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Abstract
PURPOSE The purpose of the study is to evaluate results and outcomes in a long-time follow-up period, by performing a novel testicular fixation procedure, known as "fat anchor orchidopexy" (FAO), for the treatment of palpable low inguinal undescended testis. MATERIALS AND METHODS We retrospectively reviewed all patients who underwent scrotal orchiopexy technique, from May 2013 to May 2019, at the Pediatric Surgery Division of Department of Surgical Pathology, University of Pisa (Italy). FAO (Spinelli's technique) consists in anchoring the testicles to sub-scrotal fat with a single trans-scrotal incision. All the patients enrolled had history of unilateral or bilateral undescended testis. Data collected included patient's age, operative times and complications. RESULTS A total of 150 children with cryptorchidism were treated using a single trans-scrotal orchiopexy. Of them, 130 patients (86.7%) had unilateral undescended testis and 20 (13.3%) bilateral cryptorchidism. Mean patient's age was 21 months (range: 14-28 months). All the procedures were planned in a day-surgery setting. Trans-scrotal orchiopexy was successful in all cases and no patients required an additional groin incision. No intraoperatively and postoperatively major complications were observed. Patients' post-operative pain was mild (mean pediatric visual analog scale = 2). In all cases, the healing process was rapid and no surgical wounds infections were reported during the post-operative period, referring excellent cosmesis results. During a mean 48-month follow-up period, no testicular retraction, recurrence or testis atrophy was reported. CONCLUSION The original Spinelli's technique (FAO) proves to be a safe and effective method for the treatment of palpable or distal-to-external-inguinal-ring testes. No immediate and delayed post-surgery complications were reported. In all cases, the anchored testicle remained in the scrotal position with normal vascularization. This novel surgical technique could give better options for scrotal fixation in case of low-lying cryptorchid testes.
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Chongxi R, Hongqiao W, Fengying L, Xin W, Hongxia Q, Lijun X. Single-incision approach for bilateral inguinal hernia repair in children: A retrospective study. Medicine (Baltimore) 2020; 99:e19376. [PMID: 32118783 PMCID: PMC7478388 DOI: 10.1097/md.0000000000019376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/12/2020] [Accepted: 01/29/2020] [Indexed: 11/25/2022] Open
Abstract
To introduce the use of a new surgical approach named single-incision bilateral inguinal herniorrhaphy (SBIH) in pediatric surgical population.This was a STROBE-compliant retrospective cohort study using data from 101 patients who had undergone bilateral inguinal herniorrhaphy in our institution. Children with bilateral inguinal hernias without contraindications for surgery, ranging in age from 6 months to 12 years, were included. Fifty-six children with bilateral inguinal hernias underwent SBIH (SBIH group) and 45 patients underwent laparoscopic bilateral inguinal herniorrhaphy (LBIH) (LBIH group). Differences in operative time, postoperative pain, recurrence, and complications between the 2 groups were analyzed. Patient satisfaction with cosmetic result was also investigated using questionnaires.There were no statistically significant differences in operative time (P = .2257), postoperative pain (P = .0607), recurrence (P = .8756), and complications (P = .7467) between the 2 groups. Interestingly, the operation time of girls in SBIH group was significantly shorter than that of the boys in this group (P < .0001), but also shorter than that of girls in LBIH group (P = .0038). Postoperative pain for boys was lower in SBIH group than in the LBIH group (P = .0340). No ascending testis, testicular atrophy, and hydrocele occurred in either group. According to the questionnaire, both procedures had equally high levels of satisfaction for cosmetic results (P = .7531).Initial results show that SBIH for pediatric patients, regardless of gender, is a safe and feasible procedure compared with LBIH with an equally low recurrence rate, few complication, and satisfactory cosmetic outcomes.
