SBA Answers and Explanations
Vivian A. Elwell, Jonathan M. Fishman, Rajat Chowdhury in SBAs for the MRCS Part A, 2018
During embryonic and foetal life, the testes and the ovaries both descend from their original position at the 10th thoracic level. This explains the long course taken by the gonadal arteries and the site of referred pain from the gonads to the umbilicus (T10 dermatome). Descent is genetically, hormonally, and anatomically regulated and depends on a ligamentous cord known as the gubernaculum. Furthermore, descent of the testis through the inguinal canal into the scrotum depends on an evagination of peritoneum known as the processus vaginalis. This normally obliterates at birth. Gonadal descent is a complicated process and therefore there are many ways in which it can go wrong. Most commonly, an undescended or maldescended testis may occur (cryptorchidism). A patent processus vaginalis may lead to the formation of a congenital hydrocele, or inguinal hernia.
Overview of Cryptorchidism with Emphasis on the Human
Tom O. Abney, Brooks A. Keel in The Cryptorchid Testis, 2020
The processus vaginalis is an outpouching of the fetal peritoneum from which the tunica vaginalis is derived. The processus vaginalis precedes the testes during its descent into the scrotum. The proximal portion of the processus vaginalis obliterates, whereas the portion distal to the external ring, the tunica vaginalis, remains patent, enveloping the testes and epididymis. The inner visceral layer covers the testis, epididymis, and distal spermatic cord. The outer or parietal layer is well attached to the other coverings of the testis and lines the scrotal chamber. The sac between these two layers normally contains a small amount of fluid and pathologically forms a hydrocele. If the processus vaginalis does not obliterate, a patent processus vaginalis or congenital hernia results.
Genital
A. Sahib El-Radhi in Paediatric Symptom and Sign Sorter, 2019
Following completion of testicular descent, the processus vaginalis closes and its lower portion becomes the tunica vaginalis testis. Failure to close results in a patent processus allowing the development of the two most common causes of painless scrotal swelling: hydrocele and inguinal hernia. Hydrocele is caused by drainage of peritoneal fluid through a narrow patent processus vaginalis (communicating hydrocele), while a wide patent processus vaginalis causes inguinal hernia by allowing omentum or bowel to pass into the scrotum. Failure to close the processus vaginalis in females results in formation of a patent pouch of the peritoneum with possible complication of inguinal hernia and hydrocele (hydrocele of canal of Nuck). The four most common painful causes of testicular swelling are testicular torsion, torsion of testicular appendage, incarcerated inguinal hernia and epididymitis/orchitis. Children with any of these causes may present as an acute scrotum, which is a medical emergency defined as scrotal pain, swelling and redness.
The risk of inguinal hernia repair after radical prostatectomy – a population-based cohort study
Published in Scandinavian Journal of Urology, 2022
Mikko Ahtinen, Jaana Vironen, Teemu J. Murtola
Two possible modifications to the minimally invasive prostatectomy technique to lower the risk of inguinal hernia after surgery have been proposed. They are the spermatic cord isolation method and the processus vaginalis transection method. The first one is the method where the peritoneum is dissected bluntly free from elements of the spermatic cord at the level of the internal inguinal canal. The second method includes similar steps added with transection and ligation of processus vaginalis just distal to the peritoneum. These techniques are intriguing as they may prevent the retraction of transected vas deferens from pulling the peritoneum towards the inguinal canal. They have been suggested to lower the risk of post-surgical inguinal hernia after prostatectomy. Still, the evidence, even from randomized studies, has not changed the standard prostatectomy technique [19].
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
Starting with inguinal surgery to mobilise the testis and considering laparoscopy only after inguinal exploration if sufficient length was not achieved, would still be our approach when no operative difficulty is anticipated beyond the specific circumstances and special situations outlined in the present report. However, this may compromise visualisation due to a pressure drop with the insufflated gas escaping through the inguinal incision, if the patent processus vaginalis was inadvertently opened, a common occurrence in redo surgeries, especially if significant inguinal dissection is needed due to fibrosis. It is also possible to deliver the testis back to the peritoneal cavity in order to redirect the spermatic vessels into a shorter route. However, we only opted to use this sparingly.
Image of the month: cyst of the canal of Nuck
Published in Acta Chirurgica Belgica, 2018
Banu Karapolat, Hatice Ayça Ata Korkmaz, Gulgun Kocak, Eser Bulut
Being a rare developmental disorder, cyst of the canal of Nuck is seen mainly in adolescence in women and appears as a mass generally not exceeding 3 cm, localized in the inguino-labial region; it is painless, relatively hard, irreducible in the abdominal cavity and not growing with a valsalva maneuver [2]. In cases with a cyst large enough in size, a translumination test shows no other texture except for the fluid in it. It is difficult to make a diagnosis based solely on anamnesis and physical examination in such cases. Imaging techniques such as high-resolution ultrasound scan or magnetic resonance (MR) imaging can help the clinician to make a diagnosis in the preoperative period. In an ultrasound scan, a cyst of canal of Nuck appears as an anechoic or hypoechoic unilocular lesion extending to the surface in the shape of a sausage or comma in the pubic tubercule and the medial part of the groin at the level of the superficial inguinal ring and ultrasound scan is a highly accurate imaging modality. An MR scan is useful in complicated cases, particularly in those involving additional pathologies and it appears as a well-defined, thin-walled cystic lesion in hypointense on T1-weighted and hyperintense on T2-weighted series [1]. Additionally, an MR scan shows very well the anatomic structures surrounding the cyst, communication between the cyst and the peritoneal cavity, and the extension of the cyst of the canal of Nuck, which allows for successful surgical planning and excision [3]. Indirect inguinal or femoral hernia, tumors such as lipoma, leiomyoma or sarcoma; abscess, lymphadenopathy, hematoma, vascular anomalies, and ganglion cysts should be considered in differential diagnosis [4]. The final diagnosis is established through surgical exploration and histopathological examination of the removed specimen. Complete excision of the cyst and high ligation of the open neck of processus vaginalis are sufficient for treatment.
Related Knowledge Centers
- Gubernaculum
- Hematocele
- Inguinal Hernia
- Peritoneum
- Embryo
- Hydrocele
- Tunica Vaginalis
- Testicle
- Canal of Nuck
- Testicular Torsion