Internal Inguinal Ring Research Articles

Laparoscopic management of a newborn with a right Amyand′s hernia and a left incarcerated inguinal hernia

A one month old boy presented with left incarcerated inguinal hernia. After unsuccessful manual reduction, we decided to perform laparoscopic herniorrhaphy. Laparoscopic examination showed a left hernia with intestinal loops that entered into the internal inguinal ring, on the right side there was an unknown patency of the peritoneal vaginal duct with the appendix completely incarcerated within the sac. On the left side, the loops were reduced with a combined technique of external manual pressure and internal pulling by forceps; the bowel was inspected, and the hernia was repaired. On the right side, the appendix was strongly adherent with the peritoneal vaginal duct, and the reduction was not possible. The appendix was dissected from the sac using a 3-mm monopolar hook and than reduced into the abdomen, then right herniorrhaphy was performed. Two days after surgery, the baby had fever and abdominal distension. He was re-operated through mini-Pfannenstiel incision and an ischemic appendix was identified and removed. Postoperative period was uneventful. In our case, laparoscopy allowed for simultaneous reduction under direct visual control, inspection of the incarcerated organ, definitive repair and incidentally discovery and treatment of the contralateral incarcerated Amyand's hernia. In case of incarcerated appendix, appendectomy is preferable during the same procedure to reduce the incidence of postoperative complications.

A case of 46, XY DSD presenting as a crossed ectopic gonad with a contralateral sliding inguinal hernia

A three-month-old boy was referred to our facility for the treatment of a right impalpable testis, left inguinal hernia, and penoscrotal hypospadias with asymmetric external genitalia. The left gonad was palpated in the left scrotum. The chromosomal study revealed a normal male 46, XY karyotype. Operative findings showed that the right streak gonad, uterus, and fallopian tubes were in the wall of the left hernia sac, forming a sliding hernia. Laparoscopy confirmed that the right gonadal vessels had crossed to the left internal inguinal ring. Herniorrhaphy was done and the right streak gonad, uterus, and fallopian tubes were excised. An exploration of the left gonad revealed an ovotestis. The ovary was removed, and a left testicular biopsy was simultaneously performed. A one-stage hypospadias repair using Koyanagi procedure was also performed. The pathological findings showed an ovarian stroma in the right gonad and left ovary. Only Sertoli cells were detected in the biopsied specimen from the left testis.

A randomized prospective trial comparing clinical outcomes 3 years after surgery by Marcy repair and Prolene Hernia System® repair for adult indirect inguinal hernia

PurposeThe use of mesh in the surgical repair of adult indirect inguinal hernias is widely recommended in Western countries, but no randomized controlled trials have so far been reported in Japan. The purpose of the present randomized prospective trial was to compare a mesh method with non-mesh method for surgical repair of primary adult indirect inguinal hernias in which the diameter of the internal inguinal ring was up to 3.0 cm (I-1 or I-2 of Japanese Hernia Society Classification).MethodsPatients with a primary unilateral inguinal hernia and I-1 or I-2 surgical findings were randomized to undergo either Marcy repair or Prolene Hernia System® repair. Primary endpoints were recurrence, infection, and pain, with follow-up continued for 3 years postoperatively.ResultsNinety-one of 479 patients with an inguinal hernia during the study period did not meet the exclusion criteria, and 46 were allocated to Marcy repair and 45 were allocated to Prolene Hernia System® repair. No recurrence was observed in either group, and no significant differences were identified between the groups in any of the primary endpoints.ConclusionThis randomized prospective trial of I-1 and I-2 inguinal hernias suggests that Marcy repair is not inferior to PHS repair. A large-scale randomized controlled trial appears warranted to confirm whether to use mesh for Japanese adult I-1 and I-2 hernias.

