Inguinal herniation of a transplant ureter: rare cause of obstructive uropathy

We present a rare case of late renal allograft failure from ureteral obstruction resulting from inguinal herniation. A 72-year-old man presented with an elevated creatinine and hydroureteronephrosis of a transplanted kidney on ultrasound. Noncontrast computed tomography demonstrated an inguinal hernia containing ureter, and a nephrostomy tube was placed. The hernia and ureter were temporarily reduced during antegrade stent insertion. Creatinine normalized and we performed inguinal herniorrhaphy with polypropylene mesh. The ureter was not reimplanted. Renal function remained stable after nephrostomy tube removal. Simple herniorrhaphy without ureteral reimplantation may fix the case of ureteral obstruction from inguinal herniation.     

Inguino-scrotal herniation of the ureter containing stones

Background

Inguino-scrotal herniation of the ureter is a rare and difficult situation for a surgeon, especially if only recognized during inguinal hernia repair.

Methods

An 83-year-old gentleman, with a previous history of radiation treatment for squamous anal cancer, presented with a large left inguinoscrotal hernia causing occasional pain at the base of the scrotum. Follow-up, post-radiation therapy CT scan showed a hernia sac containing the bladder and large bowel. Calcifications in the sac were interpreted as bladder stones, in keeping with the history of left renal calculi.

Results

During hernia repair careful dissection revealed a herniated portion of the left ureter located alongside a large hernia sac, complicated by ureteral calculi. Following stones extraction and ureteral repair, hernia repair with mesh was successfully accomplished. Pathogenesis of ureteric herniation is reviewed.

Conclusion

A herniated ureter is potentially a source of serious renal or ureteral complications. When discovered, ureteric hernias should be surgically repaired. If preoperative detection of a ureter herniation alongside an inguinal hernia is missed, awareness of the existence of this condition may help avoid iatrogenic ureteral damage injury during a complex hernioplasty. Documentation of unexplained, sizeable and distinct calcifications in an inguino-scrotal hernia sac, particularly in a patient with a history of urolithiasis, may suggest the presence of a herniated, calculus-filled ureter. In such cases, retrograde pyelograms may be considered for a definitive diagnosis prior to surgery.

     

Transverse colon diverticulitis simulating inguinal hernia strangulation: a first report

BACKGROUND: Strangulation is the most serious complication of inguinal hernia. Diverticulitis, a common condition, is usually localized in the left colon. The association of complicated inguinal hernia and diverticulitis is rare. METHODS: We report the case of a 73-year-old male patient who presented with a suspicion of strangulated inguinal hernia. RESULTS: CT and operative findings showed transverse colon diverticulitis lodged in an incarcerated inguinal hernia without signs of strangulation. Surgical hernia repair was undertaken while the treatment of diverticulitis was conservative. Follow-up was uneventful. CONCLUSION: This is a first report of documented transverse colon diverticulitis simulating inguinal hernia strangulation.     

Inverted papilloma of ureter: a rare cause of hydronephrosis

A case of hydronephrosis with a rare underlying cause in a 35 years old male is described. He reported with pain in the left lumbar region with a past history of left ureterolithotomy. The ultrasound and IVU studies were suggestive of left hydronephroureter. CT Scan showed left hydronephroureter with narrowing at the lower end of left ureter. Ureterorenoscopy (URS) confirmed polypoidal lesions in the left lower ureter, completely obliterating the lumen and involving the whole circumferential wall of the lower ureter. The biopsy of the lesion revealed an inflammatory polyp. Accordingly open surgical intervention was planned. Excision of the lower third of left ureter with ureteric reimplantation was done with a Boari flap. The histopathology report of the lower third of ureter confirmed inverted papilloma of ureter. The patient made a smooth postoperative recovery.     

Intrascrotal herniation of the ureter

We describe one case of intra-scrotal hernia of the right ureter. The anomaly was recognized on a pre-operatory urogram. It was an extra-peritoneal ureteral hernia. There are two types of ureteral hernia: the para-peritoneal hernia with a peritoneal sac; the extra-peritoneal type with only a fatty hernia. The mecanism of the latter illustrated by our case is a prolapse of the retro-peritoneal fat. It is not possible to practice an urogram before the cure of every inguinal hernia, so the prevention in this rare situation of the damage of ureter is to be cautious in the resection of huge lipomas and sliding fat when operating on inguinal hernias.     

