Laparoscopically assisted colpopoesis using sigmoid colon]

Presentation of one case of scrotal vesical hernia in a 66-year old patient who presented with scrotal mass, micturition difficulty and two-phase micturition that improved when pressure was exerted on the scrotum. Diagnosis was established by physical examination and CUMS. The patient underwent surgery during which a direct inguinal hernia due to paraperitoneal vesical sliding was found. Right herniorrhaphy was performed with Shouldice's technique. Postoperative radiological monitoring showed normal vesical morphology. The pathogeny, classification and treatment, as well as the differential diagnosis uncommonly reported by the authors consulted, are commented.     

Standard versus individually planned irradiation field in radiotherapy of infradiaphragmatic lymph node sites]

PURPOSE: The aim of this study was to determine the utility of scrotal sonography in the evaluation of patients with scrotal pain or swelling following inguinal hernia repair. METHODS: From our database, we identified patients who were referred for sonographic evaluation because of persistent scrotal pain or swelling after inguinal hernia repair between July 1994 and February 1996. Sonograms and medical charts were reviewed retrospectively. RESULTS: Eight patients were included in this study. Doppler sonography demonstrated evidence of testicular infarction in 2 patients and absence of intratesticular diastolic flow in 1 patient. Five patients had postoperative fluid collections with sonographically normal testes. CONCLUSIONS: Scrotal sonography can diagnose testicular infarction following hernia repair and distinguish postoperative fluid collections from recurrent hernias.     

Risks of transplanting kidneys from hepatitis B surface antigen-negative, hepatitis B core antibody-positive donors

OBJECTIVES: An indirect inguinal hernia is a common cause of inguinoscrotal swelling in young boys. We describe 3 cases of an extremely unusual entity that has a similar clinical presentation to more commonly diagnosed intrascrotal processes. METHODS: Two patients presented with acute hemiscrotal enlargement and pain, and a third patient presented with scrotal enlargement only. All patients underwent a scrotal ultrasound evaluation and subsequent inguinoscrotal exploration. RESULTS: All patients had a multiseptated peritesticular fluid-filled mass on ultrasound evaluation. Subsequent inguinoscrotal exploration revealed a torsion of the indirect hernia sac in each case. A high ligation and excision of the sac was curative. CONCLUSIONS: Torsion of a hernia sac is an extremely rare entity, and current sonographic imaging fails to clearly diagnose this unusual phenomenon. Because pediatric urologists are commonly called to evaluate a child with an acutely swollen scrotum, awareness of this diagnosis is important.     

Torsion of a malignant undescended testis

Cryptorchid testis have a greater risk of malignant change than do normally descended testis. The undescended testis would also be susceptible to torsion by the mechanism of increase in testicular size. A 36-year-old man of torsion of malignant undescended testis is presented. He was diagnosed as having incarcerated inguinal hernia on his first visit to general surgeon due to acute left lower abdominal pain. At laparotomy, a 7.5 x 5.5 x 3.0 cm3, greyish tan color mass was found. The pathological diagnosis is choricarcinoma and teratoma, mixed germ cell tumor. We would emphasise that in any patient presenting with acute abdominal symptoms and an absent scrotal testis, the possibility of a complication of torsion of undescended testis should be considered.     

Predicting recovery from common whiplash

Epididymo-orchitis (EO) is said to be extremely rare in infants and children. It is usually diagnosed after scrotal exploration for symptoms which mimic manifestations between EO and torsion of the cord and its appendage. The pathophysiologic mechanisms for the development of EO are not well known. Although some causative agents of EO have been reported, in most cases there was no clear etiology. We report a 3-month-old male infant who had been well until the day prior to admission when irritability, left testicular swelling, scrotal erythema with a hot sensation were noted by his mother. He was treated medically after excluding the possibility of an emergent surgical condition (such as torsion of the cord and its appendage, or incarcerated hernia) by means of physical examinations, abdominal and inguino-scrotal sonography, laboratory studies, and testicular radionuclide scintigraphy. A catheterized sample of urine for culture yielded Escherichia coli. There was the possibility that the EO was caused by hematogenous rather than local spread from an infection of the urinary tract. He was treated with a 10-day course of intravenous cefazolin and amikacin. Following this, he improved clinically and a repeat catheterized urine sample remained sterile on culture. In addition, a bilateral inguinal hernia and hydrocele were detected by inguino-scrotal sonography and were operated on the 11th hospital day. He was discharged on the 16th day of hospitalization and remained well 11 months after discharge.     

