Acute testicular ischemia caused by incarcerated inguinal hernia

Testicular Vascularization after Pediatric Inguinal Hernia Repair: A Systematic Review and Meta-Analysis

BACKGROUND

The effect of pediatric inguinal hernia repair (IHR) on testicular vascularization remains unclear. Manipulating the spermatic cord during surgery may reduce blood flow due to edema and vasoconstriction. This can lead to testicular atrophy. The study aims to review current knowledge of testicular vascular impairment following IHR in children.

METHODS

A systematic literature search was conducted in PubMed/Medline, Embase, Cochrane Library, and Web of Science. Methodological quality was assessed using validated tools. Data were extracted, and a pooled data analysis was performed.

RESULTS

Ten studies were included in the systematic review. Six of these studies were eligible for meta-analysis. This revealed a significant decrease in testicular vascularization during the short-term follow-up (1 day-1 week) after IHR using the open surgical approach. This decrease was not present after laparoscopic intervention. There was no more increased resistance in the vessels at long-term follow-up (1 month-6 months), suggesting that the impaired vascularity is only temporary.

CONCLUSIONS

There seems to be a short-term transient vascular impairment of the testis after open IHR in children. This might be of clinical relevance to prefer the laparoscopic approach for IHR in children, even though the open approach is the gold standard, in contrast to adult IHR. The impact on testicular function and sperm quality later in life remains unclear. Comparative studies of both techniques are needed to determine if there is a significant difference in testicular vascularity. Long-term studies are necessary to assess the impact of transiently reduced vascularity on sperm quality and fertility later in life.

Timing of Pediatric Incarcerated Inguinal Hernia Repair: A Review of Nationwide Readmissions Data

INTRODUCTION

In pediatric patients, incarcerated inguinal hernias are often repaired on presentation. We hypothesize that in appropriate patients, repair may be safely deferred.

METHODS

The Nationwide Readmissions Database was used to identify pediatric patients (aged < 18 y) with incarcerated inguinal hernia from 2010 to 2014. Patients were stratified by management approach (Early Repair versus Deferral). Overall frequencies of these operative strategies were calculated. Propensity score matching was then performed to control for patient age, comorbidities, perinatal conditions, and congenital anomalies. Outcomes including complications, surgical procedures, and readmissions were compared. Outpatient surgeries were not assessed.

RESULTS

Among 6148 total patients with incarcerated inguinal hernia, the most common strategy was to perform Early Repair (88% versus 12% Deferral). Following propensity score matching, the cohort included 1288 patients (86% male, average age 1.7 ± 4.1 years). Deferral was associated with equivalent rates of readmission within one year (13% versus 15%, P = 0.143), but higher readmissions within the first 30 days (7% versus 3%, P = 0.002) than Early Repair. Deferral patients had lower rates of orchiectomy (2% versus 5%, P = 0.001), wound infections (< 2% versus 2%, P = 0.020), and other infections (7% versus 15%, P < 0.001). The frequency of other complications including bowel resection, oophorectomy, testicular atrophy, sepsis, and pneumonia were equivalent between groups. Three percent of Deferrals had a diagnosis of incarceration on readmission.

CONCLUSIONS

Deferral of incarcerated inguinal hernia repair at index admission is associated with higher rates of hospital readmissions within the first 30 days but equivalent readmission within the entire calendar year. These patients are at risk of repeat incarceration but have significantly lower rates of orchiectomy than their counterparts who undergo inguinal hernia repair at the index admission. We propose that prospective studies be performed to identify good candidates for Elective Deferral following manual reduction and overnight observation. Such studies must capture outpatient surgical outcomes.

A neglected case of strangulated right groin hernia presenting with perforated ileum, vanished right testis and necrotizing fasciitis of the right groin: A case report

INTRODUCTION AND IMPORTANCE

Hernias are one of the commonest procedures performed by general surgeons. Irreducibility, intestinal obstruction, and strangulation are common outcomes of a groin hernia when there is disregard and a delay in elective surgery. Studies have shown a considerable incidence of these hernia complications, along with the associated morbidity and death, because of delayed presentation. Testicular gangrene following incarcerated hernias is a rare entity in the adult population.