Laparoscopic classification of the impalpable testis

Purpose We present a classification for the nonpalpable testis (NPT) based on laparoscopic findings and suggest guidelines for the interpretation of these findings. Patients and methods From October 2002 to December 2010, 121 patients with NPT underwent laparoscopy at two tertiary centers of Pediatric surgery in Egypt. The lower abdomen and pelvis were inspected to identify the following structures and their inter-relationships: the internal inguinal ring (and its patency), spermatic vessels, vas deferens, and testis. The laparoscopic findings were documented by one of the authors who attended all procedures, and video recordings were available in some cases. Further management was dependent on laparoscopic findings, classification, and plan of treatment. Results The study included 117 patients with 142 nonpalpable testes. Their mean age was 4.9 years. Among patients with unilateral NPT, a contralateral palpable undescended testicle was always associated with a viable NPT (100%), whereas a contralateral scrotal testis had an equal chance (50%) of finding a viable NPT, without a significant difference whether it was right or left sided. Conclusion Failure of normal testicular descent leads to a spectrum of anatomical variations that can be precisely and safely defined by laparoscopy in about two-thirds of patients with nonpalpable testes. In the remaining one-third of patients, including inguinal exploration after laparoscopy can help us to exclude a missed viable inguinal testis. Keywords : cryptorchidism, laparoscopy, testis

Bilateral xanthogranulomatous funiculitis and orchiepididymitis in a 13-year-old adolescent boy

Xanthogranulomatous orchitis is an extremely rare inflammatory nonneoplastic lesion of the testis. We report a case of a 13-year-old adolescent boy who presented a painless left hemiscrotal swelling. The subsequent ultrasonography and magnetic resonance imaging revealed the presence of abnormal expanding tissue located in both testes and spermatic cord, reaching the internal inguinal ring. Testicular tumor markers were normal. The frozen section examination of the surgical specimen showed only inflammatory tissue and not neoplastic tissue. No orchiectomy was performed. Definitive histopathologic diagnosis was xanthogranulomatous inflammation. To our knowledge, this is the youngest case of xanthogranulomatous orchiepididymitis and funiculitis found in medical literature.

Ventrally dislocated attachment of the ovarian suspensory ligament, a risk factor for tubal occlusion as a postoperative complication of inguinal hernia repair: efficacy of laparoscopic inguinal hernia repair for preventing tubal damage

Although the traditional cutdown inguinal hernia repair in children is well established, tubal occlusion has been reported as a complication in girls. The purpose was to investigate the mechanism of this complication and the efficacy of laparoscopic repair for preventing tubal occlusion. Between October 2006 and May 2010, we performed laparoscopic hernia repair in 100 girls (54 with a right hernia, including 2 with an inguinal ovarian hernia, 40 with a left hernia, including 3 with an inguinal ovarian hernias, and 6 with bilateral hernias). During laparoscopic repair we examined the anatomical relationship between the ovary, ovarian suspensory ligament, internal inguinal ring, and round ligament on both sides. In 17 cases, 5 with an inguinal ovarian hernia and 12 without, the suspensory ligaments were ventrally dislocated and attached around the internal inguinal ring, and the ovary and fallopian tube were positioned near the internal inguinal ring and above the pelvic brim on the side of the original hernia. This ventrally dislocated attachment may facilitate sliding of the ovaries and tubes into the hernial sac and induce tubal occlusion as a postoperative complication of inguinal hernia repair. The laparoscopic procedure makes it easy to prevent this complication.

Cystic Rete Testis in a 3-Year-Old Gypsy Vanner Colt: A Case Report

A 3-year-old Gypsy Vanner colt was presented at the Auburn University College of Veterinary Medicine for castration. The left testicle of the horse was present within the scrotum, but neither the right testicle nor the epididymis was found during external palpation of the right inguinal ring. Removal of the retained testicle by a routine inguinal approach by traction on the gubernaculum and dilation of the internal inguinal ring was not possible. During a parainguinal approach to the abdomen, an enlarged cystic testicle was discovered. Histopathologic diagnosis was cystic rete testis. This case report stresses the importance of preoperative ultrasonographic assessment of cryptorchid testicles to decrease surgical time.

