Internal Inguinal Ring Research Articles

Nerve‐Identifying Inguinal Hernia Repair: A Surgical Anatomical Study

Pain syndromes of somatic and neuropathic origin are considered to be the main causes of chronic pain after open inguinal hernia repair. Nerve-identification during open hernia repair is suggested to be associated with less postoperative chronic pain. The aim of this study was to define clinically relevant surgical anatomical zones facilitating efficient identification of the three inguinal nerves during open herniorrhaphy. Through dissection of 18 inguinal areas of embalmed and unembalmed human cadavers, identification zones were developed for the inguinal nerves (in particular for the genital branch of the genitofemoral nerve). The iliohypogastric nerve was identifiable running approximately horizontally and ventrally to the internal oblique muscle perforating the external oblique aponeurosis at a mean of 3.8 cm (range 2.5-5.5 cm) cranially from the external ring. When present, the ilioinguinal nerve was identifiable running ventrally and parallel to the spermatic cord, dorsally from the aponeurosis of the external oblique muscle. Identification of the genital branch of the genitofemoral nerve was more comprehensive. The course of the genital branch is laterocaudal at the level of the internal inguinal ring. Based on the newly defined identification zones, peroperative identification of all inguinal nerves is possible. Further research is warranted to assess clinical feasibility of these zones and to evaluate the influence of (facultative) division, preservation or omittance of the identification of inguinal nerves on the incidence of chronic pain.

Laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children: clinical outcome of 972 repairs done in 3 pediatric surgical institutions

Background/Purpose In 1995, we developed laparoscopic percutaneous extraperitoneal closure (LPEC) to treat inguinal hernias in children. This study evaluated LPEC's safety, efficacy, and reliability in 3 hospitals. Methods In 2 hospitals, LPEC was the standard procedure used to repair inguinal hernias in children, and in 1 hospital, it was done optionally in girls. During LPEC, a 4.5-mm laparoscope was placed through an umbilical incision, a 2-mm grasping forceps was inserted on the left side of the umbilicus, and a 19-gauge LPEC needle with suture material was inserted at the midpoint of the right or left inguinal line. The hernial sac orifice was closed extraperitoneally by circuit suturing around the internal inguinal ring using the LPEC needle. Results Nine hundred seventy-two LPECs were performed on 711 children (age range, 18 days to 19 years): 384 boys had 500 internal inguinal rings closed and 327 girls had 472 internal inguinal rings closed. Operating time for uni- or bilateral inguinal hernias ranged from 10 to 30 minutes. No complications occurred during surgery. The recurrence rate was 0.73% during follow-up (range, 5 months to 10 years). No hydroceles or testicular atrophy occurred after surgery. Conclusion Laparoscopic percutaneous extraperitoneal closure for inguinal hernia in children appears to be safe, effective, and reliable.

Laparoscopic orchiectomy for the adult impalpable testis – experiences in a rural teaching hospital

Undescended testis is a relatively common condition in boys. The standard treatment is orchiopexy. In adults, orchiopexy is done only if sufficient length can be mobilized. Otherwise, orchiectomy is ideal as undescended testis predisposes to carcinoma. The incidence of carcinoma increases with age. The aim of this study is to highlight the value of laparoscopy in treatment of impalpable testis and simultaneously repair associated hernias. This is our experience in a rural tertiary hospital. In our rural hospital, it is not uncommon to see men aged 30 years or more presenting with unilateral absence of testis/empty hemiscrotum. A total of 35 patients were studied. Ultrasonography of the abdomen was done to localize the exact position of the testis; it was detected in 12 cases. A computed tomography (CT) scan was done in the other 23 cases and was positive in 16. The testis was found in the retroperitoneum (close to the internal inguinal ring) in 12 cases and in the inguinal canal in 23 cases. There were associated hernias in 9 patients. Laparoscopy accurately identified the exact location of the missing testis and resection was also accomplished and associated hernias were repaired laparoscopically. In countries like India, the majority of the population is poor and illiterate. By the time a boy or young man with an undescended testis arrives at the hospital, it is already too late to do orchiopexy. Even though most of our patients had no symptoms, orchiectomy had to be done because of the risk of torsion and malignant transformation. By using laparoscopy in these patients, the advantages of minimally invasive surgery can be utilized. Laparoscopic orchiectomy seems to be advantageous and well received by patients. We preferred the laparoscopic approach for the obvious benefits of less pain, better cosmesis, and early discharge.

