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     

A case of embryonal rhabdomyosarcoma of the spermatic cord

A case of rhabdomyosarcoma of the spermatic cord in a 6-year-old boy is reported. On February 26, 1986, he visited Nakamura Hospital with the chief complaint of enlargement of the left scrotal content. The contralateral scrotum was normal. The left scrotal content was a hard thumb-head-sized tumor. The left testis and epididymis were not distinguishable from the tumor. On the same day, left high inguinal orchiectomy was performed. The tumor was 3.5 by 2.5 by 2.5 cm in size and was distinguishable from the testis, epididymis and tunica vaginalis. Histopathological findings were embryonal rhabdomyosarcoma and it appeared to have originated from the spermatic cord. Two years after operation, the boy is living without metastasis. Including our experience, 101 cases of the paratesticular rhabdomyosarcoma found in Japanese literature are reviewed and briefly discussed.     

腹股沟可触及睾丸的隐睾的微创治疗

目的探讨腹股沟可触及睾丸的隐睾的微创治疗方法。方法2007年8月～2008年3月对60例腹股沟区可触及睾丸的隐睾,根据睾丸位置高低,采取经阴囊或腹腔镜辅助下睾丸固定手术。结果经阴囊睾丸固定术24例,睾丸位于外环口与阴囊上极之间,23例固定于阴囊底,1例固定于阴囊上极。经阴囊转腹腔镜睾丸固定术2例,均为右侧,睾丸位于外环口与阴囊上极之间,经隐囊手术睾丸下降位置不满意,转为腹腔镜手术将睾丸固定于阴囊底。经腹腔镜睾丸固定术34例,其中睾丸位于腹股沟内16例（41.1%）,位于近外环口处18例（52.9%）,合并腹股沟斜疝8例（23.5%）,均在腹腔镜下行内环口结扎,术后睾丸固定于阴囊底部。60例B超随访3～6个月,平均4.3月,无睾丸萎缩及回缩,无腹股沟斜疝的发生。结论可触及睾丸的腹股沟隐睾如果能推到阴囊上极,则可选择经阴囊切口的睾丸固定术;如果不能将睾丸推到阴囊上极或经阴囊切口不能将睾丸固定到阴囊底时,可选择腹腔镜手术。2种手术方法睾丸固定位置满意,可作为临床医师的参考手术方式之一。     

Acute idiopathic scrotal edema: A rare cause of scrotal erythema

The acute idiopathic scrotal edema (AISE) is a self-limited condition of uncertain etiology, characterized by an inflammatory scrotal sac thickening without expansion to the underlying layers of the scrotal wall or to the endoscrotal structures. We describe a case of a 9-year-old boy with no previous relevant medical or surgical history who presented with left acute scrotal edema and erythema extending to the ipsilateral inguinal region, perineum, buttock and upper thigh. Laboratory results were normal and the ultrasound showed thickening and edema of the left scrotal layers with a color-Doppler sign revealing intense hypervascularity of the peritesticular scrotal soft tissue with a normal testis and epididymis. Remission of symptoms occurred 60?h after presentation. This case highlights the importance of recognizing this rare condition that has characteristic clinical and ultrasonographic features. A correct diagnosis can avoid unnecessary surgical exploration of the scrotum.     

A case of giant obsolete hydrocele testis

A 58-year-old man visited the urological clinic in Prefectural Tohkamachi Hospital with complaint of swelling of bilateral scrotal contents. He had no history of fever, pain or difficulty of urination. Physical examination revealed a giant mass of adult-head size in right scrotum and left inguinal hernia of fist growth. Surgical extirpation of the right scrotal mass and left inguinal herniorrhaphy was performed and the mass was diagnosed as obsolete hydrocele testis and weighed 1,600 g. The excised hydrocele sac showed marked thickening and dark brown pus amounted to about 1,400 ml, which was negative in bacterial culture. Histological examination revealed partial deposits of cholesterol and calcification in tunica vaginalis with extremely atrophic testis and destructive spermatogenesis. The findings suggested the existence of long-term infection in hydrocele testis. The etiology and pathogenesis of this disease is discussed.     

