Increase in endogenous thrombopoietin in healthy donors after automated plateletpheresis

Inguinoscrotal bladder hernias are uncommon clinical facts more predominant in males aged between 50 and 70. This entity has no specific clinical character and diagnosis usually happens in the course of surgical repair of inguinal hernia. In about 3%-10% cases, it appears associated to inguinal hernia. Discussion of two case-reports of patients with giant inguinoscrotal bladder hernia; one patient with synchronous association to bladder transitional carcinoma. The literature on the clinical, diagnostic and therapeutic aspects is revised. The high index of suspicion for making a pre-operative diagnosis, specially in aged patients with inguinal hernia and expanded prostate signs and symptoms is highlighted. Emphasis is placed on the need for surgical hernia repair prior to prostate and/or bladder transurethral surgery.     

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.     

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.     

Fetal inguinoscrotal hernia: sonographic diagnosis and obstetric management

Fetal inguinal hernia is a rare antenatal diagnosis. We present the sonographic features and outcome of a fetus diagnosed at 36 weeks' gestation as having an (indirect) inguinoscrotal hernia. Sonographic criteria for antenatal diagnosis are discussed within the context of differential diagnoses raised by the presence of a perineal mass. Guidelines for obstetric management and counselling are suggested.     

Pediatric hernias and hydroceles

Hernias and hydroceles are common conditions of infancy and childhood, and inguinal hernia repair is one of the most frequently performed pediatric surgical operations. As a result of improved neonatal intensive care, more and more premature babies are being delivered, and consequently the incidence of neonatal inguinal hernia is increasing. The most important aspect of the management of neonatal inguinal hernias relate to its risk on incarceration, and emphasis is placed on this point. This article covers the embryology, incidence, clinical presentation, and treatment of groin hernias and hydroceles, as well as dealing with abdominal wall hernias other than umbilical hernias. This article places special emphasis on when a patient with a hernia or hydrocele should be referred to a pediatric surgeon.     

Laparoscopic evaluation for a contralateral patent processus vaginalis: part III

OBJECTIVES: Between May 1, 1992 and August 1, 1996, 759 consecutive children younger than 10 years of age were evaluated and treated for known inguinal hernia. These children were participating in a prospective investigation of the potential role of diagnostic laparoscopy in the evaluation of the contralateral inguinal anatomy. The initial two series of data (parts I and II of this three-part series) were previously presented at the 1993 and 1995 American Academy of Pediatrics meetings. METHODS: Of 759 patients, 100 children were diagnosed with bilateral inguinal hernias and therefore did not undergo laparoscopy. Thirty-two patients did not undergo laparoscopic evaluation due to technical difficulties or complicated clinical situations. The patient's contralateral inguinal region was carefully examined under anesthesia, and predictions were made regarding the likelihood of contralateral patent processus vaginalis (CPPV). Six hundred twenty-seven children underwent diagnostic laparoscopy to confirm the presence or absence of CPPV. Laparoscopy was initially exclusively performed through the umbilicus prior to repair of the known hernia, but over the last 26 months, 250 children successfully underwent laparoscopy through the ipsilateral hernia sac. RESULTS: Of patients younger than 1 year of age, 114 were diagnosed with both a known unilateral hernia and CPPV, whereas 132 had a unilateral hernia only (46% versus 54%). Among children older than 1 year of age, 148 (39%) were diagnosed with unilateral hernia and CPPV, and 233 (61%) were diagnosed with a unilateral hernia alone. After examination under anesthesia, 233 of the 627 patients were suspected of having a CPPV, and 107 were confirmed at laparoscopy (46%). The remaining 394 patients were not believed to have a CPPV. Normal inguinal anatomy was confirmed in 234 patients (59%), but 160 patients were found at laparoscopy to have a CPPV (41%). CONCLUSIONS: A contralateral patent processus vaginalis may be present in a surprising number of young patients being evaluated for a known inguinal hernia. Laparoscopy can be performed without a separate incision when the ipsilateral hernia sac is of sufficient width to allow passage of the scope. Laparoscopy is the best method for evaluating the contralateral inguinal region, particularly in younger children, as it prevents unnecessary inguinal exploration and it decreases the risk that the child will later present with a clinical contralateral hernia.     