Analysis of anomalies of the epididymis and processus vaginalis in human fetuses and in patients with cryptorchidism treated and untreated with human chorionic gonadotrophin

To analyse the incidence of epididymal anomalies and the structure of the processus vaginalis (PV) in patients with cryptorchidism treated or not with human chorionic gonadotrophin (hCG), and to compare these findings with human fetuses with testes in the scrotum. We assessed 24 fetuses with a gestational age of 23-35 weeks, and 114 cryptorchid patients (mean age 10.3 years). The patients were divided into two groups of those who used hCG (55, 65 testes) and those who did not (59, 75 testes). The sample was divided into six groups of possible anatomical relationships between the testis and the epididymis, according to a previous classification. Two situations were considered to analyse the PV: (a) total obliteration between the internal inguinal ring and the upper pole of the testis; and (b) total patency. Epididymal anomalies were found in 35% of patients with cryptorchidism and in only 4% of normal fetuses. Of the 47 cases of epididymal anomalies in patients with cryptorchidism 23 (49%) were treated with hCG and 24 (51%) were not. The PV was patent in 58% of patients with cryptorchidism and in only 5% of fetuses. Considering the three groups, the epididymal anomalies were more frequent when the PV was patent. Patency of the PV and the incidence of epididymal anomalies were more frequent in patients with cryptorchidism. The existence of epididymal anomalies did not influence testicular migration in patients treated with hCG.

Minimal Access Surgery in the Neonate

After completing this article, readers should be able to: 1. Review physiologic, anatomic, and technical issues related to minimal access surgery in the neonate. 2. Describe conditions in which minimal access surgery can be used in neonates. Historically, pediatric surgeons were slow to adapt to minimal access surgery (MAS) techniques compared with the adult surgical community. However, MAS now is widely established in infants and children. Differences in size and physiology have necessitated a number of surgical and technological modifications to apply MAS techniques to this population. This review outlines the important differences between children and adults with respect to MAS and provides examples of the use of MAS for diseases seen in infants. ### Physiologic Issues The physiologic response to pneumoperitoneum in children is more pronounced than in adults. Peritoneal insufflation with carbon dioxide has been shown to cause hypercarbia, acidemia, and decreased oxygenation in the pediatric piglet model. (1) In infants, however, there is no detrimental effect on blood pressure, heart rate, or oxygen saturation during short periods of pneumoperitoneum, and elevations in end-tidal CO2 can be counteracted readily by increasing the minute ventilation. (2) Hypercarbia-induced pneumoperitoneum in infants is associated with changes in cerebral blood flow and cardiac output. Nevertheless, laparoscopic procedures have been performed safely with proper anesthetic management in children who have even severe congenital cardiac abnormalities such as hypoplastic left heart syndrome. (3) Hypothermia also can be a concern due to rapid insufflation of unwarmed CO2 gas, mandating the moderation of flow rates. (4) ### Anatomic Issues A number of anatomic factors set children apart from adults and must be accounted for when performing laparoscopic surgery in this age group. Young children and infants have thinner abdominal walls than adults, so extreme care must be exercised when placing trocars. Due to the small size of the abdomen, the working …

Vasal Reconstruction Above the Internal Inguinal Ring: What Are the Options?

Vasal Reconstruction Above the Internal Inguinal Ring: What Are the Options?

