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Abdominoscrotal hydrocele (ASH) is a variant of hydrocele that rarely occurs in adults. ASH has two sacs, one in the scrotum and one in the abdomen connected through the inguinal canal. Abdominoscrotal haematocele is a rare complication of ASH. We report a 57-year-old male patient who presented to a tertiary care hospital in Puducherry, India, in 2019 with complaints of swelling in the scrotum for 15 years and abdominal pain for two months. Both the swellings were soft and cross fluctuation was present. Imaging confirmed the diagnosis of ASH. During a diagnostic laparoscopy, the abdominal sac was decompressed and found to have thick brownish fluid suggestive of haematocele. It was demonstrated that both sacs were connected. Due to difficulty in the dissection of the sac, the procedure was converted to an open procedure. Both the sacs were excised and Lytle’s repair was done for the dilated internal ring. The patient recovered and no recurrence of any swelling in the abdomen or scrotum was found at the end of a one-year follow-up. Keywords: Testicular Hydrocele; Scrotal Hydrocele; Testicular Haematocele; Scrotal Haematocele; Laparoscopic Surgical Procedure; Laparoscopic Surgery; Case Report; India.

Purpose: Reviewing surgical procedures using fasciocutaneous and myocutaneous flaps for inguinal reconstruction after lymphadenectomy in metastatic penile cancer. Material and Methods: We reviewed the current literature of the Pubmed database according to PRISMA guidelines. The search terms used were “advanced penile cancer”, “groin reconstruction”, and “inguinal reconstruction”, both alone and in combination. The bibliographic references used in the selected articles were also analyzed to include recent articles into our research. Results: A total of 54 studies were included in this review. About one third of penile cancers are diagnosed with locally advanced disease, often presenting with large lymph node involvement. Defects in the inguinal region resulting from the treatment of metastatic penile cancer are challenging for the surgeon and cause high patient morbidity, rendering primary closure unfeasible. Several fasciocutaneous and myocutaneous flaps of the abdomen and thigh can be used for the reconstruction of the inguinal region, transferring tissue to the affected area, and enabling tensionless closure. Conclusions: The reconstruction of defects in the inguinal region with the aid of flaps allows for faster postoperative recovery and reduces the risk of complications. Thus, the patient will be able to undergo potential necessary adjuvant treatments sooner.

The aim of our study was to recommend a novel method for measuring the distance from the umbilicus to intra-abdominal organs, as well as recommend an instrument length that would accommodate transumbilical laparoendoscopic single-site (U-LESS) surgeries to these areas. From CT scans of 50 men and 50 women, we calculated the distance from the umbilicus to 11 intra-abdominal points of interest using two triangles oriented perpendicular to each other. Using known lengths of the triangles, we used the Pythagorean theorem to calculate distances with and without insufflation. Distances were measured from the umbilicus to the xyphoid process, superior most aspect of the spleen, neck of the gallbladder, bifurcation of the descending aorta, adrenal glands, superior pole(s) of the kidneys, inferior most aspect of the inguinal canal, suprapubic margin, and the apex of the prostate (or female bladder neck). We found that an instrument working length of 43 cm would be sufficient to facilitate U-LESS surgery for all of our patients to each of the measured points of interest. The technique described in this paper serves as a useful method by which to measure the distance from the umbilicus to any intra-abdominal point of interest. These measurements would allow surgeons to correctly select instruments with adequate length when planning to perform U-LESS surgery.

Laparoscopic triple neurectomy is an available treatment option for chronic groin pain, but a poor working knowledge of the retroperitoneal neuroanatomy makes it an unsafe technique. Describe the retroperitoneal course of iliohypogastric, ilioinguinal, lateral femoral cutaneous and genitofemoral nerves, to guide the surgeon who operates in this region. Fifty adult cadavers were dissected resulting in 100 anatomic specimens. Additionally, 30 patients were operated for refractory chronic inguinal pain, using laparoscopic triple neurectomy. All operations and dissections were photographed. Measurements were made between the nerves of the lumbar plexus and various landmarks: interneural distances in a vertical midline plane, posterior or anterior iliac spine and branch presentation model. The ilioinguinal and iliohypogastric nerves were independent in 78% (Type II) and separated by an average of 2.5 ± 0.8 cm. In surgery study, only 38% were recognized as Type II and at a significantly greater distance (3.5 ± 1.2 cm, p