Endoscopically guided percutaneous repair of inguinal hernia through a 2-cm incision. Minihernia repair

BACKGROUND: The laparoscopic repair of inguinal hernia is still controversial. Transabdominal preperitoneal repair violates the peritoneal cavity and may result in visceral injuries or intestinal obstruction. The laparoscopic extraperitoneal approach has the disadvantage of being technically demanding and requires extensive extraperitoneal mobilization. The Lichtenstein repair gives good long-term results, is easy to learn, can be performed under local anesthesia, but requires a larger incision. METHODS: We describe a novel percutaneous tension-free prosthetic mesh repair performed through a 2-cm groin incision. The inguinal canal is traversed with the aid of a 5-mm video-endoscope and the canal is widened using specially designed balloons. Spermatic cord mobilization, identification and excision of the indirect sac, and posterior wall repair are carried out under endoscopic guidance. RESULTS: Between October 1993 and July 1995, 85 primary inguinal hernia repairs (48 indirect and 33 direct) were performed on 81 patients (80 men, one woman) by the author (A.D.). The mean age was 41 years (range 17-83 years). Six repairs were performed under local anesthetic. Mean operative time was 42 min (range 25-74). Mean hospital stay was 1.2 days (0-3 days). The mean return to normal activity was 8 days (2-10 days). Eight complications have occurred: a serous wound discharge, two scrotal hematomas, a scrotal swelling that resolved spontaneously, wound pain lasting 2 weeks, an episode of urinary retention, and two recurrences early in the series (follow-up 1-22 months). CONCLUSION: The endoscopically guided percutaneous hernia repair avoids the disadvantages of laparoscopy (i.e., lack of stereoscopic vision, reduced tactile feedback, unfamiliar anatomical approach, risk of visceral injury), yet the use of endoscopic instrumentation allows operation through a 2-cm incision. The minihernia repair thus combines the virtues of an open tension-free repair with minimal access trauma.     

Role of intracellular calcium concentration on tumor cell death from hyperthermia

PURPOSE: We determined the incidence of iatrogenic injuries to the vas deferens at a tertiary care university infertility center and the results of surgical repair. MATERIALS AND METHODS: Records of 472 patients surgically explored for obstructive azoospermia between 1984 to 1996 were reviewed. Enrollment criteria included history of inguinal, pelvic and scrotal (other than vasectomy) surgery. Conventional ipsilateral and crossover vasovasostomies and vasoepididymostomies were performed. Patency rate was defined as presence of complete sperm with tails in a postoperative semen analysis. Followup included a minimum of 2 semen analyses. Only naturally conceived pregnancies were included. RESULTS: Of 472 patients 34 (7.2%) had an iatrogenic injury to the vas deferens with a mean obstruction interval of 20.5 +/- 1.9 years. Mean patient age was 36.7 +/- 1.8 years. Iatrogenic injury to the vas deferens was secondary to bilateral inguinal hernia repair in 19 patients, unilateral hernia repair in 11, renal transplantation in 2, appendectomy in 1 and spermatocelectomy in 1. Pediatric inguinal hernia repair was the most common etiology of the vasal injury (20 patients), followed by adult inguinal hernia repair (10). A total of 36 microsurgical reconstructive procedures were performed, including 20 ipsilateral and 16 crossed vasovasostomies and vasoepididymostomies. There were 26 patients (29 procedures) available for followup (mean 21.0 +/- 3.7 months). Total patency rate per procedure was 65% and pregnancy rate was 39%. Patency and pregnancy rates per conventional ipsilateral procedures were 62.5 and 35.7% and per crossover procedures 64.2 and 42.8%, respectively. CONCLUSIONS: Pediatric inguinal hernia repair is the most common cause of iatrogenic injury to the vas deferens. Results of treatment of iatrogenic injury to the vas deferens are somewhat lower than for patients with obstructive azoospermia due to vasectomy. Iatrogenic injuries are associated with longer vasal defects, impaired blood supply and longer obstructive intervals frequently resulting in secondary epididymal obstruction. Crossover reconstruction is particularly useful when contralateral testicular atrophy is present. Intraoperatively aspirated sperm should be cryopreserved for later use in case the reconstruction fails.     