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Botham SJ, Fillmore EP, Grant TS, Davies H, Hutchinson C, Tunstall R. Age-related changes in inguinal region anatomy from 0 to 19 years of age. Clin Anat 2019; 32:794-802. [PMID: 31066950 DOI: 10.1002/ca.23402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/02/2019] [Accepted: 05/04/2019] [Indexed: 11/10/2022]
Abstract
Knowledge of the age-related changes in inguinal region anatomy is essential in pediatric urological and abdominal surgery, yet little is published. This study aimed to determine the position of inguinal region structures and growth of the surrounding pelvis and inguinal ligament in subjects from 0 to 19 years of age. Anonymized contrast-enhanced CT DICOM datasets of 103 patients (63 male: 40 female) aged from 0 to 19 years had left and right sides analyzed by three independent observers. Exclusion criteria were applied. Growth of the pelvis and inguinal ligament were determined using fixed bony reference points. The position of the deep inguinal ring and femoral vasculature were determined as ratio of inguinal ligament length, measured from the anterior superior iliac spine. Growth of the pelvis in vertical and horizontal dimensions and of the inguinal ligament followed a positive polynomial relationship with increasing age, with no observed increase in growth rate during puberty. From 0 to 19 years, the deep inguinal ring moved superolaterally with respect to the inguinal ligament (from 0.74 to 0.60 of the distance along the inguinal ligament) and the femoral artery and vein moved medially (from 0.50 to 0.58, and 0.61 to 0.65 of the distance along the inguinal ligament, respectively). The position of the femoral artery, vein, and deep inguinal ring followed a logarithmic relationship with age. No significant left:right side or male:female differences were observed. From 0 to 19 years of age the femoral vasculature and deep inguinal ring change position as the pelvis grows around them. Clin. Anat. 32:794-802, 2019. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Sean J Botham
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Erin P Fillmore
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Thomas S Grant
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Harvey Davies
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Charles Hutchinson
- Warwick Medical School, University of Warwick, Coventry, United Kingdom.,University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
| | - Richard Tunstall
- Warwick Medical School, University of Warwick, Coventry, United Kingdom.,University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
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Neheman A, Levitt M, Steiner Z. A tailored surgical approach to the palpable undescended testis. J Pediatr Urol 2019; 15:59.e1-59.e5. [PMID: 30563750 DOI: 10.1016/j.jpurol.2018.08.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 08/18/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Orchiopexy for a palpable undescended testis can be approached through a traditional inguinal incision or trans-scrotally. Despite the possible advantages of the scrotal approach, including reduced postoperative pain and shorter recovery, it is not consistently advocated. OBJECTIVE The objective of this study was to present the experience with a tailored approach to orchiopexy based on physical findings. STUDY DESIGN This is an extended case series. MATERIALS AND METHODS The mobility of the testis as described at examination under anesthesia informs the choice of surgical approach. If a 'low' palpable testis (defined as testis that can be manipulated to the scrotum) was found, a scrotal approach was used. In cases of 'high' palpable testis (testis that cannot be manipulated to scrotum), the inguinal approach was used. Success was defined by location and size of the testis 3 months after surgery. RESULTS A total of 259 orchiopexies were performed in 181 boys (78 bilateral). Scrotal approach was used in 125 (48%) and inguinal in 134 (52%) orchiopexies. Operative time was significantly shorter for the scrotal approach, 25 min vs. 40 min for inguinal orchiopexy (P < 0.05). The overall success rate was 98% with no statistical difference between the groups. Three children from the inguinal group and two from the scrotal group required an additional procedure for persistent undescended testis. The rates of testicular atrophy and hypotrophic testis were higher in the inguinal group than the scrotal group (5/134 vs. 0/125; P < 0.05 and 17/134 vs. 6/126; P < 0.05, respectively). DISCUSSION The substantial cohort of patients selected for trans-scrotal orchiopexy experienced success rates and rates of atrophic and hypotrophic testis comparable with those found in the published literature. Furthermore, trans-scrotal operative times were significantly lower than those of inguinal procedures, and less patients required re-operation in the trans-scrotal group. Limitations of this study include significantly higher age at operation in trans-scrotal patients and a difficulty accurately classifying hypotrophic testes. Furthermore, the higher atrophic rate in the inguinal group vs. the scrotal group likely reflects the vulnerability of a testis that is located higher and not the superiority of the scrotal approach. CONCLUSION This tailored approach to a palpable undescended testis appears simple, safe, and effective, providing high success rate with marginal complications. It is considered a preference in cases of low undescended testis, whereas the standard two-incision inguinal orchiopexy may better serve those with high undescended testis.