Objective To document marked hemorrhage as a complication of inguinal cryptorchidectomy and its successful treatment with a novel chitosan-based hemostatic agent. Study design Case report. Animals One healthy 5-year old quarter horse cryptorchid. Methods The horse was presented for routine unilateral cryptorchidectomy after prior hemicastration. An inguinal approach was made to the abdomen, and the right external pudendal artery was lacerated at the level of the internal inguinal ring, requiring multiple anesthetic events over a 2-week period in attempts to control hemorrhage. A chitosan-based hemostatic agent was packed into the wound to gain control. Results Chitosan granules placed in the wound successfully controlled the hemorrhage, whereas the use of gauze packing alone failed. There were no immediate or long-term complications to the chitosan granules; the horse was doing well 18 months postoperatively, and the client was satisfied with the outcome. Conclusion Major hemorrhage was demonstrated from the external pudendal artery and caused difficulties because it occurred deep within the inguinal canal during an inguinal cryptorchidectomy. A chitosan-based hemostatic agent was successfully used to achieve hemostasis. Clinical significance The external pudendal artery should be avoided in the medial commissure of the inguinal canal. The use of chitosan-based hemostatic agents warrants further investigation in horses because these products may be useful for controlling major hemorrhage from various causes in equine practice.

Pseudomyxoma peritonei (PMP) is a rare disease that most commonly results from the rupture of an appendiceal mucinous neoplasm. It is characterized by mucinous ascites that disseminates throughout the abdomen and pelvis, and at times to the inguinal canal, in which some patients may complain of inguinal hernia as the initial complaint. The incidence of PMP with concomitant inguinal hernia is reported to be 7.3-9.6% in the current literature. We report a 70-year-old Hispanic male who initially presented with signs of a right inguinal hernia, and on computed tomography (CT) scan, was subsequently found to have a large collection of right lower quadrant cysts extending into the right inguinal canal and hemiscrotum. Patient underwent exploratory laparotomy and was found to have a large right retroperitoneal mass with PMP with mucinous contents herniating through the right inguinal canal encased within peritoneal sac and had surgical debulking of peritoneal cavity and right hemiscrotum. The patient was discharged 9 days later. PMP that presents with an inguinal hernia is a special entity that warrants a discussion on the optimal management of inguinal involvement of a mucinous tumor. J Curr Surg. 2020;10(3):49-53 doi: https://doi.org/10.14740/jcs415

The diverticulitis is a frequent disease of the gastrointestinal tract. It may lead to a variety of severe complications. In some cases, it has to be surgically treated. Herein, we present a rare case of a 66-year-old man, who suffered from a painful, visible “fist sized” mass of the left lower abdomen. A perforated diverticulitis with abdominal, cutaneous abscesses and destruction of the inguinal canal with mesh dislocation was diagnosed and successfully surgically treated.

Abdominoscrotal hydrocele (ASH) is an uncommon congenital anomaly in which a scrotal hydrocele extends to the abdomen through the inguinal canal in an hourglass fashion. Coexisting undescended testes (UDT) have mainly been reported in pediatric populations and are mostly located along the inguinal canal. We present a 66-year-old male with a history of neglected left cryptorchidism, who presented with a progressive ipsilateral inguino-scrotal swelling suggesting indirect inguinal hernia. On physical examination, inguino-scrotal hydrocele was suspected. Abdomen and pelvis computed tomography scan and magnetic resonance imaging revealed an abdominoscrotal cyst with a pathognomonic dumbbell appearance of an ASH, as well as an intra-abdominal testicle that proved to be intracystic, atrophic, and hypovascular. The patient underwent successful radical en-bloc excision of the ASH and testis via an extended inguinal approach. To our knowledge, this is the first case with this constellation of urogenital abnormalities to be reported in an aged man. What makes this case further unique and interesting is the unusual ASH’s relationship with the patient’s cryptorchid testicle and peritoneal sac.