Management of neonates with large abdominal wall defects and undescended testis

Objectives To assess, in a retrospective study, the outcome of different treatment modalities in newborns with undescended testes secondary to large abdominal wall or diaphragmatic defects. Large abdominal and diaphragmatic defects are known to be associated with cryptorchidism, yet the reported incidence varies widely. Methods A total of 112 neonates with large abdominal wall or diaphragmatic defects were treated from 1981 to 2005. Of the 55 male patients in this series, 9 (16.4%) presented with abdominal testes and 4 had an extra-abdominal testis (7.3%). Results The 2 patients undergoing primary orchiopexy had testes of normal size and in the normal position at last follow-up. In one of these patients in whom the testis was brought down to the internal inguinal ring, spontaneous descent occurred and the testis on the affected side was normal. The other patient required additional surgery and had an atrophic testis at last follow-up. In 1 patient with severe concomitant malformations, primary orchiectomy was performed. The 4 patients who did not receive initial treatment all lost their testes owing to atrophy. Conclusions The results of the present study have indicated that primary orchiopexy should be attempted in all cases of abdominal wall defects associated with abdominal cryptorchid testes because it yields better testicular salvage rates. In cases in which the spermatic cord is not long enough to place the testis into the scrotum, mobilization and fixation at the lowest site possible resulted in better outcomes than leaving the testis in the abdomen.

Laparoscopic inguinal hernia repair—a prospective personal series of 542 children

Purpose This series prospectively evaluates a consecutive personal series of children undergoing laparoscopic hernia repair. Methods A total of 712 inguinal hernias were corrected laparoscopically in 542 children (396 boys and 146 girls, aged 4 days to 14 years, median 1.6 years). The internal inguinal ring was closed with a 4-0 nonabsorbable suture using 2-mm instruments. Patients were prospectively video-documented. Results There were no serious intraoperative complications. Operating time was comparable to open surgery. The contralateral inner ring was open on the left side in 16% of boys and 12% of girls, and on the right side in 18% of boys and 32% of girls. Direct hernias were found in 2.3%, femoral hernias in 1%, hernias en pantalon in 0.7%, and a combination of indirect and femoral hernia in 0.2%. Follow-up to date is 1-84 months (median 39 months). There were 4.1% hernia recurrences, 0.7% hydroceles and 0.2% testicular atrophies. Cosmesis is excellent. Conclusions Laparoscopic inguinal hernia repair can be a routine procedure with results comparable to those of open procedures. It is well suited for recurrences. The vas remains untouched. The visualization of structures is clear and leads to a defect-specific closure. The advantages of the laparoscopic approach include the following: its technical ease, it is an outpatient procedure, the cord structures remain untouched, the type of hernia is obvious, trocar placement is identical for any side or hernia type, clear visualization of the anatomy. Routine video documentation renders the diagnostic accuracy objective and absolute. Finally, recurrences are easier dealt with, be it from a previous open or from a laparoscopic approach. Although recurrences were slightly more frequent in the early stages, now they are closer to the rate with the open procedure.

Chylous ascites following retroperitoneal lymphadenectomy for testes cancer

A 31-year-old man underwent a radical orchiectomy for a stage I mixed germ-cell tumor with angiolymphatic invasion. A subsequent laparoscopic retroperitoneal lymphadenectomy was complicated by a laceration to the aorta at the ostia of the more inferior of two right renal arteries. This was repaired following conversion to an open laparotomy. The patient presented 14 days later with genital swelling and increasing abdominal girth. Physical examination, abdominal and pelvic CT, laboratory albumin testing, lymphoscintogram and lymphangiogram. Chylous ascites with tracking of lymphatic fluid into the left groin through a defect in the internal inguinal ring. Conservative management with salt restriction, a medium-chain fatty-acid diet and diuretics; exploratory laparoscopy, during which a small left inguinal hernia was repaired and chylous fluid was drained. Following further leakage, the patient was placed on total parenteral nutrition, followed by image-guided sclerotherapy with doxycycline.

