtaining approval from the local ethics committee, 60 male patients who were undergoing inguinal surgery and were classified as American Society of Anesthesiologists physical status class I were included in the study. The present study was conducted in 2003 in a military hospital with a capacity of 100 beds. The patients were randomly assigned to three groups of 20 patients: group 1, 0.5 mL saline added to 3 mL (15 mg) hyperbaric bupivacaine; and groups 2 and 3, 2 µg dexmedetomidine and 4 µg dexmedetomidine added to 3 mL (15 mg) hyperbaric bupivacaine, respectively. Medications were administered by intrathecal injection in a total volume of 3.5 mL. The postoperative analgesic characteristics, effects on spinal anesthesia and side effects were recorded. Demographic characteristics were similar among the groups. The mean (±SD) time to onset of pain was 220.75±112.7 min in group 1, 371.5±223.5 min in group 2 and 1042.50±366.78 min in group 3. Time to first pain sensation in group 3 was significantly longer than that in groups 1 and 2 (P<0.001). Two different doses of dexmedetomidine, an α2-adrenoceptor agonist with analgesic effects, resulted in an increased duration of analgesia and efficacy, decreased postoperative analgesic use and was associated with no notable adverse effects.