1530 ADOLESCENT HYDROCELECTOMY A SCROTAL OR INGUINAL APOPROACH?

You have accessJournal of UrologyPediatrics: Congenital Anomalies - Lower Urinary Tract & Genitalia I1 Apr 20121530 ADOLESCENT HYDROCELECTOMY A SCROTAL OR INGUINAL APOPROACH? Jason P. Van Batavia, Angela M. Fast, and Kenneth I. Glassberg Jason P. Van BataviaJason P. Van Batavia New York, NY More articles by this author , Angela M. FastAngela M. Fast New York, NY More articles by this author , and Kenneth I. GlassbergKenneth I. Glassberg New York, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1298AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Hydroceles found early in life are associated with a patent processus vaginalis, which requires correction via an inguinal approach. When hydroceles present later in adulthood, they are rarely associated with a patent processus vaginalis and a transscrotal approach is preferred. Adolescent boys are between these extremes and the correct approach to hydrocele repair is unclear. In patients undergoing laparoscopic varicocelectomy (LV) and who coincidentally had a known hydrocele that required surgery, we sought to determine laparoscopically how often these patients had an open ring to extrapolate what approach, inguinal vs. scrotal, should be used for the for adolescent hydrocelectomy, whether or not a varicocele is present. METHODS Using our IRB-approved prospectively maintained adolescent varicocelectomy database, the operative reports and charts of all patients that underwent LV were reviewed. Data was collected on boys who underwent simultaneous LV and hydrocelectomy and the presence of ipsilateral open or closed internal inguinal rings were noted. The approach to hydrocelectomy, ie. inguinally vs. scrotally, was also recorded and in all cases a Jaboulay-type repair was performed. At the time of transscrotal hydrocelectomy, the cephalad portion of the hydrocele was probed to detect for a proximal patent processus vaginalis. RESULTS Of 412 patients who underwent LV since 1997, operative reports were available in 306 (mean age 15.7 yrs, 50 bilateral). Ten boys had known right hydroceles, 2 had known left hydroceles, and 1 had bilateral hydroceles at the time of presentation. Of these 14 hydroceles in 12 patients (4% of all LV patients), only 2 (both on the right) were associated with widely open internal inguinal rings. Both of these right hydroceles were repaired with an inguinal approach and all others were repaired transscrotally. The patient with bilateral hydroceles had closed rings bilaterally. No recurrences were noted after repair. CONCLUSIONS In this cohort of adolescents undergoing laparoscopic correction of varicoceles, only 14% of synchronous hydroceles were associated with an open internal inguinal ring or patent processus vaginalis that required inguinal repair. The majority can be repaired safely with a transscrotal approach. On the basis of these observations, we believe that adolescents undergoing hydrocelectomy should be approached transscrotally and recognize that 14% might need an additional inguinal incision. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e619 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jason P. Van Batavia New York, NY More articles by this author Angela M. Fast New York, NY More articles by this author Kenneth I. Glassberg New York, NY More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1529 OPENING THE INGUINAL CANAL IS UNNECESSARY IN INGUINAL ORCHIOPEXY