The use of Mersilene mesh in adult inguinal and femoral hernia repairs: a comparison with classic techniques

A retrospective review of both mesh classic inguinal hernia repairs performed under the guidance of a single surgeon showed that Mersilene mesh is safe to use and that the recurrence rate is significantly improved by using the mesh for repair. Mersilene mesh is easier to use than other types of mesh and should be used routinely in the repair of inguinal and femoral hernias.     

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.     

Perforated appendicitis within an inguinal hernia: case report and review of the literature

The finding of the vermiform appendix within an inguinal hernia sac is not uncommon. However, it is rare to find a perforated appendix within an inguinal hernia. An unusual case of an incarcerated and perforated appendix within an inguinal hernia complicated by an intra-abdominal abscess is reported herein. Perforated appendix as a cause of abscess was revealed during abdominal exploration. Clinicians are encouraged to be aware of this unusual entity, which is rarely recognized before exploration.     

Longitudinal follow-up of blood lymphocyte subpopulations from birth to 1 year of age

The features of the rare interstitial hernia, as seen in four children, are described. All were boys ranging in age from 7 days to 7 years. The presenting sign was swelling in the right side of the abdomen associated with undescended testis. The hernias arose at the deep inguinal ring and expanded superiorly between the internal and external oblique muscles. Repair involved a standard herniotomy and orchidopexy through an oblique inguinal incision-except in one patient with a vanishing testis. The importance of being aware of this rare type of hernia is stressed.     

Chronic inguinal pain after transperitoneal mesh implantation. Case report of net shrinkage

The implantation of a mesh is an essential step in laparoscopic inguinal hernia surgery. We present the case of a 22-year-old man who developed an unspecific and refractory syndrome of inguinal pain after a TAPP procedure for a primary inguinal hernia. Repeated reoperation for removement of clips and nerve transection were unsuccessful. By a transinguinal approach, 18 months after the first operation we removed a preperitoneal Prolene mesh which had shrunk and folded to 30% of its original size. The problem of biocompatibility of meshes currently used in inguinal hernia surgery is discussed.     

Torsion of uterine fibroma associated with incarcerated inguinal hernia in pregnancy. Case report

The incidence of inguinal hernias in pregnancy is 1:1000 about. Much more frequent are uterine leiomyomas, reported in 0.5-2.6% cases. We describe a rare case of a 31 old woman at the 20th week of pregnancy affected with a torsion of uterine leiomyoma associated with right inguinal incarcerated hernia, operated urgently (myomectomy and Bassini inguinal plastic).     

The care of the anterior teeth. The 3rd annual meeting of the Swiss Union for Preventive and Restorative Dentistry (SVPR) of 1 November 1997 in Bern]

We report an unusual case of a 22-year-old man who presented with the left testis spontaneously ascended to a non-scrotal position. The testis had been documented to be intrascrotal without any sign of up-migration when the man was 12 years old. On surgery, the cryptorchid testis was found to be located within the superficial inguinal pouch. The testis was atrophic with the spermatic cord too short. On dissection, a remnant string of the closed processus vaginalis was observed within the cord, and the distal end of the gubernaculum was abnormally attached to the fascia near inguinoscrotal junction. Histopathologic findings of the testis were that of the Sertoli-cell-only syndrome which may represent the end-stage of germinal cell hypoplasia, a pathologic sequela common in postpubertal undescended testis. We recommend 3 diagnostic criteria for the acquired undescended testis and emphasize that testicular descent should be confirmed in infancy and re-confirmed periodically through puberty by the health care physician. Our observations seem to support the theory that acquired undescended testis may be caused by a postnatal failure of the spermatic cord to elongate in proportion to somatic growth.     

