The secondary external inguinal ring and associated fascial planes: surgical anatomy, embryology, applications

Classically, two inguinal rings are defined: internal and external. We previously introduced a third one, the secondary internal inguinal ring, deep to the classic internal. Here, we present a fourth ring, the secondary external inguinal ring, initially described by McGregor (Surg Gynecol Obstet 49:273–307, 1929), but now forgotten. Embryologically, this ring may be formed by evagination of Scarpa’s fascia during testicular descent. Anatomically, it is located 2 cm below the pubic tubercle. It is formed by Scarpa’s fascia that covers the spermatic cord anteriorly; medial and lateral fascial reflections delineate the ring and form the spermatic cord canal. The cord is attached to the posterior wall of the canal. The canal ends at the entrance of the scrotum, where Colles’ fascia fuses with coverings of the cord. Adjoining the secondary external ring, at the same surgical layer and communicating with the subcutaneous abdominal space, are four subcutaneous pouches: laterally, the superficial inguinal pouch; medially, the perineal, femoral, and pubic pouches. Surgically, an inguinoscrotal hernia passes though the secondary external ring and obtains an extra outer layer by entering the spermatic cord canal. Underdevelopment of the ring leads to incomplete testicular descent or ectopic testis. We recommend reconstruction of Scarpa’s ring after orcheopexies and herniotomies in children. After urethral rupture distal to the urogenital diaphragm, urine may fill the subcutaneous abdominal space, pouches, and scrotum, due to their communication around the secondary external ring. In females, this ring was not found, possibly because of the non-descent of the ovaries through (and beyond) the inguinal canal.     

THE GENITOFEMORAL NERVE MAY LINK TESTICULAR INGUINOSCROTAL DESCENT WITH CONGENITAL INGUINAL HERNIA

The genitofemoral nerve (GFN) hypothesis for inguinoscrotal testicular descent proposes that calcitonin gene-related peptide (CGRP), released from the genitofemoral nerve, controls the migration of the gubernaculum from the inguinal region to the scrotum between 26 and 40 weeks of gestation. The processus vaginalis provides a channel through which the testis descends from the abdomen to the scrotum. Following descent of the testis the processus vaginalis undergoes luminal obliteration and disappearance between the internal inguinal ring and the upper pole of the testis. The mechanism underlying closure of the processus is unknown and failure for it to occur normally results in congenital inguinal hernia, scrotal hydrocele and possibly even an ‘ascending’ testis. Recent work in our laboratory suggests that CGRP, released from the genitofemoral nerve, may cause fusion and disappearance of the processus vaginalis. We propose that abnormalities in the GFN link a spectrum of disorders encompassing congenital undescended testis, inguinal hernia, scrotal hydrocele and ascending testis.     

An inguinal hernia with cryptorchidism with a Leydig cell tumor in an elderly man: A case report

IntroductionCryptorchidism is common in children but is rare in the elderly. It often presents with a constellation of signs and symptoms similar to routine inguinal hernias. We present the case of an elderly man with cryptorchidism containing a Leydig cell tumor and provide clinical insights.Presentation of caseAn-84-year old man was admitted with an incarcerated right lower quadrant hernia. Both testes were absent on palpation of the scrotum. After reduction of the hernia, computed tomography scan revealed a round lesion in the hernia sac, which was suspected to be the ectopic testis. Laparoscopic exploration was performed in combination with an open anterior approach. The hernia orifice was the right internal inguinal ring, and the inguinal canal was obliterated by adhesions because the spermatic cord did not pass through it. The ectopic testis was resected with the hernia sac, and the hernia repaired with a KUGEL™ patch (Bard, USA).DiscussionLaparoscopic exploration was useful to delineate the anatomy of this unusual inguinal hernia. The open anterior approach was necessary to dissect the ectopic testis and the hernia sac. Pathological findings revealed tumor cells with clear cytoplasm in the resected testis, diagnosed as a Leydig cell tumor.ConclusionThe combination of laparoscopic and anterior approaches facilitated the surgical treatment of an unusual inguinal hernia with cryptorchidism. The resected ectopic testis should undergo thorough histopathologic examination.     

