疝环充填式无张力修补术治疗老年腹股沟疝治疗体会

目的总结疝环充填式无张力修补术治疗老年腹股沟疝的临床经验。方法回顾性分析我院2001年10月至2007年11月应用疝环充填式无张力修补术治疗56例老年腹股沟疝的临床资料。结果疝环充填式无张力修补术操作简便,术后恢复快,并发症少。复发率低。结论疝环充填式无张力修补术是治疗老年腹股沟疝的理想方法,操作简便,值得基层医院推广。     

Re-recognizing the pathogenesis of inguinal hernias

Over the past century, there has been a significant increase in the understanding of groin anatomy as it is related to inguinal hernia. But no one really knows the function of iliopsoas in sealing the inguinal canal and promoting defecation in squatting position. This paper presents the hypothesis that iliopsoas plays an important role in iliopsoas-abdominal reflex by strengthening the groin region, and thus offers a new insight into the study of the pathogenesis of groin hernia and defecation in the aged. This discovery may explain why squatting instead of sitting is better for defecation and urination and why the elderly males are more susceptible to groin hernia. Moreover, the colorectal disease might also benefit from this discovery.     

Percutaneous fine-needle aspiration biopsy in malignant lymphoma: a case report of an unusual cytologic presentation

A case of an elderly Hispanic male who presented with clinical findings suspicious for lymphoma and cytologic evidence suggestive of carcinoma is presented and discussed. Percutaneous fine-needle aspiration biopsy of a group of mesenteric lymph nodes and a pleural fluid specimen showed clusters of tumor cells suggestive of carcinoma. Electron microscopic analysis of the pleural fluid showed comparable clusters of tumor cells, which proved to be lymphoma cells enveloped by macrophages. Histologic, electron microscopic, and histocytochemical examination of an enlarged inguinal lymph node confirmed the diagnosis of lymphoma with several alpha-naphthyl acetate esterase-positive macrophages interspersed among the tumor cells. To date, the phenomenon of macrophages enveloping lymphoma cells, so as to simulate tumor cell clustering, has not been reported. It is, however, an important possibility to keep in mind with cytologically distinguishing a lymphoma from a carcinoma.     

The iliopubic tract: an important anatomical landmark in surgery

A band of fascial thickening, termed the iliopubic tract, lies on the posterior aspect of the inguinal region and has been described in the surgical literature as playing an important role during herniorraphy. This study was undertaken to examine the gross and microscopic anatomy of the iliopubic tract in 12 cadavers. The results confirmed that the iliopubic tract can be readily identified as a thickening of the transversalis fascia running deep and parallel to the inguinal ligament. It attaches to the superomedial part of the pubic bone medially, but laterally its fibres fan out within the fascia transversalis and fascia iliaca without bony attachment to the iliac spines. In contrast to the inguinal ligament, the histological analysis of the iliopubic tract shows a high elastin to collagen ratio. The functional signficance of this structure merits further study, but there is no doubt that it is important in many approaches to inguinal herniorraphy. For this reason it is considered that the iliopubic tract deserves greater emphasis in the anatomy teaching of the inguinal region.     

Lateral femoral cutaneous neuralgia: an anatomical insight

A detailed anatomic study was carried out on the lateral femoral cutaneous nerve to better understand the etiology and treatment of lateral femoral cutaneous neuralgia. As it passed from the pelvis into the thigh, the lateral femoral cutaneous nerve ran through an "aponeuroticofascial tunnel," beginning at the iliopubic tract and ending at the inguinal ligament; as it passed through the tunnel, an enlargement in its side-to-side diameter was observed, suggesting that the fascial structures proximal to the inguinal ligament may be implicated in the genesis of lateral femoral cutaneous neuralgia. The finding of pseudoneuromas at this location, distant from the inguinal ligament, supports this hypothesis. The anterior superior iliac spine is located approximately 0.7 cm from the lateral femoral cutaneous nerve and serves as the bony landmark for nerve localization. Within the first 3 cm of leaving the pelvis, the lateral femoral cutaneous nerve was observed deep to the fascia lata; therefore, surgical dissection within the subcutaneous fascia may be conducted with relative impunity near the anterior superior iliac spine just inferior to the inguinal ligament. In 36% of cases there was no posterior branch of the nerve, which is correlated to lateral femoral cutaneous neuralgia symptoms often being limited to the anterior branch region. An accessory nerve was found in 30% of cases.     