CASE PRESENTATION

Here we present a case of a 30-year-old male presented with gangrenous vanished testis, perforated ileum and necrotizing fasciitis of the right groin after a neglected strangulated right inguinal hernia.

CLINICAL DISCUSSION

Testicular infarction/gangrene is most commonly secondary to testicular torsion, an emergency that teenagers frequently experience. When it complicates inguinal hernia, it typically results in ischemia, infarction, and gangrene due to compression and impairment of the vascular supply within the inguinal canal. In cases like our where there is a necrotizing process in the groin, we feel it's appropriate to approach from the abdomen and do the resection first and proceed with the radical debridement after that.

CONCLUSION

Early diagnosis and intervention with emergency surgery are crucial for strangulated inguinal hernia and prevents unnecessary escalation of the problem with progressive infectious and necrotic destruction of adjacent tissues.

Immediate Versus Delayed Surgical Management of Infant Cryptorchidism With Inguinal Hernia

INTRODUCTION

Cryptorchidism is commonly treated with orchiopexy at 6-12 months of age, often allowing time for undescended testicle(s) (UT) to descend spontaneously. However, when an inguinal hernia (IH) is also present, some surgeons perform orchiopexy and inguinal hernia repair (IHR) immediately rather than delaying surgery. We hypothesize that early surgical intervention provides no benefit for newborns with both IH and UT.

METHODS

The Nationwide Readmissions Database was used to identify newborns with diagnoses of both IH and UT from 2010 to 2014. Patients were stratified by management: IHR performed on initial admission (Repair) or not (Deferral). Demographics, outcomes, and complications were compared. Results were weighted for national estimates.

RESULTS

We analyzed 1306 newborns (64% premature) diagnosed with both IH and UT. IHR was performed at index admission in 30%. Repair was more common in premature babies (43% vs. 8% full-term, p < 0.001) and patients with congenital anomalies (33% vs. 27% without congenital anomaly, p = 0.012). There was no difference in readmission rates. Repair patients had higher rates of orchiectomy than did Deferral. No Deferral patients were readmitted for bowel resection, and <1% were readmitted for orchiectomy or hernia incarceration.

CONCLUSION

In newborns with UT and IH, immediate repair is not associated with improved outcomes. Even with incarceration on initial presentation, rates of readmission with incarceration or bowel compromise for patients who undergo Deferral of surgery are minimal. Moreover, Repair newborns have higher rates of orchiectomy. We found no benefit to early operative intervention; thus, we recommend waiting until 6-12 months of age to reassess for surgery.

LEVEL OF EVIDENCE

Level III TYPE OF STUDY: Retrospective Comparative Study.

Do Not Get It Twisted: Common and Uncommon Manifestations of Testicular Torsion

Color flow and spectral Doppler ultrasound are the backbone of scrotal imaging when evaluating acute scrotal pain. Testicular Torsion is one of the most common causes of acute scrotal pain but can be a challenging diagnosis both clinically and sonographically. This article will review the pertinent Doppler ultrasound findings that can help make the diagnosis of both complete and partial torsion. A review of other causes of testicular ischemia will also be included as these pathologies can mimic Testicular Torsion.

Nonscrotal Causes of Acute Scrotum

Acute scrotum is characterized by intense acute scrotal pain, which may be associated with other symptoms and signs such as abdominal pain, inflammation, and fever. Many pathologic conditions can present in this way, most which involve the scrotal contents. Nonscrotal conditions, however, can rarely present clinically only as acute scrotum: among them, renal colic, aneurysm rupture or other causes of retroperitoneal hemorrhage, primary abdominal or pelvic tumors and metastases, pancreatitis, pelvic inflammation, and muscle injuries. The pathophysiologic characteristics of the clinical presentation, clues for diagnosis, and imaging features of a series of nonscrotal lesions presenting clinically with acute scrotal pain are herein reported and illustrated. In patients presenting with acute scrotal symptoms and normal scrotal ultrasound findings, nonscrotal causes of acute scrotal pain should be considered in the differential diagnosis. Therefore, an ultrasound investigation of the abdomen, groin, and thighs is indicated.