Urinary excretion of pancreatic stone protein in diabetic nephropathy

The abnormal persistence of the patent processus vaginalis determines the appearance of four types of pathology, depending on the grade and sort of communication: communicating hydrocele, hydrocele of cord, scrotal hydrocele and intrafunicular hernia. We have revised our casuistry of children with patent processus vaginalis pathology for the two last years (1995-1996), and we have found 75 communicating hydrocele cases, 5 hydrocele of cord and 16 scrotal hydrocele cases, on children between 1 month and 13 years old. The diagnostic was done after physical exploration with transillumination and inguino-scrotal ultrasound. Initially, conservative treatment was followed, which was enough for 58 patients (60.4%). In the 38 cases (39.6%) in which there were no improvement, surgical treatment via inguinal was carried out, with good results in nearly all cases. As a conclusion, we can assert that ultrasound is an excellent diagnostical method for patent processus vaginalis pathology and conservative treatment must have priority upon surgery, since a great number of spontaneous resolutions are observed, most of all on children aged less than two years old.     

Effects of dietary coconut oil, butter and safflower oil on plasma lipids, lipoproteins and lathosterol levels

BACKGROUND: Complications that develop in groin hernias, such as irreducibility and obstruction, with or without strangulation may make an easily treatable condition a life-threatening one. Identification of risk factors that may predict development would help place the patient in a high-risk group. Priority admission and early elective surgery for such a patient would avoid significant mortality and morbidity. METHODS: This is a 10-year combined prospective and retrospective study of children and adults. Records of complicated groin hernias were identified from July 1985 to July 1995 from the outpatient department and available inpatient medical records. The same number of controls of simple uncomplicated hernias were then chosen using random number tables from among the large number belonging to the same time period. These two groups were then compared and analysed using statistical methods for age, sex, side of hernia, site of hernia (inguinal/femoral), duration of hernia, length of the waiting list for elective surgery, and contents of the hernial sac along with some other parameters to identify patients with high-risk factors. RESULTS: Age was found to be a significant risk factor and predicted complications in both elderly adults and very young children. Sex of the patient (male) and side of hernia (right) were significant risk factors in children only. Site of hernia was an important risk factor and adults with femoral hernia were most likely to experience complications. Duration of hernia for less than a year proved to be the most important risk factor for both children and adults. The majority of patients with complicated hernias had not presented earlier in the outpatient department, which implies that most hernias that become complicated do so within a very short time before patient referral. Mortality was high in patients with coexisting diseases, while morbidity was affected by viability of contents of the hernial sac which in turn was directly affected by duration of irreducibility or delay in presentation. CONCLUSIONS: The risk factors useful in predicting complications in an adult patient with groin hernia were age (older age group), duration of hernia (short duration), type of hernia (femoral more than inguinal) and coexisting medical illness. In children, the risk factors were age (very young), gender (male), short duration of hernia and side (right side).     