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Affiliation(s)
- A Neheman
- Department of Urology, Division of Pediatric Urology, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Levitt
- Department of Urology, Division of Pediatric Urology, Assaf Harofeh Medical Center, Zerifin, Affiliated to Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Z Steiner
- Department of Urology, Meir Medical Center, Kefar Sava, Affiliated to Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Chua ME, Silangcruz JMA, Gomez O, Dy JS, Morales ML. Circumcision-incision orchidopexy: A novel technique for palpable, low inguinal undescended testis. Investig Clin Urol 2017; 58:468-473. [PMID: 29124248 PMCID: PMC5671968 DOI: 10.4111/icu.2017.58.6.468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 07/05/2017] [Indexed: 11/18/2022] Open
Abstract
Given that both orchidopexy and circumcision are commonly done in a single operative setting, we adopted a technique of combined orchidopexy and circumcision using a single circumcision incision. We applied this new technique to boys with palpable, low inguinal cryptorchidism. Here we describe a case series of 7 boys who underwent concurrent orchidopexy via the circumcision site. We present this novel technique and discuss our preliminary outcomes, including the anatomic basis and feasibility. The technique appears to be an alternative for concurrent circumcision and cryptorchid cases with palpable, low inguinal testes.
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Affiliation(s)
- Michael E Chua
- Institute of Urology, St. Luke's Medical Center, Quezon City, Philippines
| | | | - Odina Gomez
- Institute of Radiology, Section of Pediatric Radiology, St. Luke's Medical Center, Global City, Philippines
| | - Jun S Dy
- Institute of Urology, St. Luke's Medical Center, Quezon City, Philippines
| | - Marcelino L Morales
- Institute of Urology, St. Luke's Medical Center, Quezon City, Philippines.,Department of Urology, National Kidney and Transplant Institute, Quezon City, Philippines
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High single scrotal-incision orchidopexy as the standard technique in infants aged 6-24 months. Arab J Urol 2017; 15:78-81. [PMID: 28275524 PMCID: PMC5329722 DOI: 10.1016/j.aju.2016.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 10/31/2016] [Accepted: 11/20/2016] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE To prospectively investigate the effectiveness of high single scrotal-incision orchidopexy (HSSIO) for palpable undescended testis (PUDT) in infants aged 6-24 months. PATIENTS AND METHODS From March 2012 to July 2014, 46 age range-restricted (6-24 months) infants with 57 PUDT underwent HSSIO after obtaining written consent from their parents. The exclusion criteria were ectopic, retractile testes and recurrent cases. All infants were examined before surgery in the outpatient department and after anaesthesia induction immediately before surgery. All infants had general anaesthesia with a caudal block. The operative time, intraoperative and postoperative complications, and follow-up of the infants at 0.5, 3 and 6 months were recorded and analysed. RESULTS The mean (SD; range) operative time was 23.45 (3.28; 18-29) min. A hernia sac was found in 39 (68.4%) UDTs. For postoperative complications, only one infant developed a scrotal haematoma that was managed conservatively. The procedure was successful in 56/57 PUDT (98%). An auxiliary procedure was needed in one case, to obtain more length of the cord by extension of the incision to the external ring. CONCLUSION HSSIO is a safe and feasible technique, with many benefits, and as such should be considered as the standard technique for orchidopexy in infants aged 6-24 months.
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Nazem M, Dastgerdi MMH, Sirousfard M. Outcomes of pediatric inguinal hernia repair with or without opening the external oblique muscle fascia. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2015; 20:1172-6. [PMID: 26958052 PMCID: PMC4766824 DOI: 10.4103/1735-1995.172985] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 01/04/2015] [Accepted: 06/23/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Considering that complications and outcome of each method of pediatric inguinal hernia repair are one of the determinants for pediatric surgeons for selection of the appropriate surgical technique, we compared the early and late complications of two inguinal repair techniques, with and without opening the external oblique muscle fascia. MATERIALS AND METHODS In this double-blind clinical trial study, boy children aged 1-month to 6 years with diagnosed inguinal hernia were included and randomly allocated into two groups for undergoing two types of hernia repair techniques, with and without opening the external oblique muscle fascia. Surgical complications such as fever, scrotal edema and hematoma, and wound infections classified as early complication and recurrence, testis atrophy and sensory impairment of inguinal area classified as late complications. The rates of mentioned early and late complications were compared in the two interventional groups. RESULTS In this study, 66 patients were selected and allocated to the two interventional groups. The prevalence of early and late complications in two studied groups were not different significantly in two interventional groups (P > 0.05). Operation time was significantly shorter in inguinal repair techniques without opening the external oblique muscle fascia than the other studied technique (P = 0.001). CONCLUSION The findings of our study indicated that though early and late complications of the two repair methods were similar, but the time of procedure was shorter in herniotomy without opening the external oblique muscle, which considered the superiority of this method than inguinal hernia repair with opening the external oblique muscle.