改良Lichtenstein疝修补术与Lichtenstein疝修补术的对比研究

目的比较改良Lichtenstein疝修补术与Lichtenstein疝修补术手术方法,探讨更加合理的手术方式。方法回顾分析我科316例成年腹股沟疝患者,其中162例实施改良Lichtenstein疝修补术,另154例实施Lichtenstein疝修补术。结果改良Lichtenstein组与Lichtenstein组平均手术时间30 min,改良Lichtenstein组无复发病例,Lichtenstein组复发5例,两组住院时间无差别,均未见睾丸萎缩。结论改良Lichtenstein修补腹股沟疝是目前较理想的术式之一,复发性腹股沟疝和老年高危患者应首选改良Lichtenstein术式。     

The usefulness of mouse breast tumor models for testing and optimization of breast cancer vaccines at old age

Cancer is an age-related disease and with the graying of the society, there is an increasing need to optimize cancer management and therapy for application in elderly patients. Cancer vaccines that can be applied in both prevention and therapy are potentially less toxic than chemotherapy or radiation and could, therefore, be especially suitable for older more frail cancer patients. In this study, we used syngeneic metastatic (4TO7) and non-metastatic (64pT) breast tumor models to obtain valuable information on the potential usefulness of MAGE-encoding cancer vaccines in metastatic and non-metastatic breast cancer at old age. First, we tested a mouse Mage-b DNA vaccine in young mice and found a significant preventive effect on the development of metastases. However, little effect was observed on primary breast tumors. Second, we studied tumor progression in relation to aging and found significant smaller tumors in old compared to young mice. This was associated with an increase in the percentage of CD8(+) T cells in the inguinal lymph nodes at the site of the tumor at old age. These findings suggest that breast cancer immunotherapeutic approaches could be a valid strategy even in elderly patients.     

Acute appendicitis in an incarcerated inguinal hernia.

A preterm infant with acute appendicitis in an incarcerated inguinal hernia is described. We suggest that extraluminal compression of the neck of a hernial sac caused by incarceration may be a predisposing factor for appendicitis.     

Cytomegalovirus Enteritis Causing Ileal Perforation in an Elderly Immunocompetent Individual

Cytomegalovirus (CMV) infection is usually subclinical in immunocompetent individuals, however it can be life threatening in an elderly immunocompetent individual. We report a case of CMV enteritis causing ileal perforation in a physically active elderly man. An 88-year-old healthy man presented with abdominal pain and diarrhea. After initial conservative treatment, emergency laparotomy was performed for ileal perforation. The diagnosis of CMV enteritis was based on histological findings revealing many large cells with CMV inclusion bodies in the surgical specimen. In elderly individuals, even though they are immunocompetent, CMV enteritis may result in major complications such as bowel perforation, and it should be included in the differential diagnosis of diarrhea if it is resistant to conventional treatment.     

Cytology of primary vaginal melanoma: An unusual report on fine needle aspiration

Primary malignant melanoma of the vagina is an extremely uncommon malignancy comprising of less than 10% malignancies of the female genital tract and 0.3% of all melanomas. Melanoblasts are neural crest derivatives and are notorious for causing primary cutaneous neoplasms. However, they involve virtually every organ of the body including eye, intestines and ocular mucosa, probably due to aberrancies in cell migration. Vagina is a rare site and primary melanoma of the vagina occurs in postmenopausal women with vaginal discharge, bleeding, or mass as common presenting complaints. Only a handful of case reports are available describing this entity on biopsy and PAP smear samples; however, fine needle aspiration has seldom been discussed. In the present report we discuss a case of an elderly female who complained of mass protruding through the vaginal opening, FNAC was done from the mass as well as from the right inguinal lymph node. An extensive clinicoradiological workup, and immunohistochemical confirmation is essential to rule out metastatic lesions and confirm primary. Diagn. Cytopathol. 2017;45:252–256. © 2016 Wiley Periodicals, Inc.     

Incidental perivascular epithelioid cell tumor in an inguinal hernia sac

Perivascular epithelioid tumors (PEComa) are uncommon mesenchymal neoplasms demonstrating positivity for muscular and melanocytic immuno-markers. Included in this category are angiomyolipoma, lymphangioleiomyomatosis, and clear cell sugar tumors. Lesions which do not fit into these categories are classified as “not otherwise specified”. We present a case of an incidentally discovered PEComa within inguinal hernia sac contents in a 70-year-old woman. It consisted of spindled and epithelioid cells with bland oval nuclei, small nucleoli and clear to light eosinophilic cytoplasm. There was no atypia or mitoses. The lesion was strongly positive for HMB45 and smooth muscle actin. Pelvic soft tissue and peritoneal PEComas are rarely reported in literature and very little is known about their prognosis. We discuss the immunohistochemistry, differential diagnosis, and pathogenesis of PEComas.     

The development of the gubernaculum and inguinal closure in the marsupial Macropus eugenii

This study reports the developmental anatomy of testicular descent and inguinal closure of the tammar wallaby (Macropus eugenii) from birth to maturity. In females the ovary migrated caudally between days 10 and 20 after birth. The gubernaculum differentiates into the round ligament in the abdomen and extra-abdominally as the ilio-marsupialis muscle of the mammary glands. In males the testes migrated to the internal inguinal ring by day 20 post partum (pp), coinciding with the enlargement of the gubernaculum, and from the internal inguinal ring to the scrotum between days 20 and 65 pp. During descent there was an increase in the hyaluronic acid concentration in cells of the gubernaculum and scrotum. Development of the cremaster muscle began by day 10 pp on the periphery of the gubernaculum and its basic structure was completed by day 60 pp. After descent the inguinal canal closed between days 50 and 60 pp, but a small irregular lumen persisted, somewhat similar to that seen in the congenital scrotal hydrocoele of humans. Tammars have a hopping mode of locomotion and, like humans, are essentially bipedal. We suggest that inguinal closure evolved in these two species because their upright posture may otherwise lead to a high incidence of inguinal hernias.     

