Inguinal hernia repair
S Asbury, A Mishra, KM Mokbel, M Fishman Jonathan in Principles of Operative Surgery, 2017
Complications following an inguinal hernia repair are best classified as wound, scrotal, operative, nerve injury and general. An attempt should be made to identify indirect hernial sac on the cord and, if present, it should be secured with clips and separated from the spermatic cord structures as far as the deep inguinal ring. An appropriately sized Prolene mesh is placed on the posterior wall of the inguinal canal, making a suitably sized slit in the lateral end of the mesh to accommodate the spermatic cord. Preperitoneal laparoscopic hernia repair (TEP) is indicated for bilateral and recurrent inguinal hernias only. This procedure is performed under a general anaesthetic, with the patient in a supine position, after informed consent has been obtained. The patient is prepared and draped so that two-thirds of the lower abdomen is exposed. A direct hernial sac can then be identified and its contents carefully separated from the overlying weakened transversalis fascia.
Testicular Cancer
Dongyou Liu in Tumors and Cancers, 2017
The testicular collecting system, testicular tunics, and spermatic cord, as well as the rete testis (principally of the intratesticular location), are sometimes referred to as the paratesticular region. Testicular cancer constitutes about 1.5 percent of male neoplasms and 5 percent of urologic malignancies globally, with an annual incidence of 3-8 cases per 100,000 men in Western countries and 0.5-3 cases per 100,000 men in Africa, Asia, and South America. Risk factors for testicular cancer include a history of cryptorchidism or undescended testis, Klinefelter syndrome, a familial history of testicular cancer among first-degree relatives, Down syndrome, Li-Fraumeni syndrome, the presence of a contralateral tumor or IGCNU, subfertility or infertility, tallness, previous marijuana exposure, vasectomy, trauma, mumps, and HIV infection [3]. Diagnosis of testicular germ cell tumors involves physical examination, biochemical tests for elevated serum tumor markers, ultrasonography, CT/MRI, and histological confirmation via testicular biopsy. Treatment for seminoma and teratoma primarily involves orchiectomy with high ligation of the spermatic cord.
Embryology, Anatomy, and Physiology of the Male Reproductive System
Karl H. Pang, Nadir I. Osman, James W.F. Catto, Christopher R. Chapple in Basic Urological Sciences, 2021
Mesonephric ducts are the embryological origin of the male reproductive system. The paramesonephric (Müllerian) duct forms the genital system in females. The urogenital system develops from the intermediate mesoderm. The initial stages of development are similar in both sexes up to the 7th week. The primitive gonads initially form as a pair. The testis passes through the inguinal canal (week 24-28), drawn caudally into the scrotum (week 28-35) by the gubernaculum. The abdominal cavity peritoneum forms a reflected fold — processus vaginalis (PV). The PV is obliterated at/soon after birth. The spermatic fascia (three layers) surrounds the spermatic cord. Failure of fusion leads to the separation of the labioscrotal folds without a median raphe - Appears as a bifid scrotum, often seen with proximal hypospadias.
Microscopic subinguinal varicocelectomy in 100 consecutive cases: Spermatic cord vascular anatomy, recurrence and hydrocele outcome analysis
Published in Arab Journal of Urology, 2018
Ahmed M. Al-Kandari, Abdulnasser Khudair, Abdelghaffar Arafa, Fouad Zanaty, Ahmed Ezz, Mohamed El-Shazly
Objective: To evaluate the detailed vascular anatomy of the spermatic cord during subinguinal microscopic varicocelectomy and to assess the outcome of the cases with regard to varicocele recurrence and hydrocele formation. Patients and methods: In all, 100 varicocele cases including 74 left-sided and 26 bilateral, comprising 126 spermatic cord units with clinically palpable varicoceles underwent microscopic subinguinal varicocelectomy. Detailed description of vascular anatomy of the spermatic cords was reported. The number of spermatic, cremasteric, and inguinal veins was recorded. A record of testicular arteries and lymphatics was noted. Testicular delivery was done in all the cases and assessment of the gubernacular veins was reported. The patients underwent clinical evaluation, as well as scrotal Doppler ultrasonography, to detect varicocele recurrence and hydrocele formation. The mean (range) postoperative evaluation period was 6 (3–12) months. Results: The mean number of spermatic veins was 14 on both sides. The mean number of spermatic arteries on both sides was 1.3. For lymphatics, the mean number was around three on both sides. The gubernacular veins were noted in 75% of the cases on the left side (mean number of 1.2) and in 85% on the right-side, (mean number of 1). The mean number of cremasteric veins on the left and right sides was 1.4 and 1.2, respectively. Finally, inguinal floor vessels were noted in 9% on the left-side and were not seen in the right-side cases. The incidence of varicocele recurrence was 2% and for hydrocele that was not clinically significant was 0.07%. Conclusion: Microscopic subinguinal varicocelectomy accurately evaluated the detailed vascular anatomy of the spermatic cord, achieving excellent surgical outcome with minimal varicocele recurrence and hydrocele formation. Microscopic subinguinal varicocelectomy should be the ‘gold standard’ for varicocelectomy.