You have accessJournal of UrologyPediatrics: Congenital Anomalies - Lower Urinary Tract & Genitalia I1 Apr 20121529 OPENING THE INGUINAL CANAL IS UNNECESSARY IN INGUINAL ORCHIOPEXY Frank J. Penna, Jack S. Elder, and Mireya Diaz Frank J. PennaFrank J. Penna Detroit, MI More articles by this author , Jack S. ElderJack S. Elder Detroit, MI More articles by this author , and Mireya DiazMireya Diaz Detroit, MI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1297AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In boys with an inguinal testis, the traditional approach is to perform an inguinal incision, open the inguinal canal, mobilize the testis and spermatic cord, repair the inguinal hernia if present, and place the testis in a dartos pouch in the scrotum. In boys, the inguinal canal is short and during inguinal hernia repair, it is often unnecessary to extend the dissection to the internal inguinal ring in order to mobilize enough length. The purpose of this study is to determine if performing a modified inguinal orchiopexy (without opening the inguinal canal) results in a successful orchiopexy. METHODS Boys with an inguinal testis who underwent orchiopexy were reviewed retrospectively. Patient age and surgical approach (inguinal, with or without inguinal dissection, or prescrotal) were recorded. Only if the testis did not reach the dartos pouch was the inguinal canal opened and a standard orchiopexy performed with inguinal dissection. Presence of an inguinal hernia was also noted. All patients underwent clinical follow-up at 4-6 weeks. Boys with an ectopic, abdominal or absent testis and those undergoing previous inguinal surgery were excluded. RESULTS A total of 254 boys with 323 undescended inguinal testes were reviewed. The results are shown in Table 1. Overall, 171 underwent a modified inguinal orchiopexy without opening the inguinal canal, 36 underwent inguinal orchiopexy with standard inguinal dissection, and 116 underwent prescrotal orchiopexy. A total of 123 (38.1%) testes were associated with an inguinal hernia that was repaired during orchiopexy. Of those with a hernia, 92 underwent a modified inguinal orchiopexy, 23 underwent a standard inguinal orchiopexy, and 9 were corrected via a prescrotal approach. There was one complication of testicular re-ascent in the modified inguinal orchiopexy group. Inguinal (M) Inguinal (S) Prescrotal Total No. testis 171 36 116 323 Mean age (yrs.) 5.1 5.9 4.9 5.1 Hernia 92(54%) 23(64%) 9(8%) 123(38%) No. side Lt 79 20 56 155 Rt 92 16 60 168 No. complications 1(0.5%) 0(0%) 0(0%) 1(0.3%) (M) = modified, (S) = standard CONCLUSIONS In boys with an inguinal undescended testis, orchiopexy can be performed without opening the inguinal canal, even if there is an associated inguinal hernia, with the decision being dependent upon the ability to mobilize the testis and spermatic cord into the dartos pouch. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e619 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Frank J. Penna Detroit, MI More articles by this author Jack S. Elder Detroit, MI More articles by this author Mireya Diaz Detroit, MI More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Laparoscopic hernioraphy: a better approach for recurrent hernia in boys?

We aimed to compare laparoscopic hernia repair and open hernia repair in recurrent cases after first open repair according to the length of time taken to perform the procedure. Between November 2009 and December 2011, the medical records of 26 male paediatric patients who were treated with laparoscopic surgery (with Schier's intracorporal "N" suture closure) and open surgery (with high ligation technique) in our institution for recurrent inguinal hernia were reviewed for the length of the operative time and post-operative complications retrospectively. Thirteen cases operated with laparoscopic repair were regarded as Group 1 and other 13 cases operated with the open high ligation repair were regarded as Group 2. All recurrent hernia cases had been performed in other hospitals with the open high ligation technique previously. Thirteen internal inguinal ring closures in Group 1 were performed laparoscopically. In Group 2, 13 cases underwent open high ligation repair. Comparing the laparoscopic and open-repair techniques in the recurrent cases (Group 1 vs. Group 2; 32.36 vs. 61.07 min, respectively) showed that the length of the operation time was much shorter in laparoscopic repair group (Group 1) than open repair group (Group 2). A statistically significant difference was also observed (p = 0.001). No post-operative testicular atrophy or recurrence was seen until present time in all groups. We propose that laparoscopic repair in recurrent childhood inguinal hernia cases, developed after open repair, avoids entering a fibrotic inguinal canal, making the procedure easier and shorter. Laparoscopic herniorrhaphy is a good alternative option in recurrent childhood hernia.