Torsion of an intra-abdominal testis

To present a case of torsion of a nonneoplastic intra-abdominal testis with an unusual clinical presentation.A 26-year-old active duty Navy Petty Officer presented to the emergency department on 3 occasions over a 5-day period with lower abdominal pain. Physical examination demonstrated acute tenderness in the left lower quadrant with sugestion of a normal spermatic cord and atrophic testis in the left scrotum. Computed tomography scan demonstrated an intra-abdominal lesion near the internal inguinal ring. The patient underwent surgical exploration through an inguinal incision. Torsion of a nonviable intra-abdominal testis was present. The scrotum contained only the vas deferens and cremasteric muscle. An orchiectomy was performed with removal of the vas deferens and other cord structures.The unusual clinical finding of acute torsion of an intra-abdominal testis, associated with an apparent atrophic scrotal testis, presented a confusing clinical picture. Computed tomography scan did not clarify the issue sufficiently to establish a definite preoperative diagnosis. Clinical suspicion prompted early surgical intervention. Review of the current literature produced 60 reported cases of torsion of an intra-abdominal testis. Two thirds of these involved testicular neoplasm, usually seminoma. Although the clinical presentation varied, most patients had recent onset of lower abdominal pain associated with tenderness and, in half the cases, a mass. Patients almost always presented with an absent scrotal testis on the involved side, and not infrequently reported previous surgery thought to be an orchiectomy.Diagnosis of an intra-abdominal testicular torsion is rare, particularly when no neoplasm is present. A high index of suspicion must be maintained whenever there is abdominal pain and undescended testis. The surgical history and imaging studies may not clarify a confusing clinical picture.     

腹股沟直疝疝囊进入阴囊机制分析

目的 探讨腹股沟直疝疝囊进入阴囊的机制.方法 回顾性分析中山大学附属孙逸仙纪念医院胃肠外科2002年1月至2012年12月收治的20例疝囊进入阴囊的腹股沟直疝患者的临床资料,并复习相关文献,分析腹股沟直疝疝囊进入阴囊的发生机制.结果 20例患者均行腹股沟疝无张力修补术,手术顺利完成,平均手术时间（41±5） min,平均住院时间（3.4±0.6）d;术后无慢性疼痛、阴囊水肿等并发症发生;随访6个月至10年,未见复发.结论 高龄患者组织退行性变,加之病程长、腹内压增高等因素,导致逐渐增大的腹股沟直疝疝囊不断挤压并突破外环口而进入阴囊.     

A case of hernia uteri inguinalis with a left crossed ectopic testis

A 70-year-old man with the complaint of dysuria and painless swelling of the right scrotal sac and inguinal region was operated on for suspected right inguinal hernia. The hernia sac contained two testis and immature uterine tissue, which were pathognomonic of left crossed ectopic testis complicated by hernia uteri inguinalis. The chromosomes were normal. Statistics on 57 similar cases indicated that this was the eldest of all such patients reported in Japan; since he had two children, he seems to have been fertile.     

Perforated appendix and periappendicular abscess within an inguinal hernia

We report an extremely rare case of complicated Amyand’s hernia. A 61-year-old male patient was admitted with clinical signs of incarcerated right inguinal hernia and localised tenderness in the right iliac fossa. He underwent emergency surgery and the operative findings included perforated appendix and periappendicular abscess within a right inguinal hernia sac. Appendectomy and Shouldice’s herniorrhaphy without prosthetic mesh placement were performed. Histology revealed the presence of a villous adenoma near the base of the appendix. We point out that although Amyand’s hernia is a very rare clinical entity, it should always be considered in the differential diagnosis in cases with clinical signs of incarcerated right inguinal hernia, especially when there are no pathological findings on the abdominal X-rays.     

Perforated appendix in hernial sac mimicking torsion of undescended testis in a neonate

In pediatric surgical practice, finding of the vermiform appendix in an inguinal hernia sac is not that uncommon; however, a perforation is rare. There are only a few case reports of a perforated appendix with periappendicular abscess in the inguinal hernial sac in a neonate. We report an unusual case of inguinal hernia containing a perforated appendix that was clinically mimicking testicular torsion of the undescended testis.     

Ultrasonographic diagnosis of massive bladder hernia at the inguinoscrotal level: report of a case

We present a case of massive inguinoscrotal bladder hernia in a 58 years-old man with a left inguinal hernia. It was diagnosed by ultrasound during evaluation of a mass in the left inguinal region extending to the scrotum. Cystography later confirmed the ultrasound findings but provided no new information. Although filling cystography is considered to be the gold-standard radiological diagnostic procedure for this entity I the use of ultrasound should not be discarded. Firstly I because direct and indirect ultrasonographics signs characterising inguinal bladder hernias have been reported, and secondly I to help in the differential diagnosis of a scrotal mass.     

Transverse ectopia of the testis. A case report

A case of transverse ectopia of the right testis with left inguinal hernia is reported. A one-year-old-boy was admitted to our hospital with swelling of the left scrotal contents and right undescended testis. At operation, two testes were situated on the left side, one in the left scrotum and another in the left inguinal canal. Right transseptal orchiopexy was performed. Including our case, we discovered 73 cases of transverse ectopia of the testes in the Japanese literature. A brief discussion was made about the disease.     