A new simplified technique for needlescopic inguinal herniorrhaphy in children

Background Needlescopic techniques have been used recently in repairing inguinal hernias (IHs), which made this type of surgery more feasible and less invasive. The technique is being developed further. Objective The objective of this study was to describe and assess the results that can be achieved by using a new simplified technique (Reverdin needle) in needlescopic inguinal herniorrhaphy in children. Patients and Methods All patients with symptomatic IH confirmed by clinical examination were subjected to elective needlescopic herniorrhaphy. One hundred fifty patients with 186 groin hernias, from 2 hospitals in Egypt and Saudi Arabia, in the period from October 1999 to May 2002, were assigned to needlescopic inguinal herniorrhaphy using Reverdin needle. Reverdin needle was used to insert a purse-string suture around the internal inguinal ring to be tied extracorporeally. Results A total of 186 inguinal hernial defects in 150 children were repaired successfully. There were 130 males and 20 females with a mean age of 20.58 ± 21 months (range, 8-96 months). Right-sided IH was present in 86 patients (57.33%); among these patients, an opened internal inguinal ring was found and repaired in 12 cases (8%). Left-sided IH was present in 30 (20%), bilateral hernia in 19 cases (12.67%), and recurrent IH in 20 cases (10%). The mean duration of surgery was 8.7 ± 1.18 minutes for unilateral and 12.35 ± 2 minutes for bilateral hernia repair. There were no intraoperative or postoperative complications. The mean hospital stay was 6 ± 1.21 hours. Conclusion The new technique had all the advantages of needlescopic herniorrhaphy in children (less invasive, less pain, short hospital stay) combined with the advantages of reduced operating time, simplicity, and feasibility. It may be preferable to the intracorporeal suturing and knot tying. However, it needs long-term follow-up.

“Shaeer’s vasovasostomy” for bypassing inguinal obstruction of the vas deferens: intra-peritoneal versus extraperitoneal approaches

Abstract Introduction Latrogenic obstruction of the vas deferens within the inguinal canal can be managed by direct onsite vasovasostomy. However, in cases with large defect of the vas, the anastomosis may be under tension. Dissecting through the site of a previous hernia repair is tedious, and may lead to recurrence of the hernia. Aim of the Work The present work reports on an alternative technique that avoids the latter drawbacks. Patients and Methods A total of 15 patients with azoospermia due to inguinal obstruction of the vas deferens underwent bilateral repair. Ten cases were operated upon using the classical transperitoneal approach. Under laparoscopic vision, the pelvic vas was rendered intraperitoneal and its lateral-most end was clipped at the internal inguinal ring, cut and extruded from the abdomen through a port in the external inguinal ring. Vasovasostomy was performed, bridging the retrieved stump of the pelvic vas with the scrotal vas. Five patients were operated upon through the extraperitoneal approach. Results By the end of one year. Nine out of the 15 cases showed an average sperm concentration of 17±3.5 million/ml. Conclusion Pelvi-scrotal vasovasostomy (PSVV) or Shaeer’s vasovasostomy can be offered as a cost-effective and successful alternative or supplement to intracytoplasmic sperm injection (ICSI), for cases with iatrogenic large defects of the vas deferens within the inguinal canal. The transperitoneal approach is more convenient in post-herniotomy and post-herniorrhaphy cases.

Laparoscopic approach to incarcerated inguinal hernia in children

Purpose The purpose of this study was to describe the laparoscopic approach to incarcerated inguinal hernia in children. Methods After unsuccessful manual reduction, 29 patients (aged 3 weeks to 7 years; median, 10 weeks; 44 boys, 15 girls) with incarcerated inguinal hernia underwent immediate laparoscopy. The hernial content was reduced in a combined technique of external manual pressure and internal pulling by forceps. The bowel was inspected, and the hernia was repaired. Results In all patients, the procedure was successful. No conversion to the open approach was required. Immediate laparoscopic herniorrhaphy in the same session was added. No complications occurred. Conclusions Laparoscopy allowed for simultaneous reduction under direct visual control, inspection of the incarcerated organ, and definitive repair of the hernia. Technically, it appears easier than the conventional approach because of the internal inguinal ring being widened by intraabdominal carbon dioxide insufflation. The hospital stay is shorter.

