A prospective study of neonatal inguinal herniotomy: the problem of the postoperative hydrocele

Hydrocele Masking Testicular Tumour With Extensive Nodal Disease: A Case Report and Literature Review

Hydrocele is one of the most common causes of scrotal swellings. Fluid accumulation within the tunica vaginalis, a remnant of the peritoneum covering the testicle, leads to scrotal swelling. It is known to be a benign condition with no subsequent complications apart from increasing in size causing discomfort. Some patients could cope with the swelling effect and continue their life with no desire for further management while others are not fit for surgical intervention and would be treated conservatively with the same concept. However, once the testicle becomes swollen by the surrounding fluid, it would be difficult to examine the testicle itself even by an expert physician. We present here a 46-year-old patient who has been diagnosed with right hydrocele for a long time. The patient noticed general weakness and loss of weight. Initial investigations showed iron deficiency anemia and imaging showed retroperitoneal lymphadenopathy. Eventually, testicular ultrasonography showed a right testicular tumour that was masked by a hydrocele, resulting in delayed presentation of metastatic testicular cancer.

Hydrocele in Pediatric Population

Hydrocele is a collection of fluid within the tunica vaginalis. Based upon the etiology and the pathophysiology, it is divided into, the primary and secondary. The primary hydrocele includes the neonatal or the congenital, the communicating and the non-communicating or the closed or the adult type. The secondary hydrocele can develop in the substrate of a pre-existing disease. After systematic and thorough systematic and thorough research of the relevant literature, we aim at describing all the aspects of this entity, with specific emphasis on the issues that remain unanswered from the scientific community.

Optimal timing for inguinal hernia repair in premature infants: a systematic review and meta-analysis

BACKGROUND

The optimal timing of repair for inguinal hernia in premature infants remains a controversial topic. Our objective was to assess the clinical effects of inguinal hernia repair done before or after neonatal intensive care unit (NICU) discharge.

METHODS

MEDLINE, Embase, CINAHL, and CENTRAL were searched in July 2018. Publications comparing clinical outcomes of the premature infants with inguinal hernia repair before (early) and after (delayed) NICU discharge were identified. Two reviewers independently screened studies, extracted data, and assessed for quality. Results were pooled using random effects meta-analysis.

RESULTS

Of 640 publications identified, six comparative studies assessing a total of 1761 premature infants were included. Meta-analysis indicated no statistically significant difference in incarceration rate (odds ratio (OR) 2.15, 95% confidence interval (CI) 0.83-5.58, I² = 0%), surgical complications (OR 2.36, 95% CI 0.66-8.41, I² = 0%) and other secondary complications. However, the odds of recurrence and respiratory difficulty was significantly increase in the early group compared to delayed (OR 4.12, 95% CI 1.17-14.45, I² = 0%; OR 3.59, 95% CI 1.10-11.75, I² = 42%).

CONCLUSIONS

Repair of inguinal hernia in premature infants before NICU discharge may increase the odds of recurrence, but not incarceration or surgical complications.

LEVEL OF EVIDENCE

Level III.

Effects of Laparoscopic Hernia Repair by PIRS (Percutan Internal Ring Suturing) Technique on Testicular Artery Blood Supply

Purpose: Percutaneous internal ring suturing technique (PIRS) is a minimally invasive technique in pediatric inguinal hernia repair. In the present study, a negative effect on testicular blood flow using PIRS technique has been investigated. Methods: Forty male patients were included in the study prospectively. Two groups were formed as conventional open surgery (Group I) and PIRS technique (Group II). The resistive index (RI) value of the testicular artery was measured prospectively by using SMI (superb micro-vascular imaging) software with the color doppler ultrasound technique preoperatively and postoperatively at the first month. Results: Inguinal hernia was present on the left in 35% (n = 14) of the patients and on the right in 65% (n = 26) of the patients. There was no statistically significant difference (p = 0.727) between Group I and II with regard to preoperative RI value (0.66 ± 0.07 vs. 0.66 ± 0.45, respectively). Similarly, there was no statistically significant difference (p = 0.220) between Group I and II with regard to the RI values measured at the postoperative first month (0.58 ± 0.04 vs. 0.60 ± 0.04, respectively). Although the postoperative RI values decreased compared to the preoperative values in both groups, this difference was not statistically significant. (p = 0.447 in Group I, and p = 0.175 in Group II for intragroup comparison). Conclusions: Besides PIRS technique has the advantages provided by all other laparoscopic techniques defined for inguinal hernia repair, there is no significant difference between this technique and conventional open surgery with regard to testicular blood flow. It is an innovative candidate technique instead of the open surgery method besides its additional advantages.