Testicular cancer with inguinal lymph node metastasis in a patient with prior orchiopexy for undescended testis: a case report

A 36-year-old man referred to our hospital with the chief complaint of painful left inguinal mass and fever. He had undergone left orchiopexy for undescended testis at 10 years of age. With the suspicion of an incarceration of inguinal hernia, an operation was performed. However, there was no hernia sac, and only swelling inguinal lymph nodes were found. Pathological diagnosis of the nodes was metastatic embryonal carcinoma, with suspicion of testicular origin. As scrotal ultrasonography revealed a hypoehcoic mass within the left atrophic testis, left high orchiectomy was performed. Pathological diagnosis of the left testicular mass was seminoma. A definite diagnosis was left testicular cancer, mixed type of seminoma and embryonal carcinoma, with inguinal nodes metastasis, pT1N2M0. He received 3 courses of bleomycin, etoposide, and cisplatin (BEP) chemotherapy, and there has been no sign of metastasis nor recurrence 18 months after the operation. To our knowledge, this is the 11th case in Japan of testicular cancer with inguinal node metastasis in a patient with prior orchiopexy for undescended testis.     

Report of a 45, X male with monoorchism and distal hypospadias

We present the rare case of a 5-year-old boy with a 45, X karyotype. The boy's family pedigree analysis was unremarkable. On admission, he was 97.4 cm tall (2.0 SD below normal references) and weighed 13.9 kg (1.0 SD below normal references). Mild mental retardation was suspected on the PPVT scale. Physical examination revealed a well-developed penis with subglanular hypospadias. His left testis was located well down at the bottom of the scrotum and the right testis was impalpable. Unilateral testicular agenesis and persistence of müllerian remnants within the hernia sac were noted on the previous records of inguinal exploration on the right side. The left testis was biopsied through a scrotal incision and prepubertal testicular tissue was confirmed. No ovary was found on laparotomy exploration. Hypospadias was repaired with meatal advancement and glanuloplasty (MAGPI) urethroplasty. His postoperative course was uneventful. Our report represents a rare case of a boy with a 45, X karyotype. Current theories for testicular development were reviewed.     

Adenocarcinoma of the rete testis. A case report

Adenocarcinoma of the rete testis is a rare malignant tumor with a poor prognosis. About 60 cases of this adenocarcinoma have been reported in the literature. The diagnosis is often difficult and made incidentally. Herein, we report a case of adenocarcinoma of the rete testis and review the literature. Our patient was an 80-year-old man who presented with painless scrotal swelling for 2 years. Physical examination revealed an enlarged, hard mass of the left scrotum. The serum markers alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (beta-HCG), and carcinoembryonic antigen (CEA) were negative. Magnetic resonance imaging (MRI) showed a left hydrocele with central necrosis of the testis. After 4 months, the patient presented with appetite loss, general fatigue, and pain in the left scrotum. Positron emission tomography (PET) was performed in another hospital, and the patient was referred for a left testicular tumor, multiple lung metastases, and para-aorta lymph node metastasis. The patient underwent left high inguinal orchiectomy. Pathological examination revealed a hard whitish mass around the testis involving the epididymis and tunica vaginalis and spreading under the subcutaneous tissue. Histological examination revealed adenocarcinoma in the hilum of the testis, which extended to the subcutaneous tissue but not to the surface of the scrotum. The tunica albuginea was intact, and no invasion of carcinoma in the testis was seen. After the histological diagnosis of adenocarcinoma of the rete testis was confirmed, computed tomography (CT) was performed and showed multiple pulmonary nodules and para-aortica lymph node swelling of 3 cm diameter. Because the patient did not wish to receive chemotherapy or other aggressive treatment, he has been followed-up with palliative care since his diagnosis. Although local recurrence has occurred 4 months later, he is still alive for 8 months since his diagnosis.     

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.     

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.     

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.     

Inflamed vermiform appendix within the sac of incarcerated left inguinal hernia

A 54-year-old male complained of a continuous pain together with an irreducible swelling of the left inguinal region 8 hours prior to admission to the surgical emergency department. His physical examination revealed a very painful, erythematous, irreducible swelling in the left inguinal region without abdominal peritoneal irritation. Routine blood tests disclosed mild leukocytosis. Abdominal plain X-ray film was not specific, and ultrasonography revealed a 10 cm in length inactive, edematous intestinal section within the inguinal hernia. With the diagnosis of strangulated inguinal hernia, he underwent surgical exploration through a transverse inguinal incision. By opening the hernia sac, 6-8 cc inflammatory fluid drained out, and an inflamed vermiform appendix adhered to the inner surface of the sac was seen. Appendicectomy and primary hernia repair were performed at the same time through the inguinal incision. The postoperative course was uneventful, and the histological examination of the specimen revealed an inflamed appendix.     

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.