Circumcaval ureter with synchronous ipsilateral transitional cell carcinoma of the renal pelvis and the urinary bladder: Report of a case and review of the literature

We report a case of concomitant transitional cell carcinoma (TCC) in a circumcaval ureter and invasive bladder cancer. The diagnosis was based on the findings of excretory urography (IVU) and contrast-enhanced computed tomography (CT). IVU showed a typical J-shaped deformity in the dilated right proximal ureteric segment with moderate hydronephrosis and a filling defect in the renal pelvis, while abdominal CT with contrast showed right hydronephrosis with an intrapelvic tumor. The patient underwent radical cystoprostatectomy and nephroureterectomy. No recurrence was detected after 12 months of follow-up.     

Internal supravesical hernia repaired via the anterior approach alone: A case report

IntroductionInternal supravesical hernia is one of the rarest types of inguinal hernia. The hernial orifice is surrounded by the transverse vesical fold, median umbilical fold, and medial umbilical fold.Presentation of caseA 75-year-old male presented with lower abdominal pain and nausea. Plain abdominal CT showed that the bladder was suppressed by small bowel near the left internal inguinal ring. A part of the small bowel wall seemed to be inlaid, and so the patient was diagnosed with a strangulated left inguinal hernia. The hernia repair operation was performed via the anterior approach. There was no internal hernial sac found, but there was a walnut-sized mass in the properitoneal space. A diagnosis was made intraoperatively of internal supravesical hernia with strangulated small bowel. Small bowel resection and hernial orifice closure were performed.DiscussionAlthough internal supravesical hernia can present with distinctive CT findings, preoperative diagnosis is extremely difficult. Internal supravesical hernia in previous reports has been repaired via open laparotomy or laparoscopic surgery; however, we successfully repaired this intraoperatively-diagnosed internal supravesical hernia by the anterior approach alone.ConclusionThe patient with internal supravesical hernia diagnosed intraoperatively could be treated via the anterior approach alone successfully. Depending on the situation, the anterior approach can be an option.     

Elective laparoscopic surgery for sigmoid colon carcinoma incarcerated within an inguinal hernia: report of a case

Primary colon carcinoma within an inguinal hernia sac is very rare and most reported cases were found at emergency open surgery for an incarcerated hernia. We report a case of incarcerated sigmoid colon carcinoma diagnosed preoperatively and treated with elective laparoscopic surgery. A 67-year-old man with a 2-year history of swelling of the scrotum and a breast lump was referred to us for surgical treatment of an irreducible left inguinal hernia and a right breast tumor. Blood examination results showed severe anemia. Computed tomography scan and endoscopic biopsy confirmed sigmoid colon carcinoma incarcerated in the left inguinal hernia. Thus, we performed definitive laparoscopic sigmoidectomy and conventional hernia repair for preoperatively diagnosed sigmoid colon carcinoma within an inguinal hernia.     

Inguinal hernia of seminal vesicle cyst

Seminal vesicle cysts are uncommon abnormalities in the pelvis. The case of a seminal vesicle cyst that extended through the inguinal canal is reported. A 35-year-old man presented with left inguinal swelling. He was diagnosed with a left inguinal hernia. However, the interpretative diagnosis was a spermatic cord tumor. The operation was changed to tumor resection. The tumor existed along with the vas deferens from part of the parietal peritoneum outside the inguinal tunnel to the deep pelvic space. The cylinder-shaped tumor was 3 cm in diameter and 20 cm long. Pathological examination revealed a seminal vesicle cyst that extended through the inguinal canal. To the best of our knowledge, this is the first case report of a seminal vesicle cyst inguinal hernia.     

Inguinal hernia of the bladder. Report of 6 cases]

The authors report 6 cases of inguinal hernia of the bladder seen between 1976 and 1996. All patients were males with a mean age of 67 years (range: 53 to 80 years). The hernia was situated in the right groin in all patients. No patients presented any suggestive clinical features. In 5 patients, the diagnosis was established by IVU, indicated for another disease associated with the hernia and, in one patient, the hernia was discovered after an operative wound to the bladder. Treatment consisted of elimination of bladder neck obstruction in 3 patients and reintegration of the bladder and abdominal wall repair in 4 patients. The postoperative course was uneventful.     

When a hernia is not a hernia: the evaluation of inguinal hernias in the cirrhotic patient.