Classifying Hydroceles of the Pelvis and Groin: An Overview of Etiology, Secondary Complications, Evaluation, and Management

INTRODUCTION

A hydrocele is defined as the pathological buildup of serous fluid in the pelvis and groin due to various etiologies such as diseases or trauma. It has distinct clinical manifestations, particularly discomfort and psychosocial distress. Understanding the anatomy, embryology, and physiology associated with hydrocele formation is crucial to understand its onset and progression.

MATERIALS AND METHODS

A MEDLINE^® search was conducted using keywords for the relevant classification of hydrocele and its etiology, complications, sexual barriers, evaluation, and management.

RESULTS

Appropriately classifying the hydrocele as primary, secondary communicating, secondary noncommunicating, microbe-induced, inflammatory, iatrogenic, trauma-induced, tumor-induced, canal of Nuck, congenital, and giant is important for identifying the underlying etiology. Often this process is overlooked when the classification or etiology is too rare. A focused evaluation is important for this, so that timely management can be provided. We comprehensively review the classifications, etiology, and secondary complications of hydrocele. Pitfalls of current diagnostic techniques are explored along with recommended methods for accurate diagnosis and current treatment options.

CONCLUSION

Due to the range of classifications and etiologies of hydrocele in the pelvis and groin, a deliberate differential diagnosis is essential to avoiding imminent life-threatening complications as well as providing the appropriate treatment.

Incidence of metachronous contralateral inguinal hernias in children following unilateral repair - A meta-analysis of prospective studies

PURPOSE

The objective of this review was to systematically evaluate the incidence of a metachronous contralateral inguinal hernia (MCIH) in children with unilateral inguinal hernia and therefore to propose or to reject routine contralateral groin exploration.

METHODS

Electronic searches restricted to prospective studies with a minimal follow-up of 1year included MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials.

RESULTS

Six studies involving 1669 children were included. Overall MCIH was 6% (95% CI from 4% to 8%). The odds for MCIH development were significantly larger in children with an initial left-sided hernia (OR 2.66 with 95% CI from 1.56 to 4.53) and in children with open contralateral processus vaginalis (CPV) (OR 4.17 with 95% CI from 1.25 to 13.9).

CONCLUSIONS

The overall incidence of MCIH following unilateral inguinal hernia repair in children is 6%. Initial left-sided hernia (8.5%) and open CPV (13.8%) are risk factors for MCIH development. Female gender (8.2%) and younger age (<1year) (6.9%) non-significantly increase the risk of MCIH.

Inguinal hernia in neonates and ex-preterm: complications, timing and need for routine contralateral exploration

BACKGROUND/PURPOSE

Aim of this study was to present a series of neonates and ex-preterm babies who underwent inguinal hernia repair focusing on complications and possible indication to perform routine contralateral groin exploration.

METHODS

This is a retrospective study of a series of consecutive patients weighing less than 5 kg who underwent inguinal hernia repair between January 2007 and December 2012. Only the affected side was treated. Patients have been routinely followed up postoperatively. We resorted to available outpatients' charts and admission notes to record demographic data, surgical details, complications and the occurrence of metachronous hernias. A questionnaire was administered to all patients' relatives to confirm the long-term outcome.

RESULTS

One hundred fifty-four patients were operated for a total of 184 herniotomies (88 right sided, 36 left sided and 30 bilateral). Median length of follow-up was 42 months (range 6 months-7.5 years). Thirteen patients (13/124 = 10.5 %) developed metachronous hernia that proved to be significantly more frequent in patients weighing less than 1,500 g at birth (p < 0.05). We observed 10 % of complications, including 2.7 % testicular atrophy and 4.5 % recurrence. Atrophy proved to occur more frequently in patients who experienced preoperative incarceration (p < 0.05). No other risk factors were identified.

