Scrotal Emphysema Research Articles

Pneumoscrotal Emphysema

Introduction: Pneumoscrotum is a rare condition manifested by the accumulation of gas in the scrotum. Two conditions are included under the term of pneumoscrotum, palpable scrotal emphysema, and pneumoatocele. Pneumoscrotal emphysema has many etiologies, one of them is due to thoracic cage trauma, after a chest tube insertion or any other cardiothoracic procedures, causing pneumothorax and pneumoperitoneum. Case report: We report the case of a 2-year old boy who was admitted to the hospital for productive cough with signs of respiratory insufficiency on physical examination. An X-ray followed by a CT scan were obtained, and bilateral pleural effusion along with consolidation were disclosed. A chest tube was inserted to improve the vital signs of the patient; however, a subcutaneous emphysema of the scrotum developed caused by pneumothorax. Conclusion: Pneumoscrotal emphysema is a self limited condition, defined as accumulation of air within the scrotum. The etiological factor must be understood in order to start the proper management and treatment.

Traumatic scrotal emphysema: An underreported benign condition and a brief review of its mechanism

Scrotal emphysema, also known as pneumoscrotum, is an uncommon condition due to the subcutaneous accumulation of air in the scrotum. Air accumulation may be local, due to infection in the scrotum, or of distant origin from lung, peritoneal or retroperitoneal sources.In the present case, a twenty-seven-year-old patient was brought dead to the emergency with a history of road traffic collision. The patient sustained multiple injuries to the head, chest, and abdomen and the scrotum appeared to be distended with palpable crepitus. Subcutaneous emphysema of the chest and abdominal wall was absent. The presence of air in the scrotum was confirmed by visualizing the air bubble in a water-filled syringe. Though it appears to be a benign condition, efforts should be made to find out it's primary or secondary etiology. The traumatic causes of scrotal emphysema are underreported and receive little discussion in forensic pathology hence causes, and the mechanism of its development are discussed.

Prevention and treatment of peritoneal laceration in the laparoscopic totally extraperitoneal hernia repair during learning curve

Objective To explore the causes and managements of peritoneal laceration in the laparoscopic totally extraperitoneal (TEP) hernia repair during learning curve. Methods The retrospective cross-sectional study was conducted. The clinical data of 120 patients with inguinal hernia who underwent laparoscopic TEP hernia repair in the Third Affiliated Hospital of Anhui Medical University (98 patients) and Anhui Provincial Hospital (22 patients) during surgeons′ learning curve between February 2012 and January 2017 were collected. Patients underwent laparoscopic TEP hernia repair, meshes were intraoperatively placed and then fixed by medical glue. Observation indicators: (1) intraoperative situations: surgical procedure, operation time, using of mesh, intra-operative peritoneal laceration; (2) postoperative situations: time to anal exsufflation, time for fluid diet intake, occurrence of complications, duration of hospital stay; (3) follow-up: number of patients receiving follow-up, follow-up time, recurrence of hernia during follow-up, pain in inguinal region, intestinal adhesion and obstruction induced abdominal pain, incisional infection. Follow-up using outpatient examination and telephone interview within 10 days postoperatively and using telephone interview at 10 days postoperatively was performed to detect the recurrence of inguinal hernia, pain in inguinal region, intestinal adhesion and obstruction induced abdominal pain and incisional infection up to May 2017. Measurement data with normal distribution were represented as ±s. Results (1) Intraoperative situations: of 120 patients, 112 underwent laparoscopic TEP hernia repair, 5 converted to laparoscopic transabdominal preperitoneal hernia repair and 3 converted to open surgery due to adhesion between hernial sac and surrounding tissues induced bleeding of separation. Total operation time of 120 patients was (71±13)minutes, including (63±7)minutes in 106 patients with unilateral hernia and (79±11)minutes in 14 patients with bilateral hernia. All the patients used intraoperatively meshes of 10.0 cm×15.0 cm and 16.0 cm×10.8 cm. Forty-eight patients had intraoperative peritoneal laceration, peritoneal laceration occurred for reconstruction of preperitoneal space in 10 patients, separation of anterolateral preperitoneal space in 11 patients and improperly operating equipment or hernial sac in 27 patients. Of 48 patients with peritoneal laceration, 40 continued to finish operation through acupuncturing into the abdominal cavity for exsufflation and then received peritoneal suture and repair, including 5 with recurrence of indirect inguinal hernia (receiving tissue repair) undergoing peritoneal repair through opening hernial sac, and 8 intraoperatively converted to other or open surgery. (2) Postoperative situations: time to anal exsufflation and time for fluid diet intake in 120 patients were (18±4)hours and (15±6)hours. Of 120 patients, 14 had postoperative complications, scrotal emphysema of 6 patients disappeared in 24 hours and inguinal and scrotal seroma of 8 patients disappeared after puncture treatment. All the patients were discharged from hospital in 2 days postoperatively. (3) Follow-up: 112 of 120 patients were followed up for 3-65 months, with a median time of 31 months. During follow-up, there was no occurrence of recurrence of hernia, pain in inguinal region, intestinal adhesion and obstruction induced abdominal pain and incisional infection. Conclusion During surgeons′ learning curve, identifying anatomy of the groin clearly, a right way to treat the hernia sac and broken peritoneum in the operation can ensure the smooth completion of the laparoscopic TEP hernia repair. Key words: Hernia, inguinal; Peritoneal laceration; Laparoscopy