Two cases of Morgagni's hernia

Two cases of Morgagni's hernia comprising protrusion of the omentum alone are reported. The treated patients were 65- and 63-year-old obese women. They were referred to our hospital because of chest pain or vomiting accompanied by abnormal shadow in right cardiophrenic angle on chest roentgenogram. Computed tomogram (CT) demonstrated a mass of fat density behind the sternum for the both patients. The first patient was diagnosed as Morgagni's hernia by pneumoperitoneum, and surgical repair was done by the transabdominal approach. Magnetic resonance imaging (MRI) was carried out for the second patient, and showed intrathoracic mass lesion which was continuous with the subphrenic tissue. Although the second patient was diagnosed as mediastinal lipoma, median sternotomy revealed that the mass lesion was Morgagni's hernia. Postoperatively, both patients recovered uneventfully. The Morgagni's hernia has been reported to be about 3% of all diaphragmatic hernia. This disease may be discovered either because it causes respiratory or gastrointestinal complaints, or because an abnormal shadow in right cardiophrenic angle on a chest roentgenogram. If air-filled structures are present in the hernia, a barium study will confirm the diagnosis. In a case with a hernia containing only omentum, the diagnosis is difficult. CT has been regarded as the procedure of choice by several authors. The coronal and sagittal views of MRI can demonstrate the relationship between the herniated structures and the diaphragm, heart, pericardium. We emphasize the role of MRI for the diagnosis of Morgagni's hernia.     

Hernia repair during endoscopic extraperitoneal lymph node dissection

Cryptorchidism is frequently associated with gastroschisis, yet little is published on its management in such circumstances. In a review of 10 consecutive boys with gastroschisis since 1980, 4 had undescended testes. Gestational age and birth weight did not differ from the 6 boys with normally descended testes. The first two patients had associated arthrogryposis multiplex congenita. The first underwent bilateral orchidopexy at 9 years of age for inguinal testes. In the second patient, the left testis was intraabdominal at the level of the sigmoid colon at birth; at 3 months of age, when a left inguinal hernia repair was required, left groin exploration revealed the testis at the internal ring and orchidopexy was performed successfully. In the third patient the left spermatic vessels were divided at the time of gastroschisis repair and the testis anchored in the prebubic area. The second-stage orchidopexy was performed at 16 months. In the last patient the intraabdominal testis could be placed in a scrotal pouch without mobilisation or division of the vessels. From our experience and a review of the literature we conclude that: 1) undescended testes are frequently associated with gastroschisis; 2) mechanical factors rather than prematurity are likely responsible for this association; 3) if the testis easily reaches the scrotum, orchidopexy can be done safely at the time of gastroschisis repair; 4) if the testis does not reach easily and appears to have a gubernaculum, it may be preferable to leave it in place since spontaneous descent can occur.     

The pathological evaluation of the pediatric inguinal hernia sac

BACKGROUND: The College of American Pathologists has suggested that institutions should establish guidelines for the evaluation of the hernia sac. In addition, some states require the submission of this tissue for pathological evaluation. Yet, neither evidence-based guidelines nor published reviews for the evaluation of the pediatric hernia sac are available. Therefore, this retrospective study was conducted to document experience with the evaluation of the pediatric hernia sac. METHODS: All reports of the evaluation of hernia sacs submitted to the Department of Pathology during an 8-year period were reviewed. The case of any report that differed in any way from "consistent with hernia sac" was evaluated for the effect of the findings on the clinical course. RESULTS: A total of 7,924 hernia sacs were submitted on 6,034 patients. Microscopic evaluation was performed on 534. A total of 7,567 (95.4%) submitted specimens on 5,743 patients were "consistent with hernia sac" and demonstrated no other findings. Three hundred fifty-seven specimens contained findings in addition to hernia sac. In no patient did the results of the evaluation have an effect on the patient care. CONCLUSIONS: There is strong evidence that the routine pathological evaluation of pediatric hernia sacs offers little relevant clinical information. Mandatory tissue submission of hernia sacs should be reconsidered.     