A simple technique of laparoscopic full-thickness anterior abdominal wall repair of retrosternal (Morgagni) hernias

Background/Purpose: Previous reports of laparoscopic repair of Morgagni hernias in children have involved relatively complex laparoscopic techniques. This report describes a simpler method of repair that we have applied to 4 children. Methods: Four children with retrosternal (Morgagni) hernias underwent primary laparoscopic repair by placement of interrupted synthetic nonabsorbable sutures through the full-thickness of the anterior abdominal wall, incorporating the posterior rim of the defect and returning back out through the anterior abdominal wall, with the sutures tied in the subcutaneous tissue. Results: The children, ranging in age from 11 to 36 months, underwent laparoscopic repair of their Morgagni hernias and had an uneventful postoperative recovery, apart from a port site hernia in one. Conclusions: This technique for primary laparoscopic repair of Morgagni hernia is easy to perform, well tolerated by the patient, and gives excellent cosmetic results. Laparoscopic closure of the defect by suturing the posterior rim of the hernia to the full thickness of the anterior abdominal wall would appear to provide a safe and effective means of repairing this type of hernia. J Pediatr Surg 38:768-770. [copy ] 2003 Elsevier Inc. All rights reserved.     

Sliding appendiceal inguinal hernia with a congenital fibrovascular band connecting the appendix vermiformis to the right testis

It is not uncommon to find the appendix vermiformis within a hernia sac; however, sliding appendiceal inguinal hernia is rare. A 9-month-old boy with an incarcerated right scrotal hernia is presented in this case report. Although the hernia was reduced through a conservative approach, appendix vermiformis remained in the hernia sac because of its attachment to the upper pole of the right testis. Exploratory surgery during the inguinal hernia repair revealed a connecting band that extended from the appendix vermiformis into the scrotum and attached to the right testicle. Histologic examination showed that the band was congenital. After reduction of an incarcerated hernia, the persistence of a thickened or a cord-like structure is a warning for the presence of a sliding hernia. We suggest that this uncommon developmental anomaly is likely to cause the processus vaginalis to remain patent, thus facilitating hernia formation. Electronic Publication     

Spigelian–cryptorchidism syndrome in an adult male complaining of primary infertility: Case report

History of cryptorchidism is present in about 10% of infertile patients seeking medical help, whereas 20% of them are azoospermic. Most of the patients with bilateral cryptorchidism have a low testicular volume and high serum FSH level. Ectopic testes are present only in 5% of the patients with cryptorchidism. The anterior abdominal wall is a rare site for ectopic testis where Spigelian hernia is usually accompanied. We present a case of bilateral ectopic anterior abdominal wall testes associated with Spigelian hernia on the left side.     

Torsion of the hernia sac within a hydrocele of the scrotum in a child

Torsion of the hernia sac is a rare disease that presents as acute scrotum in children. Including the present case, only six cases have been reported in the English literature. We report a 10-year-old boy who presented with pain and swelling of his right scrotum. Ultrasonography revealed a hypoechoic region adjacent to the normal right testis. The inflammatory changes of the right scrotum deteriorated. The patient underwent surgery and a necrotic cyst was recognized within a hydrocele of the scrotum. The cyst was not connected with the testis or epididymis and was twisted at an angle of 270 degrees. The cause of the necrotic cyst observed was anatomical and pathological torsion of the hernia sac.     