Inguinal Hernia following Lumbar Spinal Surgery in the Prone Position: A case report

An inguinal hernia shows that the protruding viscus exits from the endoabdominal fascial sac through the internal inguinal ring. Because an inguinal hernia is usually associated with incarceration, obstruction and even strangulation, it must be quickly treated whenever observed. Although there are several predisposing factors of the development of inguinal hernia, relatively little is a case report of the inguinal hernia developed by the increased intra-abdominal pressure during general anesthesia. In this case, we report a patient who developed the unexpected recurrence of left inguinal hernia following lumbar spinal surgery in prone position by increasing intra-abdominal pressure. After manual reduction was performed promptly by general surgeon, the patient was discharged without any complication on the eighth postoperative day. (Korean J Anesthesiol 2006; 51: 239~42)

HIGH INGUINAL LOUPE-ASSISTED VARICOCELECTOMY FOR SUBFERTILE MEN WITH VARICOCOCELES: TECHNICAL FEASIBILITY, CLINICAL OUTCOMES AND COMPLICATIONS

254 consecutive patients underwent high inguinal loupe-assisted varicocelectomy. All patients had at least a one year history of infertility with abnormal semen parameters and physical examination and/or color Doppler ultrasound proven varicocele. To facilitate the procedure, an x 3.0 loupe was used during spermatic cord dissection near or at level of internal inguinal ring. Semen analysis and physical examination were performed at 3 monthly intervals. No intra-operative complications occurred. The most common post-operative complications were transient scrotal pain and stitch reaction, occurring in 12% and 4% of men, respectively. Only one permanent and two transient hydroceles were observed. Recurrent or persistent varicocele was identified by physical examination and color Doppler in 5 varicocelectomies (1.4%), and by color Doppler only in 6 varicocelectomies (1.7%). Sperm motility increased from 30 +/- 8% to 46 +/- 20%, and sperm concentration. (10(6)/cc) increased from 24 +/- 18 to 41 +/- 28. The one-year pregnancy rate was 37%. High inguinal loupe-assisted varicocelectomy is a safe, simple, and effective treatment for varicocele.

Laparoscopic Evaluation of the Contralateral Groin in Pediatric Inguinal Hernia Patients: A Comparison of 70- and 120-Degree Endoscopes

Transinguinal laparoscopic groin evaluation using a 70-degree endoscope can obviate the need for a second incision when attempting to identify a contralateral patent processus vaginalis (PPV) during open repair of a symptomatic pediatric inguinal hernia. This technique can be technically unsatisfactory when a medial veil of peritoneum obscures adequate visualization of the internal inguinal ring. This study compared 70- degree and 120-degree endoscopes in identification of a contralateral PPV in the same patients. From September 2000 to October 2003, 81 patients with known inguinal hernias underwent open hernia repair and transinguinal laparoscopic evaluation of the contralateral side. The patients were 62 male, 19 female; mean age 26 months (range, 1 month-10 years); mean weight 11.7 kg (range, 2-33 kg). There were 53 right side hernias and 28 left side. Mean operative time was 43 minutes. Fifty seven patients (70%) had one or more risk factors for developing a contralateral inguinal hernia (49 were younger than 1 year old and 19 were ex-premature). Nineteen patients underwent concurrent procedures (7 circumcisions, 10 hydrocelectomies, 1 orchidopexy, 1 appendectomy). Using the 70-degree endoscope, a medial veil of peritoneum made visualization of the internal inguinal ring impossible in 14 patients (17%) and difficult in an additional 5 patients (6%). Visualization with the 120-degree endoscope was deemed to be superior in 46 (57%), equal in 35 patients (43%), and inferior in none. Overall, contralateral PPVs were detected in 31 patients (38%) with the 120-degree endoscope and in only 23 patients (28%) with the 70-degree endoscope. Had we used only the 70-degree endoscope, 8 PPVs (10%) would have been missed. None of the negative 120-degree endoscope evaluations have developed symptomatic contralateral inguinal hernias. In this trial, transinguinal laparoscopic evaluation using the 120-degree endoscope provided superior visualization and identification of contralateral PPVs. This new technique obviates the need for a separate abdominal wall puncture, reduces missed contralateral PPVs, and should be considered for use during pediatric inguinal hernia repair.