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Affiliation(s)
- Masoud Nazem
- Department of Surgery, Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Motaherh Sirousfard
- Department of Pediatric Nursing, Isfahan University of Medical Sciences, Isfahan, Iran
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Taghavi K, Geneta VP, Mirjalili SA. The pediatric inguinal canal: Systematic review of the embryology and surface anatomy. Clin Anat 2015; 29:204-10. [PMID: 26400820 DOI: 10.1002/ca.22633] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 09/15/2015] [Accepted: 09/16/2015] [Indexed: 11/06/2022]
Abstract
The inguinoscrotal region is one of the most common areas operated on in pediatric surgery. Despite this, the surface anatomy of the pediatric inguinal canal is variably defined. The aim of the current systematic review is to evaluate the development and surface anatomy of the pediatric inguinal canal. A systematic review of inguinal canal anatomy in children was conducted using the electronic databases: Medline, PubMed, Scopus, and Google Scholar. Relevant anatomical measurements and relationships were reviewed. The anatomical structures forming the walls of the inguinal canal were identified in fetuses as early as 8-10 weeks gestation. No studies addressed the developmental basis of this early defect in the lower anterior abdominal. Later gonadal development and descent has a defined role. In vivo measurements of children carried out during open surgery are inconsistent. Some studies showed rapid growth velocity of the length of the inguinal canal up to 2 years of age (with height and growth of the bony pelvis) before plateauing, while others suggested no increase in canal length prior to 10 years of age. The position of the deep inguinal ring was equally unclear; some studies suggested this was medial to the midpoint of the inguinal ligament. No studies described the position of the superficial ring, challenging the assumption that the rings are superimposed in the neonate. The dearth of studies analyzing pediatric inguinal anatomy means that changes in the position of the rings with respect to the lengthening of the canal remain unclear.
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Affiliation(s)
- Kiarash Taghavi
- Department of Pediatric Surgery, Wellington Hospital, Wellington, New Zealand
| | - von Paolo Geneta
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - S Ali Mirjalili
- Department of Anatomy with Radiology, University of Auckland, Auckland, New Zealand
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Türk E, Memetoglu ME, Edirne Y, Karaca F, Saday C, Güven A. Inguinal herniotomy with the Mitchell-Banks' technique is safe in older children. J Pediatr Surg 2014; 49:1159-60. [PMID: 24952808 DOI: 10.1016/j.jpedsurg.2013.09.065] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 09/18/2013] [Accepted: 09/18/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE There is a tendency for the majority of surgeons to open the inguinal canal in children over two years old when performing inguinal hernia repair. On the other hand, in small children, most surgeons perform the herniotomy superficially to the external ring, as in Mitchell-Banks' technique (MBT). Our aim was to compare the Ferguson hernioplasty (FH) and Mitchell-Banks' technique in terms of recurrence and complication rates in older children. METHODS We retrospectively reviewed the office medical records of children who were at least two years old and who underwent a herniotomy procedure for inguinal hernia between 1997 and 2012. RESULTS The 4520 inguinal herniotomy procedures in boys who were over two years old were included in this study. Of these cases, 1607 cases (40.2%) were operated on by a FH with opening the inguinal canal, and 2388 cases (59.8%) by MBT superficially to the external ring. The median ages were 5.1 years (range, 2.0-16.2) in the FH group and 4.6 years (2.0-14.6) in the MBT group. The total complication rates were 2.3% in the FH group and 2.9% in the MBT group (P>.05). Early complications such as wound infection, scrotal edema, and hematoma were seen in 13 (0.8%), 15 (1%), and 10 (0.6%) in the FH group, and 12 (0.5%), 18 (0.7%), and 15 (0.6%) in the MBT group, respectively (P>.05). Late complications such as recurrence, trapped undescended testis, and testicular atrophy were seen in 2 (0.12%), 1 (0.06%), and 2 (0.12%) in the FH group, and 3 (0.12%), 1 (0.04%), and 2 (0.08%) in the MBT group (P>.05). CONCLUSION The Mitchell-Banks technique is a simple and safe procedure in older boys.