The Influence of Inguinal Mesh Repair on the Spermatic Cord: A Pilot Study in the Rabbit
Published in Journal of Investigative Surgery, 2005
Christian Peiper, Karsten Junge, Uwe Klinge, Eva Strehlau, Carsten Krones, A. Öttinger, Volker Schumpelick
The permanent implantation of a polypropylene mesh during inguinal hernia repair causes chronic inflammatory changes in the surrounding tissue. We investigated the effect of this foreign body reaction on the structures of the spermatic cord in the rabbit. Eight Chinchilla rabbits underwent unilateral inguinal hernia repair by the Lichtenstein technique using Marlex (n = 4) orUltrapro (n = 4) mesh. The contralateral side was operated upon using the Shouldice repair. Three animals served as controls. Three months after operation we analyzed testicular size, testicular temperature, and arterial perfusion by excitation light of a 780-nm laser after injection of 0.5 mg/kg indocyanin green. Histological evaluation included spermatogenesis (Johnsen score) and foreign-body reaction. Testicular volume increased about 10% after each operation. The decrease of arterial perfusion and testicular temperature was more significant after mesh repair than following Shouldice operation. After mesh implantation we found fewer seminiferous tubules classified as Johnsen 10 (Marlex: 51.3%, Ultrapro: 45.0%) than after Shouldice repair (63.8%) or in the controls (65.8%). The spermatic cord showed a typical foreign-body reaction at the interface between mesh and surrounding tissue, which was not detectable after Shouldice repair. Preserved cremasteric muscle fibers protected the structures of the spermatic cord. The inflammatory foreign-body reaction of the surrounding tissue induced by the inguinal prosthetic mesh includes the structures of the spermatic cord. This may have an influence also on spermatogenesis. Therefore, we recommend strict indications for implantation of a prosthetic mesh during inguinal hernia repair.
Spermatic cord liposarcomas incidentally found during hernia surgery: is histology of any lipoma mandatory? A review of the literature
Published in Acta Chirurgica Belgica, 2020
Matthias H. Seelig, Raphael Winkels, Martin Wiese, Dirk Weyhe
Purpose: Liposarcomas found incidentally during open or laparoscopic inguinal hernia surgery are extremely rare. It is unclear, whether any adipose tissue being removed during inguinal hernia surgery must be sent for histology due to the potential risk of liposarcoma of the spermatic cord. This study aims to evaluate the frequency of liposarcomas incidentally found in the inguinal canal during hernia surgery and tries to derive evidence-based recommendations regarding the optimal management of any fatty tissue found in the inguinal canal. Methods: A literature review of the PubMed/Medline electronic databases between January 1980 and January 2019 was performed using the search terms ‘inguinal hernia’ and ‘liposarcoma’. There was only one study available on this topic. Therefore, an additional literature review was performed analyzing all reports on patients with incidentally detected liposarcomas of the spermatic cord in the inguinal canal during hernia surgery. Results: There was only one retrospective study evaluating the frequency of inguinal liposarcoma found at hernia operations with a frequency of less than 0.1%. There were 18 cases of spermatic cord liposarcomas that were truly found incidentally during operation for an unsuspected symptomatic or incarcerated inguinal hernia. These included 16 case reports with a total of 18 patients and 19 liposarcomas. All patients were male with a median age of 62.5 years (range: 24–86 years) years. Median size of liposarcoma was 10.5 cm (range: 3–30 cm). In seven patients, the inguinal liposarcoma was an extension of a retroperitoneal sarcoma. Treatment consisted of radical orchidectomy during the primary operation in 12 patients. Three out of the seven patients with retroperitoneal extension of the tumor underwent a secondary operation with complete resection of the tumor. Conclusions: Currently, there is no evidence-based recommendation available regarding the management of lipomas detected during open or laparoscopic inguinal hernia surgery. Due to the extremely low risk of the presence of a liposarcoma, routine histologic examination cannot be recommended unless the diameter exceeds 10 cm.