Diagnosis and Management of Cryptorchidism

Among males born at full term or prematurely, 1–30% are affected by cryptorchidism. Approximately 70% of cryptorchid testes will spontaneously descend by 3 mo.The cause of cryptorchidism is multifactorial. A prerequisite for testicular descent is a normal hypothalamic-pituitary-gonadal axis. In addition, an undisturbed interaction with the anatomic structures is required, as well as the appropriate hormonal milieu and environmental conditions. Hereditary factors also play a major role.The Kaplan classification distinguishes between palpable testes (80%) and nonpalpable testes (20%). The nonpalpable group includes intra-abdominal, inguinal, and absent (vanishing) testes, whereas palpable testes can be between the internal and external inguinal ring, high scrotal, or in a superficial pouch between the oblique and the Scarpa fascia in the so-called Denis Browne pouch.Therapy for undescended testis (UDT) is usually carried out when a child is between 6 and 12 mo; individuals with high UDT especially benefit from an early orchidopexy. The lower the pretreatment position, the more chance there is of spontaneous descent as well as better results of surgical intervention.Although the management of a palpable testis is standardized, there are no guidelines for the management of boys with a nonpalpable testis. It seems that both preoperative and postoperative hormonal treatment may have a beneficial effect on fertility later in life. Because of the increased risk of testicular malignancy, lifelong follow-up is mandatory.

Histología del anillo inguinal interno en pacientes con hernia inguinal indirecta: serie de casos observacional y descriptiva

Age associated changes in the histology of indirect inguinal hernia rings Background: This study has the purpose to investigate the microscopic basic histological structure of the internal inguinal ring in patients operated on for primary indirect inguinal hernia. Patients and Methods: A sample of 72 consecutive male patients older than 15 years-of-age with unilateral inguinal hernia submitted to elective surgery was studied. The primary outcome measure was the histological findings of the internal inguinal ring. All samples were processed only by histochemical techniques. Patients were divided in 3 groups according to age. Group I: patients between 15 and 40 years-of-age. Group II: patients between 41 and 70 years-of-age. Group III: patients older than 71 years. Results: All samples from the internal inguinal ring were constituted by fibrous fascial tissue with elastic fibers which were thicker in younger patients and thinner in older patients. Adipose tissue between elastic fibers was absent in younger patients and was abundant in older patients. Vascular sclerosis was minimal in Group I, moderate in Group II, and important in Group III. Acute or chronic inflammatory cells were absent in all patients. Conclusions: The histological characteristics of the internal inguinal ring in patients with indirect inguinal hernia consist on reduced density and thickness of elastic fibers and increased adipose tissue between elastic fibers. Vascular sclerosis was more severe as the age of the patients increased. These histological changes were related to normal aging.

Crossed-Fused Testicular Ectopia: A Case for the Use of Laparoscopy to Evaluate Nonpalpable Testicles