Functional testicular torsion secondary to an incarcerated inguinal hernia in a 4-month old: complete recovery at 18-hours

One of the most common urological emergencies encountered in pediatric patients in the emergency department (ED) is the acute scrotum. We present the case of a 4-month-old male that presented to our community ED with scrotal swelling and vomiting of 16-hours duration. He was diagnosed with a functional testicular torsion from an incarcerated inguinal hernia, transferred to a hospital with pediatric urological capabilities and was taken to the operating room ~2 hours later. His hospital course was unremarkable, and he was discharged on day 3, having made a full recovery without any loss of bowel or testicle. There have only been a handful of cases in the literature of a pediatric patient presenting with a functional testicular torsion as a result of spermatic cord compression from an indirect inguinal hernia, with no reported cases of complete salvage at nearly 18 hours since symptom onset.

Acute testicular ischemia following manual reduction of inguinoscrotal hernia

Testicular ischemia caused by inguinal hernia repair, and even the presence of the hernia itself, has been recognized in the medical literature, with the latter more commonly in children, but such an event after manual reduction has never been reported before. We present the case of a 67-year-old man who presented to the emergency department with a painful left groin lump. A left inguinoscrotal hernia was diagnosed and reduced "en masse" with manual pressure at the bedside. The patient was discharged but developed acute-onset left scrotal pain as soon as he got home and then re-presented 2 days later with increasing severity of the pain and swelling ever since the hernia reduction. On examination, he was febrile, with a hard, tender, and swollen left testis. Serum inflammatory markers were elevated. Conservative management with intravenous antibiotics and analgesia was commenced. An ultrasound of the testes demonstrated lack of Doppler flow to the left testis, suggestive of acute ischemia. Three days later, there were persistent temperature spikes and significant pain; therefore, the patient underwent an acute left scrotal exploration where a necrotic, black left testis was discovered and excised. He was discharged on the 1^st postoperative day; histological analysis confirmed testicular infarction.

Effect of inguinal hernia on the thickness and blood flow of spermatic cord in boys

Objective

To evaluate the effect of inguinal hernia (IH) on the spermatic cord using spermatic cord ultrasonography (SCU).

Methods

From January 2016 to January 2017, boys with IH who received SCU at the start of open herniorrhaphy (OH) were enrolled in this study. The age and weight at SCU, width of the spermatic cord (SC-W), peak systolic velocity (PSV) in the spermatic artery (SA-PSV) and velocity in the pampiniform plexus (PP-V), and the interval between the initial and the second OH in boys with metachronous inguinal hernia (MIH) were recorded, and the relationship among them was studied. Boys with unilateral IH comprised the IH group, and boys with MIH comprised the MIH group. Boys with polydactylism served as the control. One-way analysis of variance tested the differences among groups. Spearman's r tested the relationship between SC-W in the MIH group and the interval.

Results

A total of 80 boys were enrolled in this study (IH group 29, MIH group 26, and control group 25). SA-PSV and PP-V in the hernia side were faster and slower than the control, respectively. There was no significant difference in PP-V and SA-PSV of the treated side in the MIH group and in the control group. After herniorrhaphy, SC-W was tapered down to normal size. SC-W, SA-PSV, and PP-V in the treated side were all highly correlated to the interval in a curvilinear manner.

Conclusion

PSV was positively correlated with SC-W in boys with IH, and PP-V was negatively correlated; herniorrhaphy could reverse the impairment.

Testicular atrophy following inguinal hernia repair in children

PURPOSE

We sought to determine the incidence and timing of testicular atrophy following inguinal hernia repair in children.

METHODS

We used the TRICARE database, which tracks care delivered to active and retired members of the US Armed Forces and their dependents, including > 3 million children. We abstracted data on male children < 12 years who underwent inguinal hernia repair (2005-2014). We excluded patients with history of testicular atrophy, malignancy or prior related operation. Our primary outcome was the incidence of the diagnosis of testicular atrophy. Among children with atrophy, we calculated median time to diagnosis, stratified by age/undescended testis.

