Hernia and hydrocele
Brice Antao, S Irish Michael, Anthony Lander, S Rothenberg MD Steven in Succeeding in Paediatric Surgery Examinations, 2017
The deep inguinal ring is a defect in the transversalis fascia 1 cm above the midpoint of inguinal ligament, lateral to inferior epigastric vessels. The superficial inguinal ring is a defect in the aponeurosis of external oblique, located above and medial to the pubic tubercle. An indirect hernia passes through the deep inguinal ring and along the inguinal canal into the scrotum, while a direct hernia bulges through the posterior wall of the canal medial to the inferior epigastric artery through Hesselbach’s triangle. The boundaries of Hesselbach’s triangle are inferior epigastric artery (laterally), inguinal ligament (inferiorly) and lateral border of rectus abdominis (medially). An indirect hernia in a child is due to a patent processus vaginalis, which is a peritoneal diverticulum extending through the internal inguinal ring into the canal.
Clinical anatomy of the newborn
Prem Puri in Newborn Surgery, 2017
By about the sixth month in utero, the testis lies adjacent to the deep inguinal ring connected to the developing scrotum by the gubernaculum. Although the testis originates as a retroperitoneal structure, it is suspended on a short mesentery (mesorchium) within the peritoneal cavity during abdominal “descent.”49 Inguinoscrotal descent of the testis occurs between 25 and 35 weeks postconception; in this phase, it is invaginated into an elongating peritoneal diverticulum, the processus vaginalis, which subsequently becomes obliterated leaving only the tunica vaginalis around the testis. At term, about 4% of boys have an undescended testis(es); the figure is considerably higher in premature infants. By 3 months of age, the prevalence of cryptorchidism has fallen to 1.5%. The timing and process of closure of the processus vaginalis are both uncertain.50 Surgical studies have shown that a patent processus vaginalis is present in around 60% of contralateral groin explorations in infants with a unilateral inguinal hernia in the first 2 months, falling to around 40% after 2 years of age. Autopsy studies have indicated that the processus is patent in about 80% of newborns, decreasing to about 15%–30% in adults. Boys with cryptorchidism have higher patency rates.
Hernias
Alexander Trevatt, Richard Boulton, Daren Francis, Nishanthan Mahesan in Take Charge! General Surgery and Urology, 2020
As part of the full examination, focus on: Does the patient have an ‘acute abdomen’ i.e. peritonitis, guarding?Assess the patient's nutritional and hydration status (skin turgor, mucous membranes and blood pressure).Where is the hernia and what type is it?If the hernia is in the groin, is it above and medial to the pubic tubercle (inguinal) or below and lateral (femoral)? This is important as femoral hernias are more likely to strangulate.Is the hernia reducible? Ask the patient to try and reduce it.If it is an inguinal hernia, attempt to differentiate between direct and indirect by reducing it and putting pressure on the deep inguinal ring (found above the midpoint of the inguinal ligament between pubic tubercle and anterior superior iliac spine). Then ask the patient to cough. If the hernia is indirect, pressure on the deep inguinal ring will stop it from protruding in most cases (although this is not always the case). A direct hernia will not be controlled by this pressure.
Unsatisfactory testicular position after inguinal orchidopexy: Is there a role for upfront laparoscopy?
Published in Arab Journal of Urology, 2020
Ahmed Abdelhaseeb Youssef, Mahmoud Marei Marei, Mohamed Hamed Abouelfadl, Wesam Mohamed Mahmoud, Atef Salaheldin Abdulaziz Elbarawy, Tamer Yassin Mohamed Yassin
Laparoscopy was initiated through an open Hasson technique using a supra-umbilically placed 5-mm cannula. Thereafter, the peritoneal cavity was insufflated with CO2 (pressure: 8–12mmHg). We used a 5-mm 30 °scope and two 5-mm working ports. With the patient in the Trendelenburg position and the ipsilateral side up, the lower abdomen and pelvis were inspected to identify the vas deferens and testicular vessels entering the deep (internal) inguinal ring and to note the adhesions at the deep inguinal ring (Figure 1). Two 5-mm instruments were placed in the midclavicular line on each side, slightly infra-umbilically. The peritoneal fold containing the testicular vessels was dissected free, starting from the deep inguinal ring upwards, reaching as high as possible (Figure 2(a,b)). Extreme care was exercised during dissection of scar tissue (often in the form of a fibrotic ring) present at and around the deep inguinal ring.
A preventable cause of transplant hydroureteronephrosis: inguinal herniation of the transplant ureter: case report and review of the literature
Published in Acta Chirurgica Belgica, 2021
Isabelle Bosmans, Veerle De Boe, Karl Martin Wissing, Marian Vanhoeij, Daniel Jacobs-Tulleneers-Thevissen
Before surgery, sirolimus was temporarily switched to cyclosporine. Surgical exploration was done using a midline laparotomy. We found an abdominal wall defect, medial to the deep inguinal ring, with the transplant ureter prolapsing through this defect anterior of the spermatic cord (Figure 1(C)). After opening the preperitoneal space, the ureter was reduced and the defect was closed primarily. The ureter was shortened to an appropriate length and re-implanted on the bladder over a ureteral stent using the Lich-Gregoir ureteroneocystostomy technique [5]. The nephrostomy tube was removed and a Prevena® (KCI, Inc., San Antonio, TX) dressing was used for optimal wound healing. Postoperatively, serum creatinine levels dropped to the patient’s baseline level (2.33 mg/dl) with discharge on the 5th postoperative day and ambulatory removal of the ureteral stent 6 weeks later. At that time, renal function was stable. Unfortunately, long-term outcome on hernia recurrence or renal function cannot be shown since the patient was lost to follow-up.
Mixed gonadal dysgenesis with an ovotestis on imaging mimicking ovotesticular disorder of sexual differentiation
Published in Baylor University Medical Center Proceedings, 2021
Samantha Fine, Kenneth Ford, Bradley Trotter, Hoang-Kim Le, Matthew Crisp, Jose Santiago, Krista Birkemeier
A 3-month-old infant was referred to urology for hypospadias. Physical examination revealed a normal size phallus, a midscrotal urethral opening, a morphologic left labia, a nonpalpable left gonad, and a palpable gonad in a morphologic right hemiscrotum (Figure 1). Chromosome analysis revealed a mosaic karyotype 45, X/46, XY. Initial ultrasound demonstrated a normal right testicle and fluid collection behind the bladder; magnetic resonance imaging (MRI) revealed a left hemivagina filled with fluid, accounting for the sonographic finding; and fluoroscopic genitography and voiding cystourethrogram confirmed communication with the urethra (Figure 2). A uterine horn extended to the left inguinal canal, where gonadal tissue with imaging characteristics of both testicle and ovary resided (Figure 3).
Related Knowledge Centers
- Abdominal Wall
- Anterior Superior Iliac Spine
- Inguinal Ligament
- Pubic Symphysis
- Pubic Tubercle
- Spermatic Cord
- Round Ligament of Uterus
- Transversalis Fascia
- Inferior Epigastric Vessels
- Internal Spermatic Fascia