Vas Deferens Endoscopy (Vasoscopy): A New Diagnostic Tool?

To assess whether an experimental endoscopic study of the vasa deferentia is feasible. Endoscopic study of the seminal tracts was carried out during three vasectomies performed prior to open prostatectomy. A flexible endoscope, 0.56 mm in diameter, with a depth of field of 5 mm and a 3000 fiberoptic light source was used for the procedure. Endoscopy was possible for the inguinoscrotal segment of the vas deferens. The curvature at the opening of the internal inguinal ring proved impassable. Endoscopy of the vas deferens is possible with a 0.56-mm flexible endoscope, but because of the extreme curvature of the vas at the inguinal ring, the complete vas cannot be evaluated in an antegrade manner.

Systematic detection and repair of subclinical inguinal hernias at radical retropubic prostatectomy

Objectives Inguinal hernias occur in 15% of men within 1 to 2 years after radical retropubic prostatectomy (RRP). This suggests that many of these hernias may have been present at surgery, but not diagnosed. Beginning in September 2001, all patients undergoing RRP were carefully examined intraoperatively for the presence of a hernia or a dilated internal inguinal ring. In this study we define the frequency of inguinal hernias detected at RRP and the durability of repair. Methods Between September 2001 and December 2004, 430 patients underwent RRP by one surgeon. Hernias, detected in 142 men (33%), were repaired preperitoneally: direct hernias were repaired with mesh and indirect hernias with 2-0 Prolene suture. The patients were followed up for an average of 19 months (range 9 to 36). Information on postoperative hernia status was available for 315 men (73.3%). Results Of the 430 patients, 142 (33%) had hernias repaired at RRP. Of these hernias, 32% were right sided, 28% left sided, and 40% bilateral; 34% were direct hernias and 66% indirect. Of the 142 patients who underwent intraoperative hernia repair, 95 (67%) had follow-up data, and 5 (5.3%) of that group developed a hernia postoperatively. None of the hernias repaired at RRP recurred. Recurrent hernias on the side of the repair occurred in 3.1%. Conclusions Incidental inguinal hernias were commonly found (33%) at RRP. Two thirds of the defects detected were indirect. Clinical recurrence after repair was rare.

Laparoscopic percutaneous extraperitoneal closure (LPEC) method for the exploration and treatment of inguinal hernia in girls

We recently introduced the laparoscopic percutaneous extraperitoneal closure (LPEC) method for the treatment of girls with inguinal hernia. Using the LPEC method, 129 girls underwent laparoscopic herniorrhaphy. A 5 mm laparoscope was inserted via the umbilicus. A 3 mm "snake retractor" was advanced through the lateral abdominal wall to measure the length of the hernia sac and contralateral patent processus vaginalis (PPV), respectively. The hernia sac and PPV were closed at the level of the internal inguinal ring with a 2-0 non-absorbable purse-string suture using Lapaherclosure, a special 19G needle that can hold a suture at the tip. The length of the hernial sac was significantly longer than that of contralateral PPV (mean 41 mm; range 18-70 mm; P < 0.05). There were no serious complications associated with the procedure. No recurrence of hernia or metachronous contralateral hernia has been identified so far. This approach enables us to perform contralateral exploration without any additional techniques, followed by immediate and accurate closure of the hernia sac and PPV. We conclude that the LPEC method is a safe and efficacious procedure with a low recurrence rate that should be viewed as an acceptable alternative to the traditional open approach.