CONCLUSIONS

The results of our series demonstrated that, though technically demanding, herniotomy in the neonate and ex-preterm is associated with a relatively low incidence of complications. Based on our results and in accordance with literature data, we do not advocate routine contralateral exploration in case of unilateral hernia but surgery to be performed only on the symptomatic side, as soon as possible after initial diagnosis. Very low birth weight patients should be followed with care in the early postoperative period due to the higher likelihood of developing a metachronous hernia.

Urological complications of inguinal hernia surgery

BACKGROUND AND AIMS

A systematic review of the literature is presented with regard to urological complications resulting from inguinal hernia surgery. Considering the amount of inguinal hernia operations performed, the resulting complications, which may be urological in presentation, have potential late irreversible and medico-legal implications.

METHODS AND RESULTS

A Pubmed search of 'urological' 'complications' and 'inguinal hernia surgery' was carried out and clinical practice was also taken into consideration.

DISCUSSION

Approximately 75% of hernias occur in the groin; two-third of these are indirect and about one-third direct. Most of these repairs are carried out by the general surgeons and any complication, including urological, are often initially managed by the operating general surgeon. Often a urological opinion is sought late for conditions which may be reversible. We present potential urological complications, their presenting features and management.

CONCLUSION

Recognition, timely referral and appropriate treatment of urological complications after hernia surgery are necessary to avoid potential consequences and long-term morbidity.

Systematic review for paediatric metachronous contralateral inguinal hernia: a decreasing concern

PURPOSE

Controversy still surrounds the treatment of the asymptomatic inguinal region in paediatric patients with a unilateral inguinal hernia. The concern is the development of a future metachronous contralateral inguinal hernia (MCIH) and therefore the need for a second operation. Our aim was to provide a current systematic review of the evidence for routine contralateral exploration, and identify potential at-risk groups.

METHODS

Comprehensive review of the literature utilising broad search terms to identify all relevant publications. Precise inclusion and exclusion criteria to identify studies that included paediatric unilateral inguinal hernia repair without routine contralateral exploration.

DATA ANALYSIS

Chi-square with Yates' correction or a Fisher's exact test as appropriate. Numbers needed to treat (NNT) calculated with 95% confidence intervals.

RESULTS

A total of 7,130 titles and abstracts were screened and 61 studies included with data on 49,568 paediatric patients with a unilateral inguinal hernia fulfilling the inclusion criteria. 2,857 of these patients later developed a MCIH, revealing an overall risk is 5.76% (95% CI: 5.55-5.97%). The NNT for a MCIH is 18 (95% CI: 16.8-18) with 18 contralateral exploration required for the prevention of one MCIH. Patients <6 months at the time of the initial intervention were more likely to develop a MCIH; 183/1,470 (<6/12) versus 144/2,044 (≥6/12), P < 0.0001. As were patients with an original left-sided hernia; 815/6,739 versus 865/12,615, P < 0.0001. The NNTs for both of these groups were 9. There was no association with the gender of the patient; 888/14,480 (♂) versus 268/4,206 (♀), P = 0.37.

CONCLUSIONS

There is insufficient evidence to support the routine contralateral inguinal exploration in all paediatric patients presenting with a unilateral inguinal hernia. However, with patients presenting with an originally left-sided hernia or who are less than 6 months old, a parental discussion should occur about the possible benefits and risks of contralateral exploration.

Does timing matter? A national perspective on the risk of incarceration in premature neonates with inguinal hernia

OBJECTIVES

To determine the incidence of inguinal hernia in premature neonates and identify risk factors for incarceration.

STUDY DESIGN

The 2003 and 2006 Kids' Inpatient Databases were queried for diagnoses indicative of premature birth and inguinal hernia.