A 1-year-old male was referred for evaluation of a nonpalpable right testicle. In children with nonpalpable testicles, it our practice to proceed with diagnostic laparoscopy in an attempt to identify an intra-abdominal testicle or blind-ending spermatic vessels regardless of ultrasound findings. In the operating room, we performed diagnostic laparoscopy through the umbilical stump. We identified a vas deferens passing from the right side to the left side, and what appeared to be a testicle in the area of the left internal inguinal ring (Figures 1 and 2). In the left groin, we found both testicles fused together with a common blood supply, but a separate vas deferens. We placed the right testicle transseptally into the right hemiscrotum.Figure 2Right testicle entering the left inguinal ring.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Crossed testicular ectopia, or transverse testicular ectopia, is an extremely rare finding on exploration for an undescended testicle, with just slightly more than 100 cases reported in the literature to date.1Lam W.W. Le S.D. Chan K.L. Chan F.L. Tam P.K. Transverse testicular ectopia detected by MR imaging and MR venography.Pediatr Radiol. 2002; 32: 126-129Crossref PubMed Scopus (45) Google Scholar, 2Malik M.A. Iqbal Z. Chaudri K.M. Malik N.A. Ahmed A.J. Crossed testicular ectopia.Urology. 2008; 71 (984 e5-6)Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar A classification system has been proposed that accounts for accompanying anomalies, including hernias and mullerian duct structures.3Gauderer M.W. Grisoni E.R. Stellato T.A. Ponsky J.L. Izant Jr., R.J. Transverse testicular ectopia.J Pediatr Surg. 1982; 17: 43-47Abstract Full Text PDF PubMed Scopus (88) Google Scholar The ectopic testicle is usually structurally normal; however, it does carry a risk of malignancy, similar to that associated with other forms of intra-abdominal testicles.4Berkmen F. Persistent mullerian duct syndrome with or without transverse testicular ectopia and testis tumours.Br J Urol. 1997; 79: 122-126Crossref PubMed Google Scholar, 5Naouar S. Maazoun K. Sahnoun L. Jouini R. Ksia A. Elezzi O. et al.Transverse testicular ectopia: a three-case report and review of the literature.Urology. 2008; 71: 1070-1073Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Although there are reports of successful diagnosis of this anomaly using ultrasonography6Pinto C.W. Toro R.C. Mansilla K.H. Castro T.A. Fuente-Alba C.S. Crossed testicular ectopia.J Ultrasound Med. 2010; 29: 847-849PubMed Google Scholar or magnetic resonance imaging1Lam W.W. Le S.D. Chan K.L. Chan F.L. Tam P.K. Transverse testicular ectopia detected by MR imaging and MR venography.Pediatr Radiol. 2002; 32: 126-129Crossref PubMed Scopus (45) Google Scholar during evaluation of nonpalpable testicles, neither of these studies is sufficiently sensitive to safely rule out an ectopic testicle.7Gokce M.I. Burgu B. Aydogdu O. Fitoz S. Soygur T. Transverse testicular ectopia associated with persistent Mullerian duct syndrome: another entity in which magnetic resonance imaging is unreliable.Urology. 2010; 76: 1475-1477Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 8Tasian G.E. Copp H.L. Diagnostic performance of ultrasound in nonpalpable cryptorchidism: a systematic review and meta-analysis.Pediatrics. 2011; 127: 119-128Crossref PubMed Scopus (93) Google Scholar Laparoscopy has consistently demonstrated superior diagnostic accuracy in nonpalpable testicles9Papparella A. Romano M. Noviello C. Cobellis G. Nino F. Del Monaco C. et al.The value of laparoscopy in the management of non-palpable testis.J Pediatr Urol. 2010; 6: 550-554Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 10Cortesi N. Ferrari P. Zambarda E. Manenti A. Baldini A. Morano F.P. Diagnosis of bilateral abdominal cryptorchidism by laparoscopy.Endoscopy. 1976; 8: 33-34Crossref PubMed Scopus (278) Google Scholar, 11Jordan G.H. Winslow B.H. Laparoscopic single-stage and staged orchiopexy.J Urol. 1994; 152: 1249-1252PubMed Google Scholar, 12Siemer S. Humke U. Uder M. Hildebrandt U. Karadiakos N. Ziegler M. Diagnosis of nonpalpable testes in childhood: comparison of magnetic resonance imaging and laparoscopy in a prospective study.Eur J Pediatr Surg. 2000; 10: 114-118Crossref PubMed Scopus (33) Google Scholar and is instrumental in their evaluation and treatment as underscored by this unusual finding on exploration.

Laparoscopic inguinal hernia repair in children: A single-centre experience over 7 years

To evaluate 209 consecutive children who underwent laparoscopic hernia repair over a 7-year period. Technical details and clinical results are reported. A total of 284 open internal rings were closed laparoscopically in 209 children (142 boys and 67 girls, aged 30 days to 15 years, mean 44 months). One 5-mm and two 3-mm instruments were used to access the peritoneal cavity. A 270° anterolateral peritoneal incision was made. The internal inguinal ring was closed with a nonabsorbable suture. There were no significant intraoperative complications. Length of procedure ranged between 15 and 65 minutes with a mean of 30 minutes. Postoperative hospital stay ranged from 1 to 9 days. Thirty children who presented with a right-sided hernia and 23 with a left hernia (total of 53) were found to have a patent contralateral internal ring on laparoscopy. Mean follow-up was 30 months. There were 2.4% hernia recurrences and cosmesis was excellent. Laparoscopic hernia repair in children can be a routine procedure with increasing experience and better learning curve of surgeons. There is clear visualization of structures and vas remains untouched. The recurrence rate is comparable to that of the traditional open approach with a superior cosmetic result.