Experience of Fournier’s gangrene clinical diagnostics

The article represents clinical cases review of rare and serious disease - Fournier’s gangrene. 3 patients with Fournier’s gangrene aged 53±13 years were followed up in Moscow City Clinical Urological Hospital №47 and City Clinical Hospital №57 in the period from 2005 to 2015. All patients with Fournier’s gangrene were admitted to the hospital with a different referral diagnoses: «acute epididymo-orchitis», «testicular abscess», «scrotal phlegmon». Standard clinical and laboratory tests, abdominal cavity and urogenital system plain radiography and ultrasound examination were performed. For genital organs ultrasound examination a high-resolution linear transducer (6-16 MHz) was used. Ultrasonography in the admission room allowed to exclude acute scrotal diseases in all patients, Fournier’s gangrene was diagnosed in 2 patients, and suspected in 1 patient. In all patients with Fournier’s gangrene ultrasound examination revealed marked thickening of testicular coats (more than 15 mm), the accumulation of a small amount of fluid between the testicular coats and in the tunica vaginalis cavity, testicular coats intense hypervascularization; normal blood flow and the unchanged structure of the testes and epididymis. Scrotal emphysema was detected by ultrasound examination in all patients, by the plain radiography and physical examination - in 2 patients. In all cases, ultrasound helped to clarify the cause of Fournier’s gangrene: to reveal anorectal abscesses, acute prostatovesiculitis and exclude acute epididymo-orchitis, scrotal phlegmon and testicular injury. As an illustration Fournier’s gangrene observation, which occurred as an anorectal abscess complication is presented. Ultrasonography allows to confirm the Fournier’s gangrene presumptive diagnosis (to reveal soft tissue of the penis and scrotum emphysema), make differential diagnosis of Fournier’s gangrene with other external genitalia and perianal area acute diseases, determine treatment strategy.

Pneumoscrotum: report of two different cases and review of the literature.

Pneumoscrotum is the term used to describe the presence of air within the scrotum and includes scrotal emphysema as well as pneumatocele. The etiology varies; in some cases, pneumoscrotum may be due to life-threatening disease like pneumothorax or Fournier gangrene. Despite this, pneumoscrotum is a rarely debated issue. We present two different cases of pneumoscrotum and a review of the literature. The first case report is about a 29 year old male patient affected by Duchenne syndrome who showed pneumoscrotum after cardiopulmonary resuscitation that was performed for asphyxic crisis and cardiovascular arrest. We carried out local puncture with an 18-gauge needle, and the pneumoscrotum was successfully solved. The second case report is about a 56 year old male with pneumoscrotum due to Fournier gangrene who underwent radical exeresis of all necrotic tissues and drainage. This is why most of the scrotal skin and all of the penis skin were removed; as a result, the testicles, epididymis, and cavernosa corpora were externalized. On postoperative day one, the patient was feverless and underwent hyperbaric chamber therapy. No postoperative complications occurred. Accurate evaluation of the pneumoscrotum is always needed. Despite the benign course of most of the clinically evident pneumoscrotum cases, this condition should never be underestimated.

Vacuum suction fixation versus staple fixation in TAPP laparoscopic hernia repair: introduction of a new technique for mesh fixation.