Herniorrhapy in patients with advanced portal hypertension and ascites should be approached with caution, and treated conservatively whenever possible. Cirrhosis increases the risk of significant perioperative complications such as infection, recurrence, and ascites leak. This paper reports two patients operated on for suspected inguinal hernias. The first patient was referred for elective repair of a presumed inguinal hernia before liver transplantation. The second patient presented with a history of an incarcerated inguinal hernia that was previously reduced in the emergency center. After examination by residents and senior faculty the patients were scheduled for elective herniorrhaphy. Intraoperatively no inguinal hernia could be identified in either patient. However, massively dilated veins (1.5-2.0 cm in diameter) were noted entering with the spermatic cord at the internal inguinal ring. In both cases the veins were clamped, transected, and suture ligated at the internal ring. Given the unusual presentation of these dilated veins in both patients we advocate the use of preoperative Doppler ultrasound in patients with cirrhosis and suspected inguinal hernias.     

Laparoscopic finding of chylous ascites and intestinal malrotation in an infant presenting with left inguinal hernia

This case report illustrates an unexpected advantage of using the laparoscopic approach for inguinal hernia repair in infants. In this paper, we report an infant referred to us with a diagnosis of an irreducible left inguinal hernia. He presented with a 1-day history of bilious vomiting and poor weight gain on breastfeeding. On arrival, a reducible left inguinal hernia was found and he was scheduled to have a laparoscopic inguinal hernia repair. During laparoscopy, chylous ascites was noted and the transverse colon and appendix could not be visualized. This raised the suspicion of malrotation with obstruction, which was confirmed on an upper gastrointestinal contrast study. He was taken back to the operating theater and a malrotation with volvulus was confirmed at laparotomy. A Ladd's procedure was performed, and he made an uneventful recovery.     

Laparoscopic treatment of a carcinoma of the cecum incarcerated in a right groin hernia: report of a case

A carcinoma in a groin hernia is uncommon. We herein report a case of an intrasaccular carcinoma of the cecum in a right inguinoscrotal hernia with a simultaneous left inguinal hernia treated by a laparoscopic approach. A 70-year-old man presented with a painful, not completely reducible bilateral hernia. Blood examinations showed severe anemia. A computed tomography scan of the abdomen confirmed the presence of the cecum in the hernia sac, showing a round wall thickening of the herniated portion of the colon. A standard laparoscopic right colectomy with radical oncological purpose was performed. An incarcerated inguinal hernia is a relatively common surgical problem. In the case of anemia or other signs suggestive of malignancy, a specific preoperative work-up should be assessed. This case demonstrates that it is possible to perform an oncologically correct laparoscopic resection when the presence of malignancy is confirmed while performing an open traditional hernioplasty to avoid any possible contamination of the mesh.     

Atypical Mondor's disease mimicking a strangulated Spigelian hernia in a patient with a deep venous obstruction. A case report

Mondor's disease is a rare entity characterised by thrombophlebitis of the subcutaneous veins of the anterolateral thoraco-abdominal wall. The condition is usually benign and self-limiting. We report on a case of an inguinal localization of the disease, occurring on a dilated superficial epigastric vein acting as a collateral pathway due to a left ilio-femoral venous obstruction. The patient was referred to our department with a diagnosis of strangulated Spigelian hernia. General physical examination and ultrasonographic studies ruled out a complicated abdominal hernia and the presence of malignant disorders. A diagnosis of inguinal Mondor's disease in association with a chronic deep venous obstruction of the left ilio-femoral venous axis was made. The patient was treated with conservative therapy. Warfarin was promptly started in order to impede progression of the thrombotic process to the ipsilateral great saphenous vein. Though atypical Mondor's disease is usually a benign, self-limiting process, it can cause unusual clinical patterns that might give rise to clinical dilemmas for the surgeon.     

Left inguinal appendix in an HIV patient: A case report and review of literature

INTRODUCTIONThe presence of the appendix in an inguinal hernia sac is rare, with an estimated incidence of 0.51–1% of all inguinal hernias. An inguinal appendix is most commonly referred to as Amyand's hernia.PRESENTATION OF CASEA 59-year-old HIV positive male presented to our center with a left painful inguinal mass. The preoperative diagnosis was a left inguinal hernia. Intraoperatively, the sac was found to contain a non inflamed appendix; the appendix was reduced back to the peritoneal cavity and the patient underwent a tension free prosthetic left inguinal hernia repair.DISCUSSIONMost cases of inguinal appendices are right-sided and are diagnosed intraoperatively; left-sided cases as we encountered are rare and most likely the result of cecal mobility. Preoperative diagnosis of the entity is difficult and most cases are diagnosed intraoperatively. A CT scan is not necessary unless other pressing differentials need to be ruled out. Most authors agree that if the appendix is not inflamed, appendectomy, concurrently with herniorrhaphy, should not be performed to avoid perioperative septic complications.CONCLUSIONSurgical management of inguinal appendices carries a risk of septic complications. This is especially pertinent to our case, considering the immunocompromised status of our patient. The decisions in the operating room were geared toward limiting septic potential.     