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Affiliation(s)
- Erdal Türk
- Department of Pediatric Surgery, Izmir University, Faculty of Medicine, Izmir, Turkey.
| | | | - Yesim Edirne
- Denizli State Hospital, Clinics of Pediatric Surgery, 20100, Denizli, Turkey
| | - Fahri Karaca
- Denizli State Hospital, Clinics of Pediatric Surgery, 20100, Denizli, Turkey
| | - Cezmi Saday
- Aydin State Hospital, Clinics of Pediatric Surgery, 09000, Aydin, Turkey
| | - Ahmet Güven
- Department of Pediatric Surgery, Gulhane Military Medical Faculty, Etlik, 06018, Ankara, Turkey
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Novaes HFF, Carneiro Neto JA, Macedo Jr A, Barroso Junior U. Single scrotal incision orchiopexy - a systematic review. Int Braz J Urol 2013; 39:305-11. [DOI: 10.1590/s1677-5538.ibju.2013.03.02] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 05/27/2013] [Indexed: 11/21/2022] Open
Affiliation(s)
| | - Jose Abraao Carneiro Neto
- Division of Urology Bahiana School of Medicine and Federal University of Bahia and Federal University of Sao Paulo
| | - Antonio Macedo Jr
- Division of Urology Bahiana School of Medicine and Federal University of Bahia and Federal University of Sao Paulo
| | - Ubirajara Barroso Junior
- Division of Urology Bahiana School of Medicine and Federal University of Bahia and Federal University of Sao Paulo
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Sfoungaris D, Mouravas V, Petropoulos A, Filippopoulos A. Prentiss orchiopexy applied in younger age group. J Pediatr Urol 2012; 8:488-92. [PMID: 22050926 DOI: 10.1016/j.jpurol.2011.10.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Accepted: 10/12/2011] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the efficacy and safety of the operative technique for the correction of cryptorchidism described by Prentiss in the 1950s, who conducted measurements on patients over 6 years of age, and on cadaveric specimens. We applied the technique in a younger age group. MATERIAL AND METHODS We prospectively studied the results of 50 orchiopexies in children 8-59 months of age (mean 32.3 months), separated into three age groups: 8-18 (N=14), 19-36 (N=18), and 36-59 (N=18) months. The patients were selected for having their undescended testis in the inguinal canal and not reaching the scrotum after adequate inguinal and retroperitoneal dissection. We eliminated the anatomic angulation of the vas deferens and testicular vessels around the internal inguinal ring and inferior epigastric vessels, in order to improve distal scrotal positioning (Prentiss maneuver). We compared the position of the testis before and after the maneuver. We re-examined the children 1 year postoperatively for testicular position and quality. RESULTS The average gain in scrotal positioning was 6-20 mm (mean 13 mm). At follow-up, 36 testes (78%) had retained a low scrotal position, 10 (20%) a middle scrotal position, and 4 (8%) presented in an upper scrotal position. CONCLUSIONS The Prentiss maneuver is both safe and efficient when applied to the younger age group, in order to gain adequate intrascrotal cord length and to place the testis in a more distal scrotal position.
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Affiliation(s)
- Dimitrios Sfoungaris
- Second Department of Pediatric Surgery, Aristotle University of Thessaloniki, General Hospital Papageorgiou, Ring Road N. Efkarpia, Thessaloniki, Greece.
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Hale SJM, Mirjalili SA, Stringer MD. Inconsistencies in surface anatomy: The need for an evidence-based reappraisal. Clin Anat 2010; 23:922-30. [DOI: 10.1002/ca.21044] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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14
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Sanjay P, Reid TD, Bowrey DJ, Woodward A. Defining the position of deep inguinal ring in patients with indirect inguinal hernias. Surg Radiol Anat 2006; 28:121-4. [PMID: 16636774 DOI: 10.1007/s00276-006-0105-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2005] [Accepted: 11/28/2005] [Indexed: 10/24/2022]
Abstract
A preliminary survey of surgeons of all grades in our hospital revealed confusion about the position of the deep inguinal ring. Standard teaching is that the deep inguinal ring is lateral to the femoral artery. The aim of this study was to define the position of the deep ring in patients undergoing elective inguinal hernia repair. Thirty consecutive male patients undergoing indirect inguinal hernia repair under local anaesthesia were studied. The following landmarks were marked on the patient with a felt pen: anterior superior iliac spine (ASIS), femoral artery (FA), deep inguinal ring (DR), pubic tubercle (PT) and pubic symphysis (PS). The distance of each point from the ASIS was measured in centimetres. The relation of the femoral artery to the deep inguinal ring was confirmed by palpation through the deep ring during surgery. The femoral artery was consistently identified midway between the anterior superior iliac spine and pubic symphysis (mid-inguinal point). The deep inguinal ring was located medial (22/30) or above (8/30) the femoral artery, but never lateral. The mean distances from the anterior superior iliac spine to the deep ring and femoral artery were 8.8 and 7.7 cm, respectively. Contrary to standard teaching, this study demonstrates that the deep inguinal ring lies medial, not lateral, to the femoral artery. This may clarify some of the variations in textbook anatomy, and explain the difficulty in distinguishing direct and indirect inguinal hernias pre-operatively.