CLINICAL AND HISTOLOGICAL SIGNIFICANCE OF THE TESTICULAR REMNANT FOUND ON INGUINAL EXPLORATION AFTER DIAGNOSTIC LAPAROSCOPY IN THE ABSENCE OF A PATENT PROCESSUS VAGINALIS

We reviewed the histological findings of cord structures excised at inguinal exploration after diagnostic laparoscopy in patients with a nonpalpable testis with the vas deferens and spermatic vessels exiting the internal inguinal ring in the absence of a patent processus vaginalis. A retrospective review of 809 laparoscopic explorations for nonpalpable testes between 1981 and 2003 was conducted. The histological findings of the excised remnants of those patients with a closed processus vaginalis were reviewed. A total of 110 patients underwent excision of a testicular remnant at inguinal exploration in association with a closed processus vaginalis. Of the specimens 31 (28%) were on the right side and 79 (72%) were on the left side. The incidence of viable germ cell elements was 8 of 110 (7%). The presence of hemosiderin, calcification and fibrosis was identified in all 8 remnants with viable germ cell elements. The incidence of viable germ cell elements in the excised remnant when the vas deferens and spermatic vessels are identified exiting a closed internal ring in patients with a nonpalpable testis is 7%. To our knowledge no prior study has evaluated the incidence of viable germ cell elements in remnants associated with a closed internal inguinal ring. Based on these findings, we advocate inguinal exploration and excision of testicular remnants in these patients.

Spermatic cord injury associated with blunt trauma

Spermatic cord injury due to blunt trauma is an entity rarely encountered in clinical practice, and it may be mainly characterized by the onset of severe pain, swelling, or hematoma in the groin area. We present a case of a fresh spermatic cord injury caused by blunt trauma, which was correctly diagnosed after a surgical exploration. A 53-year-old healthy man had a strong blow from a handlebar on the right groin region in a motorcycle accident. He was transferred to our hospital from a rural hospital 3 hours after the accident because a hematoma was suddenly expanding in the right groin. On presentation, a 12 cm diameter painful subcutaneous hematoma of the right groin extending into the right hemiscrotum was found (Fig. 1). There was no medical history of blood dyscrasias, anticoagulant therapy, inguinal hernia, or urinary symptoms. His vital signs were normal. Contrast-enhanced computed tomographic (CT) images showed a large subcutaneous hematoma with contrast medium extravasation at the groin level and the edematous spermatic cord at the pudendal level (Fig. 2). There was no evidence of either any external iliac or femoral artery injuries. The preoperative diagnosis was a large subcutaneous hematoma bleeding from disrupted subcutaneous vessels. He was taken to the operating room for the removal of the hematoma and hemostasis 5 hours after the accident. Under satisfactory spiral anesthesia, an 8-cm diagonal incision was made over the hematoma of the right groin. A large subcutaneous hematoma as well as the contused spermatic cord was found. The cord was severely damaged at a level approximately 4 cm distal from the internal inguinal ring, and it was bleeding modestly from the internal or external cremasteric vessels. A large hematoma was contained along the distal length of spermatic cord. The vas deferens was intact. A rupture of external oblique aponeurosis and transverse fascia was found after removing the 300-g subcutaneous hematoma. A search for these layers resulted in the discovery of preperitoneal fat without any active bleeding. Based on these findings, a right orchiectomy was performed, and then, the floor of the inguinal canal was repaired by joining the edge of the internal muscle and aponeurosis of the transverse oblique muscle to the Poupart ligament. The external oblique aponeurosis was