Proper mesh fixation is critical for successful TAPP laparoscopic hernia repair. Conventional mesh fixation may cause chronic neuralgia, groin paresthesia or other complications. This study aimed at introducing a new vacuum suction technique for mesh fixation and evaluating its efficacy and safety compared with traditional staple fixation way. Clinical data of 242 patients undergoing TAPP from July 2011 to March 2014 were retrospectively analyzed. Patients were divided into vacuum suction fixation group and staple fixation group. The operation time, hospital stay, complications, recurrence, visual analogue scale pain score and cost were evaluated. All surgeries were successful. The operation time of staple group was (42.34 ± 10.15) min for unilateral hernia and (64.08 ± 16.01) min for bilateral hernias. The postoperative hospital stay was (2.76 ± 0.84) days. One recurrence was observed (0.90%). For vacuum group, the operation time was (42.66 ± 7.76) min and (63.92 ± 10.49) min, and hospital stay was (2.60 ± 0.74) days. No recurrence was observed. There was no significant difference in recurrence, operation time, postoperative pain and hospital stay between two groups (P > 0.05). Average cost were (11,714 ± 726) RMB for vacuum group which was lower than staple group (14,837 ± 1568) RMB (P < 0.05). The top three complications of staple group were scrotal emphysema (10.81%), scrotal seroma (6.31%) and temporary nerve paresthesia (4.50%) while for vacuum group, they were scrotal seroma (3.82%), temporary nerve paresthesia (3.05%), scrotal emphysema (1.53%) and uroschesis (1.53%). The incidence of scrotal emphysema was lower in vacuum group (P < 0.05). No significant difference was observed in other complications (P > 0.05). Both techniques for mesh fixation are safe and effective. There is no significant difference in recurrence, operation time, postoperative pain or hospital stay. The vacuum suction fixation technique is more economical with lower incidence of scrotal emphysema.

Abdominal and scrotal wall emphysema in a patient with severe ulcerative colitis

Severe ulcerative colitis can be associated with bowel perforation. Bowel perforation rarely leads on to abdominal wall and scrotal wall emphysema. Bowel perforation in such cases can be spontaneous or iatrogenic (colonoscopy-related). We report a rare scenario where a patient presented with abdominal wall and scrotal emphysema after topical corticosteroid enema-induced traumatic rectal perforation. Topical corticosteroids were stopped immediately after identification of rectal perforation. The patient was managed conservatively with intravenous antibiotics. With this report we intend to sensitise clinicians and topical enema manufacturers regarding this rare complication.

Subcutaneous and Scrotal Emphysema Following Suprapubic Cystostomy in a Patient With Colovesical Fistula

Subcutaneous and scrotal emphysema are rare complications of suprapubic cystostomy. We present here a rare case of an 81-year-old man with colovesical fistula who had severe subcutaneous and scrotal emphysema after percutaneous suprapubic cystostomy was performed. We inserted a new Foley catheter via the urethra, removed the suprapubic cystostomy and incised his scrotal emphysema for open drainage. The patient's subcutaneous emphysema slowly healed.

Endoscopic Cross-Trigonal Ureteral Reimplantation Under Carbon Dioxide Bladder Insufflation: A Novel Technique

To report on a novel technique of endoscopic intravesical ureteral mobilization and cross-trigonal ureteral reimplantation under carbon dioxide insufflation of the bladder (pneumovesicum) for correcting primary vesicoureteral reflux (VUR) in infants and children. Ten boys and six girls with dilating primary VUR (7 bilateral; 23 refluxing ureters) associated with recurrent urinary-tract infections and multiple pyelonephritic renal scars underwent endoscopic Cohen's cross-trigonal ureteral reimplantation with CO(2) pneumovesicum. Their ages ranged from 10 months to 13 years (mean 4.1 years). The endoscopic procedure was preceded by distention of the bladder with saline and insertion of a 5-mm Step port over the bladder dome under cystoscopic guidance. The bladder was then drained and insufflated with CO(2) to 10 to 12 mm Hg pressure with a suction catheter inserted per urethra to occlude the internal urethral meatus. A 5-mm 30 degrees endoscope was used to provide intravesical vision. Two more 3- to 5-mm working ports were inserted on the lateral bladder wall on either side. Endoscopic intravesical mobilization of the ureter, dissection of a submucosal tunnel, and a Cohen's type of crosstrigonal ureteral reimplantation using interrupted 5-0 monofilament sutures was then performed under videoscopic guidance. Bladder drainage by a urethral catheter was maintained for 24 hours postoperatively. Endoscopic cross-trigonal ureteral reimplantation under CO(2) pneumovesicum was successfully performed in all except one patient, who had displacement of a port into the extravesical space after completion of the ureteral reimplantation necessitating a small vesicotomy for closure of the mucosal defect. The mean operating time was 136 minutes (range 80-230 minutes), being 112 minutes for unilateral cases and 178 minutes for bilateral cases. Two boys developed mild suprapubic and scrotal emphysema postoperatively that subsided spontaneously. All other patients recovered uneventfully and remained well. Follow-up cystograms showed complete resolution of VUR in all except one unit that had persistent grade I reflux, thus giving a success rate of 96%. This early experience illustrates that endoscopic intravesical ureteral mobilization and crosstrigonal ureteral reimplantation can be performed safely and effectively with routine laparoscopic surgical techniques and instruments under CO(2) insufflation of the bladder, achieving a high success rate in reflux resolution that is equivalent to that obtained with the open technique but with minimal invasiveness and much faster recovery. The longer-term outcome and potential physiological effects of CO(2) pneumovesicum on the bladder and upper-tract function will need to be evaluated further.