Gastric femoral hernia in a male cadaver with gastroptosis: case report and review of the literature

The shape and the position of the stomach and its anatomic relations to the round viscera vary from individual to individual, but they also vary in the same subject depending on many factors. The downward displacement of the stomach is called gastroptosis. In the literature, there are only five case reports where the stomach constituted the content of a femoral hernia. The current study presents a case of a gastric femoral hernia in a cadaver along with a review of the relevant literature. During routine dissection of a 67-year-old male cadaver with a very large stomach and gastroptosis, a femoral hernia containing a part of the great curvature of the stomach was found. The length of the hernia sac was 5 cm, and its width was 3.5 cm. There was a disposition of the intestinal coils to the posterior wall and the lesser pelvis. The cadaver’s former medical history and skin observation before dissection excluded any previous abdominal surgery. This is the second case of stomach herniation through the femoral ring in a male subject ever reported. The symptoms in this pathology vary from complete absence to symptoms due to high stenosis of the digestive tract, stomach strangulation and stomach wall necrosis.     

Is the vanished testis always a scrotal event?

OBJECTIVE: To determine if perinatal testicular torsion resulting in a vanished testis is an event that primarily occurs in the scrotum. PATIENTS AND METHODS: The records of 54 boys identified as having a solitary testis were reviewed. The side of absence, size of the solitary testis, method of surgical evaluation (scrotal, inguinal or abdominal), surgical findings and histology of the tissue removed were noted. RESULTS: The testis was absent twice as often on the left side, the solitary testis was hypertrophic in 25 of 42 boys in whom it was evaluated, and tissue grossly or histologically consistent with a testicular 'nubbin' was removed in 52 boys. Scrotal (47) or inguinal (seven) exploration was carried out in all. Laparoscopy (28) or abdominal exploration (two) was undertaken to confirm that no testicular tissue was present in the abdomen in 30 boys, including the two in whom no tissue was found on scrotal or inguinal exploration. CONCLUSIONS: Perinatal testicular torsion occurs after descent but before fixation of the tunica vaginalis to the scrotal wall. These testes atrophy, leaving a remnant of tissue in the scrotum that can be identified on scrotal exploration in almost all cases. Therefore, it is recommended that the evaluation of the child with a solitary palpable testis start with scrotal exploration. Laparoscopy should be reserved for those in whom no tissue consistent with a testicular nubbin is found in the scrotum.     

Anatomical findings at orchiopexy

The anatomical findings at orchidopexy for cryptorchid testis were recorded for 60 boys aged between 6 months and 18 years. In 11 patients (18.3%) bilateral cryptorchidism was present. At operation, atrophied testicular tissue was found in two patients and one testis was found to be absent; 69.1% (47/68) of the remaining testes were found in the superficial inguinal pouch at operation, 27.9% (19/68) were in the inguinal canal, one was in the femoral triangle and one was high in the scrotum. In 35 testes (51.5%) there was an associated hernial sac. In 54 testes (79.4%) the gubernaculum testis was attached to an anatomical site other than the lower scrotum. In 26 (38.2%) there was a fascial block to descent into the scrotum and one or other of these findings was present in 64 testes (94.1%). These findings suggest that failure to establish a patent route from the superficial inguinal region to the scrotum and the passage of the gubernaculum along this route are the abnormalities responsible for failure of testicular descent.     

Interstitial inguinal hernia in the infant

Two infants aged four and eight weeks required an operation for an interstitial inguinal hernia. The clinical picture of this rare form of hernia is characteristic. There is a swelling in the abdominal wall between the internal inguinal ring and the anterior superior iliac spine. In addition there is almost always an ectopic testis on the affected side. Incidence, clinical picture and anatomy of the interstitial hernia are discussed.     

腹股沟疝 UHS 手术

超普疝修补装置（ ULTRAPRO Hernia System, UHS）由上片、下片和中间连接柱构成。下片位于腹膜与腹横筋膜之间（腹膜前间隙）,覆盖整个肌耻骨孔,起到了腹膜前间隙修补的作用;将上片分别固定于腹股沟韧带和耻骨结节,加强腹股沟管后壁;中间连接柱既充填了疝环缺损,又连接和稳定了上、下片,可防止网片移位造成的复发。 UHS同时对腹膜前间隙和腹股沟管后壁进行双重修补,理论上最大限度地减少了腹股沟疝的复发。     