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.     

Perioperative transfusion, postoperative infection, and recurrence of head and neck cancer

BACKGROUND: Considering the high recurrence rate after conventional inguinal hernia repair, the totally preperitoneal endoscopic inguinal hernia repair has been used. METHODS: The present experience of the authors embraces 1085 patients with a total of 1717 inguinal hernias, including 200 recurrences. The operative technique is described with emphasis on pitfalls and tricks. RESULTS: Analysis of the data concerning the first 403 patients with 1 year complete follow-up reveals a mean (SEM) operating time of 42 (1.2) min for unilateral and 58 (1.0) min for bilateral hernia repair. Mean (SEM) postoperative hospital stay was 2 (0.04) days. Complication rates during and after operation were 0.3% and 3.3% respectively. The morbidity rate at 1 month after operation was 3.5%. The recurrence rate was 0.3% at 1-year follow-up. CONCLUSION: Totally preperitoneal endoscopic inguinal hernia repair is safe and reproducible for any type of primary or recurrent inguinal hernia, even in patients with previous subumbilical surgery or severe systemic disease. Careful follow-up is mandatory to assess the late recurrence rate.     

The features of contralateral manifestations after the repair of unilateral inguinal hernia

BACKGROUND/PURPOSE: Routine contralateral exploration in infants and children with unilateral clinical inguinal hernia is performed by many surgeons in a selected population of patients based on a presumed high incidence of patent processus vaginalis. Our purpose is to report the actual incidence of contralateral manifestations in infants and children after the repair of unilateral inguinal hernia. METHODS: From July 1985 through December 1995, 1,052 infants and children with unilateral inguinal hernia or hydrocele were treated in our hospital without contralateral exploration. Among them, 1,001 patients (95.2%) were followed up for 1 to 11 years to determine if contralateral hernia developed after unilateral inguinal herniorrhaphy. RESULTS: The overall incidence of contralateral hernia was 11.6% (116 of 1,001). In boys, the incidence was 13.1%, 13.7%, and 11.7% in those under 1 year, under 2 years of age, and in total, respectively. In girls, the incidence was 9.6%, 13.9%, 11.3%, in those under 1 year, under 5 years of age, and in total, respectively. The side of the initial repair did not influence the subsequent development of contralateral inguinal hernia. In children with hydrocele, the incidence of contralateral hernias was lower (7.6%). In girls with sliding hernias the contralateral occurrence was 12.5%. CONCLUSION: Given this low incidence of contralateral hernia after unilateral inguinal herniorrhaphy, the authors do not recommend contralateral exploration for infants and children with unilateral inguinal hernia.     

Laparoscopic identification of preperitoneal nerve anatomy in the inguinal area

The laparoscopic approach has recently been utilized for inguinal hernia repair. Nerve injuries are now being reported. The femoral branch of the genitofemoral nerve and the lateral cutaneous nerve of the thigh appear most at risk. The purpose of this study was to determine the feasibility of identifying these nerves laparoscopically on either a routine or selective basis. Twenty patients scheduled for laparoscopic inguinal hernia repair were prospectively selected. An attempt was made to identify these nerves so that optimum placement of staples could occur. The femoral branch of the genitofemoral nerve was identified in 19 of 20 patients and the lateral cutaneous nerve of the thigh in 18 of 20 patients. A review of 125 laparoscopic inguinal hernia repairs revealed five nerve injuries (4%). Details are given and recommendations discussed. Knowledge of preperitoneal anatomy and awareness of the location of these nerves should lead to a safer dissection and more accurate application of staples, hopefully decreasing the incidence of nerve injury.     