RESULTS

Inguinal hernia was diagnosed during the birth hospitalization in 1463 ± 87 of 49 273 ± 1561 premature neonates (3%). Male sex, gestational age, birth weight, and prolonged mechanical ventilation were associated with inguinal hernia (all P < .01). Incarceration occurred in 176 of 1123 premature neonates (16%) who underwent hernia repair during the birth hospitalization. Delaying repair beyond 40 weeks post-conceptual age doubled the risk of incarceration (21%), as compared with 36 to 39 weeks (9%) or <36 weeks (11%, P = .002). Sex, race, and insurance were not associated with incarceration.

CONCLUSION

The risk of incarceration is doubled in premature neonates with inguinal hernia when repair is delayed beyond 40 weeks post-conceptual age. This increased incarceration risk should be one of the factors considered when deciding on the optimal timing of inguinal hernia repair.

Minimal access surgery of pediatric inguinal hernias: a review

Inguinal hernia is a common problem among children, and herniotomy has been its standard of care. Laparoscopy, which gained a toehold initially in the management of pediatric inguinal hernia (PIH), has managed to steer world opinion against routine contralateral groin exploration by precise detection of contralateral patencies. Besides detection, its ability to repair simultaneously all forms of inguinal hernias (indirect, direct, combined, recurrent, and incarcerated) together with contralateral patencies has cemented its role as a viable alternative to conventional repair. Numerous minimally invasive techniques for addressing PIH have mushroomed in the past two decades. These techniques vary considerably in their approaches to the internal ring (intraperitoneal, extraperitoneal), use of ports (three, two, one), endoscopic instruments (two, one, or none), sutures (absorbable, nonabsorbable), and techniques of knotting (intracorporeal, extracorporeal). In addition to the surgeons' experience and the merits/limitations of individual techniques, it is the nature of the defect that should govern the choice of technique. The emerging techniques show a trend toward increasing use of extracorporeal knotting and diminishing use of working ports and endoscopic instruments. These favor wider adoption of minimal access surgery in addressing PIH by surgeons, irrespective of their laparoscopic skills and experience. Growing experience, wider adoption, decreasing complications, and increasing advantages favor emergence of minimal access surgery as the gold standard for the treatment of PIH in the future. This article comprehensively reviews the laparoscopic techniques of addressing PIH.

Systematic review of the risk of developing a metachronous contralateral inguinal hernia in children

Background

This study aims to establish the risk of developing a metachronous contralateral inguinal hernia (MCIH) following open repair of a unilateral inguinal hernia in children.

Methods

A systematic review was performed using a defined search strategy. Studies in which children undergoing open repair of a unilateral inguinal hernia without contralateral exploration and who were followed up for MCIH development were included.

Results

Of 5937 titles and abstracts screened, 154 full-text articles were identified for review; 49 papers were analysed with data on 22 846 children. The incidence of MCIH was 7·2 per cent overall, 6·9 per cent in boys and 7·3 per cent in girls (P = 0·381). Children with a left-sided inguinal hernia had a significantly higher risk of developing a MCIH than those with a right-sided hernia (10·2 versus 6·3 per cent respectively; P &lt; 0·001).

Conclusion

Overall, in both boys and girls, 14 contralateral explorations are required to prevent one metachronous hernia. The risk of developing a MCIH appears unchanged in early childhood, with a slight reduction after 12 years of age. Children with a left-sided hernia have the greatest risk of developing a contralateral hernia, but ten explorations are still required to prevent one metachronous hernia. Most MCIHs occur in the first 5 years after unilateral inguinal hernia repair.

[Children's strangulated inguinal hernia]

The inguinal hernia, malformations caused by persistence of peritonea-vaginal duct, is frequent in children. It is a benign affection as long as it is not strangled. During our five-year-retrospective study, we have found 32 cases (30 boys and 2 girls) of strangled inguinal hernia. There are 78,12% of cases under five years old. In 54%, the hernia was on the right side. Malnutrition and inguinoscrotal hernia are very exposed to strangulation. We observed obstruction syndrome in 81,25% of cases. We have to deplore one case of scrotal fistulae by intestinal necrosis and two cases of testicle necrosis. For all of our patients, the peritonea-vaginal duct was closed with ligature, associated with pre-funicular parietal refection. One case of recurrence is found in postoperative time.