A 70-year-old female presented to the emergency department with a painful left inguinal mass along with intermittent nausea and vomiting but no constipation or obstipation. Her last bowel motion was on the morning of presentation. Her medical background was significant for gastro-oesophageal reflux disease, hysterectomy, a bowel containing reducible left inguinal hernia seen on ultrasound 3 months earlier for which the patient was awaiting surgical review and an episode of diverticulitis 4 years ago complicated by a 3.6 cm perisigmoid abscess. The previous episode of diverticulitis was treated successfully with intravenous (IV) antibiotics only as the abscess was not drainable. During this presentation, examination revealed a soft abdomen with the tender firm left inguinal mass with overlying erythema. Bowel sounds were present. The patient was afebrile, heart rate was 110 beats per minute and systolic blood pressure was 160 mmHg. Initial blood tests revealed a pH of 7.39, lactate of 1.1 mmol/L and a white cell count of 10.7 × 109/L. Attempts were made to reduce the left inguinal mass, but this was unsuccessful. After surgical review, a provisional diagnosis of an incarcerated left inguinal hernia was made. The patient proceeded to the operating theatre without imaging for an open groin exploration ± washout. Upon entering the inguinal canal, an abscess cavity was encountered unexpectedly (Fig. 1(a)). Laparoscopy was performed for concerns of bowel necrosis, revealing inflamed sigmoid bowel consistent with sigmoid diverticulitis as well as adherent bowel to the anterior abdominal wall and the bladder (Fig. 1(b)).

Introduction Abdominoscrotal hydrocele is a rare condition of vaginal hydrocele. Ipsilateral cryptorchidism is frequently reported as an associated congenital anomaly, however, ipsilateral indirect inguinal hernia has never been reported as an accompanying anomaly. Case presentation We reported a case of 6-month-old boy with a huge cystic mass at left scrotum extending upward to lower abdomen passing through inguinal canal. There was an unusual presentation in that this bulging mass could be entirely reduced into abdomen, mimicking patients who presented with reducible inguinal hernia. Intraoperatively, the patient was found that not only abdominoscrotal hydrocele and undescended testes were presented, but also hernia sac was simultaneously encountered. He was successfully treated and recovered uneventfully. Discussion According to the natural history of abdominoscrotal hydrocele resembling that of non-communicating hydrocele, it could be treated conservatively without surgery. However, several conditions caused by pressure effect will not be relieved and testicular dysmorphism will also not be corrected. In addition, as presented in this report, should there also be an inguinal hernia, the hernia sac should be left in place without any surgical correction. As a result, we recommend that all patients with abdominoscrotal hydrocele should be surgically treated if there is no contraindication. Conclusion The presence of hernia sac might produce a unique presentation. Since we do not know whether the patients who have abdominoscrotal hydrocele will be accompanied by indirect inguinal hernia, the patients should be treated with surgery unless they were in condition in which surgery cannot be performed., Highlights • Simultaneously indirect inguinal hernia can occur with ASH. • ASH with indirect inguinal hernia can come with unusual presentation. • All ASH should be surgically treated if they have no contraindication.

Mesenteric cysts are extremely rare intra-abdominal tumors. They usually present with an array of symptoms, usually non-specific, which leads to difficulty in diagnosing them. Occasionally these can present in the emergency as an acute abdomen. We report a rare presentation of a huge mesenteric cyst with gastric perforation, misdiagnosed clinically as obstructed inguinal hernia. A 50-year male presented with complaints of sudden severe pain in the abdomen along with swelling and pain in the right groin region with absolute constipation for the last 4 days. A clinical diagnosis of obstructed inguinal hernia was made. However, on radiological investigations, it was discovered as a giant intra-abdominal cyst herniating into the inguinal canal. On exploration, we were further surprised to find a concomitant gastric perforation. In this case report, we highlight that mesenteric cysts can present as acute abdomen and, very rarely, can be associated with an accompanying cause of surgical abdomen.

Undescended testis is most common congenital malformation in boys. Most common location is inguinal canal but rarely it is found in intraabdominal. 10% of them will grow become mass if left untreated. This case report describes cases of men of 40s with unilateral UDT and not noticeable until they felt heavy and feel palpable mass in abdomen revealed as seminoma. He is sterile and not be able to reproduce. Chemotherapy was done and the response was remarkable. This case report reiterates the need for a scrotal examination in men presenting with an abdominal mass, so as to rule out an intra-abdominal seminoma.