自体组织在腹腔镜成人腹股沟疝修补术中的应用

目的探讨腹腔镜下使用自体组织修复和加强腹股沟管后壁治疗成人腹股沟疝的可行性。方法2001年1月~2007年9月,选用脐正中襞,脐内、外侧襞,U形皱襞等自体组织,应用腹腔镜三孔法的单人双手操作腔内缝合技术,修补成人腹股沟疝173例(斜疝141例,直疝28例,股疝3例,闭孔疝1例)。结果本组173例均在腹腔镜下完成手术,无中转开放。152例单侧疝手术时间平均25min(10~40min),21例双侧疝手术时间平均40min(20~60min)。并发症包括腹膜后血肿1例,阴囊肿胀3例,鞘膜积液1例,腹股沟区淤血2例,阴囊炎1例。随访时间1~84个月,平均35个月,复发3例。结论腹腔镜下使用自体组织修补成人腹股沟疝的术式是安全可行的,创伤小,恢复快,复发率低。     

Indirect inguinal hernia masquerading as a Spigelian hernia

Inguinal hernia usually developed and descended into scrotum. The clinical presentation is inguinal or inguino-scrotal swelling. Abdominal wall weakness as it is frequently seen in African tropical zones produces often rare clinical case. We report a case of inguinal hernia presented as an abdominal wall swelling clinically suggestive of a Spigelian hernia and discuss the mechanism.     

Incarcerated anterior abdominal wall hernias in a community hospital

Summary Abdominal wall hernias are among the most common problems encontered by surgeons. It is generally agreed that a hernia should be electively repaired to avoid the complication of incarceration and its attendant risk of strangulation. Nevertheless, many patients remain undiagnosed or are reluctant to have surgical correction of hernias, and as a result many emergency procedures are performed for complications of neglected hernias. We performed a retrospective analysis of incarcerated anterior abdominal wall hernias, and we used multivariate analysis to identify variables that were predictive of gangrenous bowel. There were a total of 1680 anterior abdominal wall hernias during the study period. Surgery was performed emergently for acute incarceration in 132 patients (7.9%), 25% of these were strangulated, and 57.6% of the strangulated cases progressed to gangrene. Femoral hernias had the highest incidence of incarceration and strangulation. Independent predictors of gangrenous bowel were a pulse rate > 100, ASA class four or greater, radiographic evidence of obstruction and the presence of a femoral hernia. The overall mortality rate was 4.5% for the patients with incarceration, and 15.8% for the patients with gangrenous sac contents. The mortality from incarcerated anterior wall hernias has decreased over time, but mortality is still appreciable. Hernias should be repaired electively to avoid the complication of incarceration. The presence of gangrenous bowel can be predicted by a pulse rate > 100, ASA class four or greater, radiographic evidence of obstruction and the presence of a femoral hernia.     

Myofibroblasts defined by electron microscopy suggest the dedifferentiation of smooth muscle within the sac walls associated with congenital inguinal hernia

OBJECTIVE: To ascertain the presence of myofibroblasts in sacs associated with inguinal hernia in children, through an ultrastructural evaluation using electron microscopy. MATERIALS AND METHODS: Sacs were obtained from 10 boys and 10 girls (of similar age, approximately 45 months) with inguinal hernia and processed for electron microscopy. Thin sections were examined specifically for the presence of myofibroblasts. RESULTS: The ultrastructural evaluation showed myofibroblasts with classical electron microscopic features within all of the sacs, regardless of the gender of origin. CONCLUSION: The persistence of smooth muscle hinders the obliteration of the processus vaginalis; myofibroblasts are found in association with smooth muscle and thus such cells within the sac walls seem to originate from the smooth muscle, reflecting the dedifferentiation of smooth muscle. This dedifferentiated state may represent attempted apoptosis, which usually causes the disappearance of the smooth muscle and obliteration of the processus vaginalis after the descent of the testis into the scrotum.     

Lack of carbachol response indicates the absence of cholinergic receptors in sacs associated with undescended testis.