Primary megaureter which showed aplasia of the muscle bundles on all dilated portions: a case report

A case of primary megaureter in a 59-year-old man which might shed light on the etiology and pathology is described. Intravenous urography and the computed tomography showed a left marked hydro-nephro-ureter which compressed the bladder and right ureter. In the left ureter, dilated portions stretched beyond dilated portions; that is, five non-dilated portions lay among four dilated portions. On histological examination of this specimen, all dilated portions showed aplasia of muscle in which muscle bundles were not observed, while all non-dilated portions including ureterovesical junction showed normal muscle layers. A case presentation and brief review of the literature were made.     

Inguinal hernia containing a kidney with a duplicated system: An exceptionally rare case

An inguinal hernia is a commonly encountered surgical case, with multiple unusual contents being reported. We present an exceptionally rare case of an inguinal hernia. Computed tomography imaging of the 62‐year‐old male patient showed a large left inguinal hernia extending into the left scrotum that contained a duplicated left kidney. There was an associated large left hydrocele and incidental non‐obstructive nephrolithiasis. Left nephropexy, left orchiectomy, and repair of the incarcerated left inguinal hernia with mesh placement via a preperitoneal (retroperitoneal) approach were performed. The patient was discharged to home on post‐operative day 5 and the post‐operative course was uneventful. We discuss a possible mechanism for this rare event.     

成人先天性巨输尿管症(附35例报告)

目的：探讨成人先天性巨输尿管症的诊治特点，方法：35例成人先天性巨输尿管症，其中左侧14,全然中侧11例，双侧10例，所有病例均行B超，IVU检查，手术治疗31例39侧，其中肾输尿管切除术12例，输尿管剪裁整形或折叠后行输尿管膀胱再植术27例，结果：29例获得随访，随访时间1－5年，术侧肾输尿管积水37侧减轻，2侧无明显变化。结论：B超，IVU检查是成人先天性巨输尿管症的首先检查方法。治疗本症的原则是解除梗阻，尽量保留肾功能，手术方式是输尿管剪裁或折叠加输尿管膀胱吻合术，肾功能良好者也可保守治疗。     

成人先天性巨输尿管症37例诊疗分析

目的：探讨成人先天性巨输尿管症（CM）的诊治方法.方法：回顾性分析37例成人CM的临床资料：男18例,女19例.左侧18例,右侧10例,双侧9例.超声检查、静脉尿路造影（IVU）检查提示输尿管全段扩张伴肾盂积水22例,输尿管下段扩张9例.IVU不显影或显影不清13例;同位素肾动态显像检查提示患肾不同程度损害.手术治疗34例,其中行肾输尿管切除术2例,输尿管膀胱再植术32例.间断性双J管置入1例,保守观察2例.结果：随访32例,随访时间4个月～20年.患侧肾输尿管积水减轻29例,无明显变化3例.结论：成人CM的诊断主要依据影像学检查.治疗原则为解除梗阻、尽量保留息肾功能,应根据输尿管扩张程度选择输尿管折叠或裁剪加输尿管膀胱再植术,吻合方法推荐Lich-Gregoir术式;肾功能良好、无明显症状者可保守治疗.     

Vesical calculus formation on non-absorbable sutures used for open inguinal hernia repair

INTRODUCTION

Iatrogenic injuries to the urogenital tract are rare, with the bladder being the organ most affected. We describe a case of a vesical calculus that formed on non-absorbable sutures that were used to repair an inguinal hernia.

PRESENTATION OF CASE

A 45-year-old male presented with frank haematuria and dysuria 2 years following an open left inguinal hernia repair. A CT urography showed a vesical calculus adherent to the left anterio-lateral wall of the bladder. Cystoscopy revealed that the calculus formed on non-absorbable sutures. Cystolapaxy was performed followed by cystoscopic excision of the sutures. The patient''s post-operative course was uneventful.

DISCUSSION

Foreign bodies in the urinary bladder always act as a nidus for formation of a calculus. Iatrogenic bladder injuries are common during hernia repair. It is however rare for sutures used to repair an inguinal hernia to involve the urinary bladder wall. The patient most likely had a full bladder at the time of hernia repair or the bladder was part of the contents of the hernia sac.

CONCLUSION

This case illustrates the need to ensure that the bladder is empty prior to pelvic surgery and for surgeons to have a good understanding of inguinal anatomy to avoid injuring the contents of the hernia sac.