Scrotal swelling, extending to the inguinal region along with pain and fever suggests infection. The cause is usually epididymo-orchitis often secondary to urinary tract infection and can be complicated by diabetes mellitus. The other causes of such presentation include strangulated inguinal hernia, abscess tracking from the iliac region from appendix or diverticulitis. Extensive emphysematous pyelonephritis (EPN) spreads to perinephric and paranephric spaces. EPN can rarely track up to the inguinal canal and scrotum. We report a rare presentation of EPN mimicking left epididymo-orchitis in a 65-year-old male with uncontrolled sugars. Computed tomography of the abdomen showed left-sided EPN, spreading to the perinephric, paranephric, and paraaortic, coming down up to left inguinal region and scrotum. He responded to culture-sensitive antibiotics and percutaneous drainage.

Inguinal hernia is the most frequently diagnosed hernia and during their lifetime one third of males are diagnosed with an inguinal hernia. The age distribution is bimodal with the highest incidence in childhood and after 50 years of age. Diagnosis is usually reached through clinical examination of a lump in the inguinal region although some patients can present with intestinal obstruction. Inguinal hernia repair is the only definitive treatment and is one of the most common surgical procedures performed. It is usually performed as an elective procedure in local, spinal or general anasthesia. The repair constitutes of reinforcing the posterior wall of the inguinal canal, often using a polypropylene mesh; either via an open anterior approach or posteriorly from within the abdomen with laparoscopy. The most common complications following a hernia repair are recurrent hernia and chronic -discomfort but recurrence rates have improved with the use of mesh and laparoscopic techniques. This evidence based review describes the -epidemiology and etiology of inguinal hernia together with the most common surgical procedures; focusing on recent innovations.

Introduction: Cryptorchidism is a disorder of the testicles, when during a physical exam, testicles, one or both of them, are not found in the scrotum, but are found either along the inguinal canal or in the abdomen. Two main modalities of treatment are hormonal and surgical treatment. Aim: The aim of this paper was to determine the success rate of hormonal therapy with human chorionic gonadotropin (hCG) in undescended testicle treatment in patients treated at the Institute for Child and Youth Health Care in Vojvodina, from January 1, 2010, to December 31, 2017. Material and methods: This research included the patients from the Institute for Child and Youth Health Care in Vojvodina ages 0-18, treated from January 1, 2010, to December 31, 2017. Medical documentation has been analyzed and interpreted using methods of descriptive statistic. The research included boys with undescended testicles, to whom the hormonal therapy was indicated. Patients were divided into 3 groups ( 6 years). The therapy was applied twice a week, in the course of 5 weeks (hCG 250-1000 IJ/dose). The position 12 months after therapy was used as a final position. Results: The hormonal descend was achieved in 63 patients (62.4%) of the total number of patients. Тhe highest success rate was achieved in oldest of our patients (80%). Conclusion: Hormonal therapy with hCG leads to descent in a high percentage, with very little transitory adverse effects, and it is an important modality in undescended testicles treatment.

Introduction: Testicular cancers represent about 5% of all urological malignancies and 1-1.5% of all male neoplasms. Most of the testicular cancers are localized (68%) at diagnosis. Bulky masses in the scrotum are rare. We present a rare case of bulky testicular cancer with retroperitoneal spread through the inguinal canal. Case report: A 44-year-old man came to the emergency department referring weakness and the presence of a scrotal mass. At physical examination, a voluminous mass was found, with necrotic phenomena within the scrotum. Abdomen was tense and sore. Abdominal CT scan revealed a bulky testicular mass spreading to the retroperitoneal space through the inguinal canal with node enlargement. Patient underwent orchiectomy with excision of infiltrated scrotum skin. Histologic diagnosis confirmed a typical form seminoma. The patient was then treated with a cisplatin-based chemotherapy, with a partial response. The patient recently relapsed and he is being treated with a new line of chemotherapy and subsequent surgery with or without radiotherapy. Conclusions: We described a rare presentation of testicular cancer. This case highlights the importance of a multidisciplinary approach to rare testis tumour presentation and early diagnosis for testicular cancers.