Ambulatory inguinal hernia repair compared with short-stay surgery

Two groups of patients operated on for inguinal hernia, one outpatient group and one inpatient group, are compared with respect to subjective distress and immediate postoperative complications. The groups were chosen at random and matched for sex and age. A large number of those who received treatment as outpatients suffered marked distress during the first postoperative days. Some form of intermediary or light nursing should be tried out for the outpatients so that if necessary they can stay the night after operation at the hospital. The number of postoperative complications was equal in the two groups. With suitable patient selection and with a small number of reserve places in a light-care ward, the majority of inguinal hernia operations can be performed on outpatients, resulting in a considerable economic saving and shorter waiting time.     

Genital anomalies in human and animal models reveal the mechanisms and hormones governing testicular descent

A systematic examination of the conditions characterized by the presence of genital anomalies in humans, noting in each condition the position of the gonad, the nature of the gubernaculum and cranial suspensory ligament can provide valuable information regarding the mechanisms controlling the final position of the gonads. In conditions where MIS is absent, the gubernaculum is "feminized', resulting in a testis in the position normally occupied by an ovary or an abnormally mobile testis that can prolapse to the inguinal region. In conditions of androgen insensitivity the testis is located in the inguinal region, indicating that the first phase of descent is normal but that inguinoscrotal descent has failed to occur. Ovarian descent fails to occur in congenital adrenal hyperplasia, despite exposure of the developing fetus to high levels of androgens, indicating that androgen alone does not control gonadal descent. Moreover, ovarian descent fails to occur despite androgen-dependent regression of the cranial suspensory ligament. The correlation between the degree of Müllerian duct retention and scrotal position in mixed gonadal dysgenesis further strengthens the hypothesis that the first stage of testicular descent is controlled by MIS. The study of genital anomalies suggests that MIS controls the swelling reaction in the male gubernaculum, which is responsible for the first phase of testicular descent to the inguinal region. The second or inguinoscrotal phase of descent is androgen-dependent. Regression of the cranial suspensory ligament is also androgen-dependent: however, it is the gubernaculum and not the presence or absence of the cranial suspensory ligament which controls testicular descent. A combined knowledge of the hormonal basis controlling sexual differentiation and the biphasic model of testicular descent enables the clinician to accurately predict the internal anatomy of these complex sexual anomalies.     

Is routine pathological evaluation of pediatric hernia sacs justified?

BACKGROUND/PURPOSE: Herniorrhaphy is the most common general surgical procedure performed on children, and hernia sac material is one of the most common tissue specimens microscopically examined in the authors' surgical pathology laboratory. The risk of accidental vas deferens ligation has prompted the recommendation that all hernia sacs be examined pathologically. The authors hypothesized that the incidence of unrecognized vas deferens or epididymis ligation is actually very low and may not warrant routine pathological examination of all pediatric hernia sacs. METHODS: Over a 3-year period (1994 to 1996), pathology reports from all hernia repairs at the authors' institution were reviewed. A total of 1,494 inguinal hernia sacs were pathologically evaluated from 1,077 pediatric patients (417 were bilateral). Pathological diagnoses not affecting clinical management (ie, chronic inflammation, irritated hernia sacs, embryonal remnants, adrenal cortical rests) were classified as incidental findings. Identification of true vas deferens was classified as a positive finding. RESULTS: The study population had a mean age of 3.9 +/- 0.1 years and 963 (89%) were boys. The incidence of vas deferens injury from herniorrhaphy was found to be 0.13% (2 of 1,494), and these were recognized by the pediatric surgeon in the operating room. CONCLUSIONS: When vas deferens injury is suspected, the sample should always be sent to the pathology department for confirmation. However, no occult carcinoma or other pathology was identified, and the remainder of the histological findings did not change the clinical treatment of any child. Given a fixed cost of pathological analysis, elimination of routine hernia sac examination may result in substantial annual savings. Therefore, in the current era of cost containment, recommendations for routine pathological examination of excised pediatric hernia sacs should be reevaluated.