LAPAROSCOPIC PALOMO VARICOCELE LIGATION IN CHILDREN AND ADOLESCENTS: RESULTS OF 103 CASES

We evaluate our experience using the laparoscopic Palomo varicocele ligation (LPV) technique in male children and adolescents with varicoceles. Between September 1994 and September 2002, 122 varicoceles were treated using LPV with either mass cord vascular clip application (68) or LigaSure (Valleylab, Boulder, Colorado) vascular sealing (54). All procedures were performed as day surgery cases and patients were allowed to return to normal activities as soon as they could tolerate them. Followup was scheduled for 6 to 12 weeks and 1 year postoperatively. Testicular size was evaluated using a Prader orchidometer. Of the 122 patients 103 were evaluable at the initial postoperative visit and 96 at 1-year followup. Patient ages ranged from 9 to 19 years (mean 14.6). Operating time was 9 to 52 minutes (mean 28), although in the last 2 years (28 cases) mean operative time has decreased to 14.6 minutes. Indications for surgery included ipsilateral testicular hypotrophy in 84 cases, symptoms in 3 and parental choice in 16. At followup only 1 recurrent varicocele (vascular sealant group) was identified which was subsequently re-treated successfully using vascular sealant LPV. At 1 year 64 of 78 testes (82%) demonstrated catch-up growth and there was no evidence of testicular loss or persistent hypotrophy in the others. Reactive hydroceles were identified in 6 patients equally distributed between the 2 LPV techniques. Surgery was required on 2 of these hydroceles due to size, and the other 4 are small and are being observed. Temporary scrotal emphysema occurred in the vast majority of patients and 1 patient required laparoscopic closure of a small sigmoid serosal tear. No patients required narcotic medications for greater than 48 hours. LPV is a highly successful method to correct varicoceles in young males with catch-up growth similar to series using other accepted standard techniques. LPV can be performed safely and rapidly as an outpatient and allows early return to activity. As with the open Palomo technique, hydrocele is a bothersome complication that may require a second surgical procedure if correction is warranted.

Results and complications of laparoscopic surgery for pediatric varicocele

Background: The aim of this study was to evaluate the results and complications of laparoscopic varicocelectomy in children. Methods: Over a 36-month period, 211 children underwent laparoscopic treatment of varicocele. Their ages ranged between 6 and 17 years; the varicocele was located on the left side in 209 cases (99.1%) and was bilateral in 2 (0.9%). In 195 patients the laparoscopic transperitoneal approach was used and in 16 retroperitoneoscopy was used. Thirty children (14.2%) underwent ligation of the veins alone, and 181 (85.8%) underwent ligation of testicular veins and artery. In 15 (7.1%) cases an additional procedure was applied during the same operation. Results: Average operating time was 30 minutes and hospitalization about 24 hours. At an average follow-up of 26 months, there were 19 (9%) postoperative complications: 14 children had a left hydrocele, 3 children a scrotal emphysema, and 2 an umbilical granuloma. There were 5 recurrences of varicocele in our series: 2 (2 of 30, 6.6%) after the Ivanissevitch procedure, and 3 (3 of 181, 1.6%) after Palomo's. Testicular atrophy did not occur in any patient of this series. Conclusions: This preliminary experience shows that the results of the laparoscopic approach are comparable to those of the open approach. The ligation of testicular veins and artery is preferable to the ligation of the testicular veins alone. Hydrocele seems to be the most frequent postoperative complication and a potential problem, especially in children operated on with the Palomo procedure. J Pediatr Surg 36:767-769. Copyright © 2001 by W.B. Saunders Company.