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Affiliation(s)
- P Sanjay
- Royal Glamorgan Hospital, Llantrisant, CF72 8XR, S Wales, UK
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Conaghan P, Hassanally D, Griffin M, Ingham Clark C. Where exactly is the deep inguinal ring in patients with inguinal hernias? Surg Radiol Anat 2003; 26:198-201. [PMID: 14625793 DOI: 10.1007/s00276-003-0203-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2002] [Accepted: 09/20/2003] [Indexed: 11/24/2022]
Abstract
It is difficult to distinguish direct from indirect inguinal hernias on clinical examination. This study attempted to determine an anatomical basis for this finding. Fifty adult patients with primary inguinal hernias were assessed. The position of the deep inguinal ring (DIR) was estimated from the position of the anterior superior iliac spine (ASIS) and the pubic tubercle (PT) pre-operatively and then the actual distance from these landmarks was measured intra-operatively. The DIR was actually located at a mean of 41% (95% confidence interval (CI) 26-56%) of the way along the inguinal ligament from the PT towards the ASIS (regression slope 1.203; 95% CI 1.141-1.127), compared with the 50% which would be expected from traditional clinical methodology. The DIR was actually found at a mean of 51% (95% CI 33-69%) of the way along a line from the pubic symphysis to the ASIS (regression slope 1.421; 95% CI 1.343-1.499). Pre-operative estimates of the position of the DIR are not accurate measures of its true position in patients with inguinal hernias. Clinical examination of inguinal hernias cannot rely on a constant position of the DIR to determine whether a hernia is direct or indirect.
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Affiliation(s)
- P Conaghan
- Department of General Surgery, Jenner Building, Whittington Hospital, Highgate Hill, London, N19 5NF, UK.
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Tanyel FC, Ocal T, Karaağaoğlu E, Büyükpamukçu N. Individual and associated effects of length of inguinal canal and caliber of the sac on clinical outcome in children. J Pediatr Surg 2000; 35:1165-9. [PMID: 10945687 DOI: 10.1053/jpsu.2000.8719] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE The caliber of processus vaginalis is accepted to define the clinical outcome to be an inguinal hernia or hydrocele not based on any evaluation. The caliber of sacs and length of inguinal canals of boys and girls were evaluated to define the relation of sex, age, and the diagnosis with caliber of the sac and the length of inguinal canal. METHODS A total of 217 inguinal canals in 24 girls and 112 boys with inguinal hernia, 30 boys with hydrocele or hydrocele of the cord, and 31 boys with undescended testis have been evaluated. Twenty patients had bilateral involvement. The length of inguinal canal, and the circumference of the sac were measured. A formula was developed to predict the length of inguinal canal according to the age and sex. The circumferences of the sacs, length of inguinal canals, and the ratios of the circumference to the length were compared according to the clinical pictures. RESULTS The regression model of the relationship between the age and the length of the inguinal canal is an equation of third degree (inguinal canal in millimeters) = 0.0000119 x age 3 (months) - 0.00292 x age 2 (months) + 0.3168 x age (months) + 19.979 (r2 = 0.47). Inguinal canal is longer in boys (25.133 and 27.996 mm; P = .018), and length does not differ among diagnoses but differs according to age showing a linear growth after 24 months. Although the circumference as a sole parameter could classify only 55.3% of boys correctly, the ratio of length of inguinal canal to circumference of the sac has been the significant parameter in classifying boys into 1 of 3 groups including inguinal hernia, undescended testis, and hydrocele with a 70.2% success rate. CONCLUSIONS Inguinal canal that shows a linear growth after 24 months of age is longer in boys. Caliber is not the unique factor that determines the clinical outcome. Although the ratio of length of inguinal canal to the circumference of the sac defines the clinical picture best, even this parameter cannot classify the cases correctly. Therefore, some factors in addition to the caliber and length of inguinal canal might have roles in determining the clinical outcome.
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Affiliation(s)
- F C Tanyel
- Department of Pediatric Surgery, Hacettepe University, Faculty of Medicine, Ankara, Turkey
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