Laparoscopic gonadectomy of streak gonads within the inguinal canals in a patient with XY partial gonadal dysgenesis

A 33-year-old phenotypic female presented with primary amenorrhea. The physical examination revealed no breast development, scanty axillary and pubic hair, normal female external genitalia, and a short blind vagina. The findings of magnetic resonance imaging, karyotyping, and hormonal examinations supported the diagnosis of XY partial gonadal dysgenesis. Laparoscopic surgery showed that spermatic cords, including the bilateral streak gonads and epididymes, were within the inguinal canals. After opening the spermatic cords and identifying the lower borders of the streak gonads, the spermatic cords were transected at the level of the vas deferens. A prophylactic herniorrhaphy using polyprophylene mesh was performed due to weakening of the internal inguinal ring. Pathologic evaluation of the gonads confi rmed the diagnosis of partial gonadal dysgenesis without evidence of malignancy. A laparoscopic approach is feasible for treatment of XY gonadal dysgenesis, even if the streak gonads are present within the inguinal canal.

Bilateral Impalpable Testes: A Special Entity of Cryptorchidism

Background: Cryptorchidism is one of the most common genitourinary disorders in young boys. About 1% - 2% of boys at age of 1 year have an undescended testis (UDT); this disorder is unilateral in about 90% of individuals and bilateral in about 10%. However, bilateral impalpable testes represent a special category that should be differentiated from anorchidism as well as male pseudohermaphroditism. We investigated whether bilateral impalpable testes with its inherent hormonal and genetic factors has different outcomes in terms of success of orchiopexies compared to unilateral impalpable testes. Methods: We retrospectively analyzed the demographic and clinical findings, as well as immediate and 6 month outcomes, in patients diagnosed with bilateral impalpable undescended testes between 2006 and 2010. Findings were reported after a minimum of 6 months from the last surgical intervention. Results: Nine patients underwent laparoscopy for bilateral impalpable testes, 7 of whom had testes in the region of the internal inguinal ring. The success rate after laparoscopic exploration and open orchiopexy was 60% while the success rate with unilateral impalpable testes was 63.3% in the same study. Conclusion: Although laparoscopy is extremely useful in both the diagnosis and treatment of patients with bilateral impalpable testes, laparoscopy should be preceded by careful cytogenetic and hormonal workup for this particular group of patients. We found that the success rates of laparoscopic management of bilateral and unilateral impalpable testes were similar, as shown by testicular size clinically sassed during serial postoperative outpatient visits.

Laparoscopic Management of Intra-Abdominal Testis: 5-Year Single-Centre Experience—A Retrospective Descriptive Study

Background. Undescended testis is one of the most common urological problems in children, affecting about 1% of boys at age of 1 year. Of these, about 20% have a nonpalpable testis with a very high probability that the testis is absent. This may have a significant impact on the possibility of malignancy in these testes, as well as on the later fertility of these subjects. Methods. We retrospectively analyzed the demographic and clinical findings, as well as immediate and 6-month outcomes, in 91 patients diagnosed with impalpable undescended testes between January 2006 and December 2010. Results. Of the 91 patients, 9 had bilateral and 82 had unilateral impalpable testes. All 100 testes were managed laparoscopically. The largest group of intra-abdominal testes in this series, 42 testes, was entering the internal ring; in these, laparoscopic exploration and standard open orchiopexy resulted in a 66% success rate. The total success rate was 63.3%. Conclusion. Laparoscopy is extremely useful in both the diagnosis and treatment of impalpable testes. Objectively measured mobility of the testis towards the contralateral internal inguinal ring is an excellent intraoperative indicator for type of orchiopexy. Standardization of management may increase the success rate of orchiopexy.