LAPAROSCOPIC TREATMENT OF PEDIATRIC VARICOCELE: A MULTICENTER STUDY OF THE ITALIAN SOCIETY OF VIDEO SURGERY IN INFANCY

We report preliminary results of a multicenter study of the Italian Society of Video Surgery in Infancy on the laparoscopic treatment of pediatric varicocele. A total of 161 children 6 to 16 years old (median age 12.5) underwent laparoscopic treatment of varicocele at 6 pediatric surgery divisions. Varicocele was on the left side in 159 cases (98.7%) and bilateral in 2 (1.3%). Two boys had recurrent left varicocele. All children were treated with laparoscopy, including ligation of the spermatic veins only in 28 (17.3%), and ligation of the testicular veins and artery in 133 (82.7%). In 10 boys (6.2%) an additional procedure was done simultaneously, including closure of an apparently patent peritoneal vaginal duct on the right side in 7 and resection of epiploic adhesions between the intestinal loops and abdominal wall from previous appendectomy in the remaining 3. Average operative time was 30 minutes and hospitalization was about 24 hours. At followup there were 13 minor complications (8%), including left hydrocele in 9 children who underwent the Palomo technique, minor scrotal emphysema in 2 and umbilical granuloma in 2. In our series varicocele recurred in 1 boy (3.5%) who underwent ligation of the spermatic veins only and in 3 (2.2%) treated with the Palomo technique. Our preliminary experience shows that the results of the laparoscopic approach are comparable to those of the open approach. However, the important advantages of laparoscopy over the open approach are its minimal invasiveness and precision of intervention. Moreover, laparoscopy allows treatment of other intra-abdominal pathological conditions using the same anesthesia, as in 10 patients in our series. We believe that ligating the testicular veins and artery is preferable to ligating the testicular veins only, even if the incidence of hydrocele is not negligible after the Palomo procedure.

Laparoscopy in the management of pediatric varicoceles

Background/Purpose: The authors present their early experience with laparoscopic ligation of varicoceles in children. Methods: Over a period of 30 months, 17 children underwent laparoscopic treatment of unilateral varicoceles (age range, 7 to 16 years). Nine underwent ligation of veins alone and eight (including four children who had recurrent varicoceles) underwent ligation of testicular veins and artery. In three patients, vas-associated veins were ligated in addition to the main testicular vessels. Results: The average operation time was 30 minuts (range, 14 to 75) and hospital stay, 11 hours (range, 4 to 22). There were no technical failures. Minor scrotal emphysema developed in one child, and a painful, tender swelling above the epididymis developed in another. At an average follow-up of 24 months (range, 6 to 30), all patients were asymptomatic and had marked reduction in the size of the varicoceles. Conclusion: Further experience and long-term follow-up are clearly required before the efficacy of this procedure is established.

Laparoscopic varicocele ligation

Varicocele, an abnormal dilatation of the pampiniform plexus, frequently contributes to male factor infertility. We performed laparoscopic varicocelectomy in 20 patients with varicoceles and abnormal seminal findings. The spermatic artery was identified and preserved in 13 patients and was clipped along with the veins in 7 patients including 1 patient with bilateral varicocele. The time required for the artery-ligating surgery ranged from 90 to 120 minutes with an average of 113.2 minutes, while the time needed for the artery-preserving technique ranged from 90 to 250 minutes with an average of 158.0 minutes. Some analgesics were administered to 11 patients, while the other 9 patients needed no analgesics. All patients were able to walk within 24 hours of the operation. The mean hospitalization period after the operation was 5.9 days. Sperm concentrations significantly improved postoperatively (p < 0.05). No difference in postoperative improvement of seminal findings was observed between artery-ligating and artery-preserving groups. A slight scrotal emphysema developed during the operation in 1 patient. Abdominal pain was experienced in 1 patient, but subsided within a few days. No serious complications were observed. The laparoscopic technique may replace routine open high ligation as the surgical treatment of choice, especially in patients with bilateral varicocele.

Pharyngeal Emphysema with Airway Obstruction as a Consequence of Laparoscopic Inguinal Herniorrhaphy

Pharyngeal Emphysema with Airway Obstruction as a Consequence of Laparoscopic Inguinal Herniorrhaphy

Pneumoscrotum: Report of two cases and review of mechanisms of its development

Scrotal emphysema and, less frequently, pneumatocele are uncommon signs of pneumoscrotum caused by a variety of pathogenic and iatrogenic disease processes. The finding of air in the scrotal sac may be an early sign of a life-threatening condition or may represent an incidental finding associated with more benign conditions. The three basic mechanisms by which air becomes localized to the scrotum are discussed, the literature is reviewed, and 2 new cases are presented.

Scrotal emphysema in a burn injury patient

A burn-injured 17-year-old boy suffered from an apical pneumothorax of the right side caused either by placement of a subclavian catheter or by the blast injury. Following this, he developed scrotal emphysema. Air extended along the subcutis of the lateral thoracic and abdominal wall through a lesion in the parietal pleura up to the inguinal canal to the scrotum caused by the positive pressure breathing. After cessation of the PEEP-breathing, there was no recurrence.

Scrotal emphysema

Three cases of scrotal emphysema are reported, and the causes and effects of this oddity are discussed.