Thoracolumbar compression fractures presenting with an acute ileus

Corticosteroids are commonly used in the treatment of connective tissue diseases such as systemic lupus erythematosus. Although they are usually efficacious, osteoporosis leading to spine compression fractures is not uncommon. In this case report, we describe an elderly patient with systemic lupus erythematosus on long-term corticosteroid therapy who presented with symptoms of acute abdomen with minimal low back symptoms. No intraabdominal process was found by abdominal studies and exploratory laparotomy. Increased lower back symptoms led to further skeletal spine studies, which initially demonstrated a compression fracture at the twelfth thoracic (T12) vertebra. Later, a T8 and a fourth lumbar (L4) compression fracture were also found. Her abdominal and lower back symptoms resolved on conservative therapy. Although the rate of these occurrences are unknown, compression spine fractures should be considered in elderly patients presenting with acute abdomen after being on long-term corticosteroid therapy.     

Sclerosing extramedullary hematopoietic tumor presenting as an inguinal mass in a patient with primary myelofibrosis: a diagnostic pitfall

Sclerosing extramedullary hematopoietic tumor (SEMHT) is a rare lesion and presented as retroperitoneal or serosal-based mass. A 53-year-old man with a long history of primary myelofibrosis, presented with abdominal distension and inguinal mass. Pathologic examination of inguinal mass revealed a prominent sclerotic background with thick collagen deposits and mono, bi, or tri-lineage hematopoietic tissue containing atypical megakaryocytes and variable proportions of myeloid and erythroid series. The atypical megakaryocytes were positive for Factor VIII and CD61. SEMHT may be misdiagnosed as lymphocyte depleted Hodgkin’s disease, as a mesenchymal neoplasm, or as carcinoma, because of the presence of large atypical cells and marked fibrosis when clinical information regarding PMF is unknown. Awareness of the bizarre atypical megakaryocyte morphology with immature hematopoietic cells and of clinical history is essential to prevent misdiagnosis.     

Surface marking of the deep inguinal ring

The surface marking of the deep inguinal ring (DIR) is commonly described as being located at either the middle of the inguinal ligament (MIL) or at the mid-inguinal point (MIP); there seems to be no consensus in previous studies in patients with inguinal hernias. The present study was carried out to determine a more accurate location of the DIR in individuals without inguinal hernias. Fifty-two cadavers without inguinal hernias were dissected and the positions of the DIR, MIL, MIP and femoral artery (FA) were determined. The mean distance from the anterior superior iliac spine (ASIS) to the DIR was 62 mm, where as the mean distance from the ASIS to the MIL, MIP, and FA were 55, 66, and 65 mm, respectively. The study showed that in individuals without inguinal hernias the DIR did not correspond to the MIL or MIP, but rather to an area between these two landmarks. The surface marking of the DIR may be best described as at the mid-inguinal region.     

Reduction en-masse of inguinal hernia with strangulated obstruction

"Reduction en masse of inguinal hernia" means reduction/migration of a hernial sac into the properitoneal space. We report the CT findings in a case of reduction en masse with strangulated obstruction. CT scan demonstrated a hernial sac with fibrous constriction band at the neck, situated in the properitoneal space superior to the inguinal region, causing closed-loop obstruction. The hernial sac contained thickened bowel loop with wall enhancement and fluid suggestive of incarceration/strangulation. We propose to call this, 'The properitoneal hernial sac sign', defined as "Presence of a hernial sac in the properitoneal space (and not in the inguinal/femoral canal) containing an obstructed/incarcerated bowel loop and causing small bowel obstruction" to identify "reduction en masse of inguinal hernia".     

Fine-needle aspiration cytology of metastatic squamous-cell carcinoma arising in a pilonidal sinus, with literature review.

Fewer than 50 cases of carcinoma arising in a pilonidal sinus have been reported, with only 5 patients having documented inguinal lymph node metastases. This is the first report of the fine-needle aspiration (FNA) diagnosis of this uncommon clinical situation of squamous-cell carcinoma arising in a pilonidal sinus, metastatic to an inguinal lymph node. We report on a 59-yr-old male with squamous-cell carcinoma arising in a pilonidal sinus who presented with inguinal adenopathy. FNA biopsy of a lymph node was performed, resulting in a diagnosis of metastatic squamous-cell carcinoma. FNA biopsy is useful in the evaluation of patients with inguinal adenopathy and a history of malignancy arising in a pilonidal sinus. The possibility of this rare complication should also be considered when metastatic squamous-cell carcinoma to an inguinal lymph node is diagnosed by FNA cytology in patients having an unknown primary except for a change in a long-standing pilonidal cyst.