Laparoscopic Extracorporeal Ligation of Hernia Defects Using an Epidural Needle and Preperitoneal Hydrodissection

This article presents the extracorporeal ligation of inguinal hernia defects using an epidural needle and preperitoneal hydrodissection. Thirteen children underwent laparoscopic extracorporeal ligation of their hernia defect using an epidural needle and preperitoneal hydrodissection. A 5-mm trocar for an operative laparoscope was placed through an infraumbilical incision, a Veress needle for forceps was inserted halfway between the umbilicus and the anterior superior iliac spine on the contralateral side of the hernia, and a 17-gauge epidural needle was inserted at the point of the internal inguinal ring. The hernia defect was closed extracorporeally by a nonabsorbable suture, which was introduced into the abdomen through the epidural needle on the lower half of the hernia defect and withdrawn on the opposite side by a wire-loop through the epidural needle going along the upper half side of the hernia defect in a series of movements. When a contralateral hernia defect is present, laparoscopic-assisted extracorporeal ligation of the contralateral hernia defect is performed during the same operation. All patients were discharged uneventfully from the hospital within 24 hours postoperatively. The mean follow-up period is 6.1 months (range 2-12 mos), and no recurrence has been observed to date. This article describes a unique technique of extracorporeal circuit suturing of inguinal hernia defects using a minimally invasive technique as afforded by an epidural needle.

Transumbilical endoscopic surgery for completely enclosing inguinal hernias in children

Background/Purpose There has been great interest in natural orifice transluminal endoscopic surgery in recent years. We report another new approach for pediatric inguinal hernia repair: transumbilical endoscopic surgery (TUES). Compared with the natural orifice transluminal endoscopic surgery technique, TUES can obtain similar scarless results on the abdomen. Methods In our hospital, 2-trocar TUES was the standard procedure used to repair pediatric inguinal hernias. Through 2 intraumbilical incisions, two 5-mm trocars were inserted into the abdomen under laparoscopic guidance. With the use of a needle-holding forceps, a round needle with 2-0 nonabsorbable suture material was introduced into the peritoneal cavity through the anterior abdominal wall near the internal inguinal ring. The orifice of the hernial sac was closed extraperitoneally with a purse-string suture around the internal inguinal ring, and intraperitoneal knot-tying was performed. Results A total of 76 inguinal repairs were performed in 64 children (age range, 6 months to 9 years; median, 3.8 years; 44 boys, 20 girls). All operations were completed successfully by TUES, with the exception of one case of intraoperative bleeding because the inferior epigastric vein was punctured. The mean operating time was 20 minutes (range, 15-30 minutes). No postoperative bleeding, hydrocele, or scrotal edema in this group of patients was found, and there were no known cases of postoperative testicular atrophy or hypotrophy nor hernia recurrence on the symptomatic side. Conclusions Our preliminary experience shows satisfactory outcomes with TUES for completely enclosing inguinal hernias in children. This technique appears to be safe, effective, and reliable. The cosmetic result is excellent.

Unsuspected Perforated Richter Hernia in the Inguinal Canal Detected by F-18 FDG PET/CT

An 86-year-old man presented with fatigue and weight loss. Combined F-18 fluorodeoxyglucose positron emission tomography and computed tomography (FDG PET/CT) demonstrated a heterogeneous soft-tissue mass continuous with the small bowel in the left inguinal region, with marked hypermetabolic activity on PET images. Physical examination of the left groin demonstrated a previously unidentified nonreducible, tender mass. Surgical exploration revealed a perforated Richter hernia in the internal inguinal ring with adjacent groin abscess. Pathologic evaluation confirmed these findings without underlying malignancy.