BACKGROUND/PURPOSE: The mechanism of testicular descent remains controversial. The processus vaginalis (PV) contains smooth muscle and should have contractile activity that may contribute to descent. This study was designed to evaluate the smooth muscle of PVs associated with incomplete obliteration for spontaneous activities and responses to various stimuli, to determine if differences exist according to sex, diagnostic source, or location of the testis. MATERIALS: Peritoneal samples (n = 4); sacs from girls (n = 8) and boys with inguinal hernia (n = 12); and sacs from boys with hydrocele (n = 3), hydrocele of the cord (n = 2), or undescended testis (n = 7) were used for the current study. Tissues were attached to the isometric force displacement transducer in an organ bath containing mammalian Ringer's solution at 37 degrees C. Spontaneous mechanical activity and contractile responses of tissues to the electrical field stimulation, phenylephrine, carbachol, and serotonin were recorded. The values obtained from boys and girls with inguinal hernia and from boys with either undescended or descended testis were compared through Fisher's Exact test. RESULTS: There were no statistically significant differences in patient age between groups. Among the parameters studied, only the carbachol response of the sacs associated with undescended testis showed a significant difference compared with the others (P = .001). None of the sacs associated with undescended testis responded to carbachol, whereas all of the sacs from boys and girls with inguinal hernia responded to carbachol. CONCLUSIONS: Lack of carbachol response suggests the absence of cholinergic receptors within the sacs associated with undescended testis. The lack of cholinergic receptors may play a role in the failure of the process of testicular descent by hindering either PV elongation into the scrotum or a possible propulsive activity of the PV on the testis.     

The anatomy of gubernaculum testis and processus vaginalis in cryptorchidism

The macroscopic anatomy of gubernaculum testis and processus vaginalis has been carefully studied during 150 consecutive orchiopexies. In subcutaneous and canalicular testes a well defined gubernaculum was found representing a morphologic continuity from the testis to the bottom of the scrotum. The gubernaculum was detectable in only one of four abdominal testicles. In 75% of the patients the serous communication between the testis and the abdominal cavity was lost. 43% of the patients still had a detectable rest of the processus vaginalis of which one third presented with a clinical hernia.     

Giant pseudocyst of the anterior abdominal wall following mesh repair of incisional hernia: a rare complication managed laparoscopically.

Giant pseudocyst formation of the anterior abdominal wall, following on-lay polypropylene mesh repair for incisional hernia is an under reported complication. We report an unusual case of a 56-year-old female who underwent a polypropylene mesh repair of incisional hernia 2 years back. Subsequently she developed a giant pseudocyst of the anterior abdominal wall, which was occupying the whole of the abdomen from the xiphisternum to the pubic bone, and over both the flanks. Over a period of one year, the cyst had defied multiple attempts at aspiration. The patient underwent a laparoscopic drainage of the collection with piecemeal excision of the entire cyst wall. Histopathology of the cyst wall revealed necrotic material with intervening areas of hemorrhage. No epithelial lining was seen. There has been no recurrence in the two years of follow-up. Conclusion: giant pseudocyst of the anterior abdominal wall is a rare complication following mesh repair of an incisional hernia. Such pseudocysts can be managed successfully by laparoscopic procedures.     

Littré’s femoral hernia causing intestinal fistula

Abstruct Littré’s hernia is one of the rarest forms of hernia, characterized to contain the Meckel’s diverticulum as its sole content. The Meckel’s diverticulum in the hernial sac can be involved by those complications which occur in the diverticulum in the free abdominal cavity. A case of Littré’s femoral hernia in a 75 years old man with formation of an intestinal fistula as a result of inflammation of the Meckel’s diverticulum, probably, following mechanical trauma exerted by a phytogenic fibre, was reported, and the previous literatures were reviewed. Consequently, it was confirmed that signs and symptoms of Littré’s hernia with complications are less severe and non-characteristic compared to ordinary types, and hence its preoperative diagnosis is very difficult.