Association of hiatus hernia with asplenia syndrome

During a 13-month period, 13 patients with asplenia syndrome were evaluated with MRI for cardiovascular and visceral anomalies. The MR images were reviewed for the presence of haitus hernia which was found in three patients. One of the remaining ten patients with no MRI evidence of hiatus hernia was diagnosed as having gastro-oesophageal reflux and hiatus hernia by an oesophagogram and 24-h pH monitoring. This patient had undergone fundoplication prior to MRI. Out of the 13 patients (31%) with asplenia syndrome, 4 had hiatus hernia. It appears that among patients with the asplenia syndrome, hiatus hernia is a frequent finding. Recurrent pneumonia or bronchiolitis in patients with asplenia syndrome requires evaluation for the presence of hiatus hernia and gastro-oesophageal reflux.     

Iatrogenic diaphragmatic hernia following abdominal esophagogastrofundoplication: report of a case

The authors describe diagnosis and surgical treatment of a patient with iatrogenic diaphragmatic hernia following esophagogastrofundoduplication by Nissen's operation. The patient had presented a hiatal hernia with esophagitis chronic regurgitation and was submitted to esophagogastrofundoduplication. On the third postoperative day, the patient showed signs of dysphagia and intense dyspnea. The computerized tomography showed the presence of the gastric fundus and it's contents inside the leftpleural cavity. The patient was submitted to a left posterolateral thoractomy and an ischemic peptic ulcer in the gastric fundus, blocked by lung parenchyma was sutured. Then, the stomach was reduced into the abdominal cavity with diaphragmatic suture associated with esophageal and gastric fundus fixation to the right diaphragmatic pilar. The patient presented satisfactory immediate and late postoperative follow-up (1 year). The authors discuss and document aspects of diagnosis as well as surgical indication.     

Mumps orchitis: report of a mini-epidemic

PURPOSE: The incidence of mumps orchitis has declined dramatically since the introduction of vaccination. While in the past cases of mumps have only been seen occasionally at our institution, recently there has been a sharp increase in the number of confirmed cases. MATERIALS AND METHODS: Between June 1995 and April 1996, 11 patients with severe mumps orchitis were hospitalized at our clinic. Medical history, therapeutic measures and clinical outcome were recorded for each patient. RESULTS: All patients showed marked scrotal swelling with a temperature above 38.5 C. Serum C-reactive protein was significantly elevated (mean 140 mg./l.). The vaccination status of 1 of the 11 patients (9%) was unknown. Medical records from the remaining 10 patients indicated that they had not been vaccinated. Nine patients (82%) had a typical mumps parotitis preceding the orchitis. In 2 patients the clinical diagnosis of parotitis was uncertain but mumps serology was positive. None of the patients showed other manifestations of mumps. Antibodies to the mumps virus (IgG and IgM) were determined in 6 patients and positive in all cases. The average interval between parotitis and onset of orchitis was 10 days. All patients were hospitalized for an average of 6 days. Treatment included bed rest with local cooling, scrotal support and systemic treatment with nonsteroidal anti-inflammatory drugs. Ciprofloxacin or clavulanic acid/amoxicillin was administered as bacterial orchitis could not be excluded at initial presentation. The mean time to cessation of fever was 3.6 days (range 3 to 5). Antibiotics were administered for an average of 8.8 days (range 7 to 13) and anti-inflammatory drugs were given an average of 8.6 days (range 7 to 11). One patient required scrotal exploration. CONCLUSIONS: Since the introduction of a vaccine against the mumps virus there is a diminished risk for mumps and its complications. However, in case of scrotal swelling mumps orchitis should still be considered. Despite vaccination mumps has not been erradicated. Therefore, continued vaccination should be considered an important step in minimizing clinical outbreaks and working towards a possible eradication of this disease in the future.     