RESULTS

8897 children met inclusion criteria. Median age at hernia repair was 2 years (IQR 1-5). Median follow-up was 3.57 years (IQR 1.69-6.19). Overall incidence of testicular atrophy was 5.1/10,000 person-years, with the highest incidence in those with an undescended testis (13.9/10,000 person-years). All cases occurred in children [Formula: see text] 5 years, with 72% in children < 2 years. Median time to atrophy was 2.4 years (IQR 0.64-3), with 30% occurring within 1 year and 75% within 3 years.

CONCLUSION

Testicular atrophy is a rare complication following inguinal hernia repair, with children < 2 years and those with an undescended testis at highest risk. While 30% of cases were diagnosed within a year after repair, atrophy may be diagnosed substantially later.

LEVEL OF EVIDENCE

Prognosis Study, Level II.

Abdominal ultrasonography of the pediatric gastrointestinal tract

Ultrasound is an invaluable imaging modality in the evaluation of pediatric gastrointestinal pathology; it can provide real-time evaluation of the bowel without the need for sedation or intravenous contrast. Recent improvements in ultrasound technique can be utilized to improve detection of bowel pathology in children: Higher resolution probes, color Doppler, harmonic and panoramic imaging are excellent tools in this setting. Graded compression and cine clips provide dynamic information and oral and intravenous contrast agents aid in detection of bowel wall pathology. Ultrasound of the bowel in children is typically a targeted exam; common indications include evaluation for appendicitis, pyloric stenosis and intussusception. Bowel abnormalities that are detected prenatally can be evaluated after birth with ultrasound. Likewise, acquired conditions such as bowel hematoma, bowel infections and hernias can be detected with ultrasound. Rare bowel neoplasms, vascular disorders and foreign bodies may first be detected with sonography, as well. At some centers, comprehensive exams of the gastrointestinal tract are performed on children with inflammatory bowel disease and celiac disease to evaluate for disease activity or to confirm the diagnosis. The goal of this article is to review up-to-date imaging techniques, normal sonographic anatomy, and characteristic sonographic features of common and uncommon disorders affecting the gastrointestinal tract in children.

Common and uncommon applications of bowel ultrasound with pathologic correlation in children

OBJECTIVE

The purpose of this article is to describe the indications and techniques for bowel ultrasound for inflammatory bowel disease and other common and uncommon entities and describe and illustrate their imaging appearances, including endoscopic or surgical correlation.

CONCLUSION

Ultrasound is a useful tool for the evaluation of inflammatory bowel disease and many other bowel diseases. Radiologists must become familiar with the full potential of ultrasound in the evaluation of the bowel in children because the need for alternative radiation-free imaging techniques continues to grow.

Analysis of 3,776 pediatric inguinal hernia and hydrocele cases in a tertiary center

BACKGROUND/PURPOSE

This study describes the pediatric inguinal hernia and hydrocele experience of a tertiary care training hospital.

METHODS

A total of 3776 patients who had been operated between January 2005 and June 2009 for inguinal hernia, cord hydrocele, and hydrocele were included. The surgeries and patient follow-up were performed by 6 pediatric surgery specialists and 8 pediatric surgery residents.

RESULTS

The patient age varied from 6 days to 17 years. There were 2959 (78.4%) males and 817 (21.6%) females (ratio: 3.6:1). The hernia was on the right in 2306 (61.1%) patients, on the left in 1111 (29.4%) patients, and bilateral in 359 (9.5%) patients. Age at presentation was younger in males (p<.001). Contralateral hernia repair was required later on during follow-up in 2% of the patients. Postoperative complications developed in 1.2% of the patients. Reoperation was needed because of wound infection in 0.6%, recurrence in 0.4%, hematoma in 0.1%, testicular atrophy in 1 patient, and acquired undescended testis in 1 patient.

CONCLUSIONS

The age of first hernia symptoms was younger in males compared to females and in premature babies compared to term babies (p<.05). The recurrent hernia rate was higher in infancy. The complication rate was higher in hernia surgery in the newborn period and in cases of incarcerated hernia compared to the overall rate (p<.05). There was no indication for contralateral routine exploration.