Ultrasonographic diagnosis of varicoceles

OBJECTIVE: To assess the ability of color duplex scrotal ultrasonography to detect subclinical varicoceles and confirm the diagnosis of clinical varicoceles. DESIGN: Physical examination, color duplex scrotal ultrasonography and internal spermatic venography was performed on 64 testicular units in 33 men. SETTING: Male fertility center. PATIENTS: Two hundred sixty-two consecutive men being evaluated for male factor infertility of whom 33 agreed to undergo venography. MAIN OUTCOME MEASURES: Ultrasonographic measurement of scrotal vein diameter of patients in the supine and upright position, before and during valsalva maneuver, and scrotal vein blood flow reversal with valsalva maneuver was compared with the findings of varicocele by physical examination and venography. RESULTS: The best predictor of a varicocele was internal spermatic vein diameter, and the best overall performance of ultrasonography was achieved with the patient at rest in the supine position. The best cutoff point for venous diameter for a clinical varicocele was 3.6 mm and 2.7 mm for a subclinical varicocele, but the overall accuracy was only 63%. CONCLUSIONS: Confirmatory studies are needed to support the ultrasonographic diagnosis of varicoceles before considering surgical repair.     

Scrotoschisis associated with contralateral meconium periorchitis

Scrotoschisis, a congenital defect of the scrotal wall associated with extracorporeal testicular ectopy, has been previously reported only twice. Meconium periorchitis is another rare scrotal anomaly indicative of an antenatally healed gastrointestinal perforation. The authors present a third case of scrotoschisis and the first associated with meconium periorchitis. Several hours after birth of an otherwise-normal term baby boy, a scrotal exploration was performed with orchidopexy and primary closure of the scrotal wall defect. At 4 months of age the baby underwent a contralateral inguino-scrotal exploration with excision of a paratesticular mass of calcified meconium. The role of a normally developed scrotum in testicular descent and causes of calcified scrotal masses in infants are discussed.     

B-Myb, a repressed trans-activating protein

From April 1990 to November 1996, 313 inguinal and 14 femoral hernias were repaired in 295 subjects with a mean age of 74 years (66 to 97). Concomitant diseases increasing the operative risk were present in 206 subjects (70 per cent). A mesh repair was performed with "tension-free" or "plug" techniques in all but 23 inguinal and 2 femoral herniorrhaphies where the Bassini or the Shouldice procedures were adopted. Fifty-two inguinal hernias were recurrent, 11 emergency herniorrhaphies were performed for strangulation. Almost all operations (305), including 9 emergency herniorrhaphies, were carried out under local anaesthesia. There was no perioperative mortality. Acute intestinal bleeding occurred after surgery in a subject with colon diverticulosis. One urinary retention following emergency hernia repair under general anaesthesia and 2 following elective hernia repair under local anaesthesia in 2 subjects with hypertrophy of the prostate were observed. Some episodes of hypotension and/or bradycardia were observed either during or after surgery. Local complications following inguinal hernioplasty were 5 (1.5%) scrotal hematomas, 3 (0.9%) wound infections and 1 case (0.4%) of orchitis with atrophy after repair of a recurrent hernia. There were 1 recurrence after Bassini, 1 after Shouldice, and 1 (0.4%) after mesh inguinal hernioplasty. Using local anaesthesia and a mesh repair elective surgery of inguinal and femoral hernias can be safely and effectively performed in elderly patients. Consequently, early elective surgery should be recommended to avoid the risk of an emergency operation.     

Oesophageal hiatal hernia-induced hydropneumothorax

The patient presented with acute and constant abdominal pain. He had had a lobectomy of the left lung three months before. On the 4th day in hospital the pain increased and he went into temporary shock. The next day a hydropneumothorax and incarcerated stomach were revealed by chest X-ray and computed tomography. He was transferred to the University Hospital immediately and underwent an operation. The diagnosis was an incarcerated para-oesophageal hernia with hydropneumothorax and perforation of the stomach. As a para-oesophageal hernia may be fatal, it is important to diagnose and treat it early.