Introduction The classical lymphoscintigraphic investigations of lower-limb lymphatic edema [LLLE] sometimes reveal either no or few lymph nodes [LNs] at the root of the limb[s] and/or in the abdomen. The aim of the present paper is to report the results of performing one additional injection at the root of the edematous limb[s] to force the visualization of the LNs and/or to demonstrate the collateral lymphatic pathways in such patients. Methods and findings We retrospectively reviewed our database and found 99 patients [44 primary LLLE with 47 limbs injected and 55 with LLLE secondary to treatments for cancer with 64 limbs injected] where such an additional injection had been performed. In the 43 LLLE patients where no LNs were seen at the end of the classical exam [15 primary LLLE and 28 secondary LLLE], the extra injection showed lymphatic drainage toward LN[s] in all except 3 and when at least one LN was seen, the injection showed lymphatic drainage in every case toward the same ipsilateral [inguinal and/or iliac] LNs [as shown by the classical injection] and/or toward additional LNs. In 40.7% of patients, we observed one or more additional lymphatic pathways: prepubic superficial lymphatic vessels [LV] crossing the midline anteriorly toward contralateral inguinal LNs in 21 [18.9%], “posterior” LV [toward contralateral inguinal LNs and/or ipsi- or contralateral lumbo-aortic and/or para-renal LNs] in 14 [12.6%], but deep LV toward the ipsilateral common iliac LNs passing between the gluteal muscles in 32 [28.8%]. Conclusion Our work pinpoints one limitation of classical bipedal radionuclide lymphangiography. In patients with primary and secondary LLLE where inguinal and/or iliac LNs cannot be seen on bipedal radionuclide lymphangiography, this additional injection reveals the true lymphonodal status and shows unexpected collateral lymphatic pathways in 40% of cases. Such information is of the utmost importance in LLLE management and its acquisition is consequently recommended in these patients., SCOPUS: ar.j, info:eu-repo/semantics/published

During the human fetal period, the testes migrate from the abdomen to the scrotum, traversing the abdominal wall and the inguinal canal between the 15th and the 28th week of postconception. Cryptorchidism is very common and occurs when this process is not completed properly. In this chapter, we review the etiological factors, diagnosis, and treatment of cryptorchidism and discuss how basic research can help in understanding and treating this congenital anomaly.

Background Polyorchidism is a congenital anomaly of the urogenital system and means more than two testes. It is a rare phenomenon, where there are no more than 200 reported cases in the literature. In this case, we report a 13-month year’s old case with five testicles. Case presentation We report a rare five testicles in the genital area of a 13-month-old baby. The initial diagnosis was undescended testis (UDT) based on ultrasound findings where a testis in the abdomen and a testis in the inguinal canal were detected. Surgery with general anaesthesia was performed to diagnose and treat this case. Before surgery, four HCG 1200u injections were administered. During the operation, it was determined that the case had had five testicles. Testicles were on the left in the proximal inguinal canal, and the sac hernia was ligated parallel to the inner ring. The patient was followed up several times after surgery by a urologist, and the results showed that there were no problems, and the intervention was uncomplicated. Conclusion Based on the result, it is not possible to diagnose such cases only by examination or ultrasound in infant patients, as the patient often presents with undescended testis (UDT), so the disease is diagnosed only through surgery.

Abdomino scrotal hydrocele (ASH) is a very rare condition in which the hydrocele sac extends beyond the scrotum to the abdomen via the inguinal canal. Although various ideas have been proposed regarding this disease, there is still controversy over its etiology. We report a case of abdominoscrotal hydrocele in a one year old boy (Mofid Children's hospital, Tehran, Iran) with history of right sided herniorrhaphy one month ago in other center. Slow growing mass in lower abdomen was noted by parents. For better diagnose, ultrasound and CT scan was performed. In operation missed large abdominalscrotal hydrocele was confirmed.

We report herein a 14-month-old boy with a left-sided peeping testis. At the age of 1 month, the left testis was palpated between the inguinal canal and the scrotum. When he was 6 months old, ultrasonography showed the left testis in the inguinal canal. At the age of 13 months, the left testis was not palpable. At the age of 14 months, he underwent surgery for a planned inguinal orchidopexy with a preoperative diagnosis of an undescended testis. When the inguinal canal was opened, a patent processus vaginalis was observed and the testis was found inside the abdominal cavity. The patent processus vaginalis was closed, a dartos pouch was created and the testis was guided into the pouch and fixed to its wall. We describe a case of a peeping testis moving from the inguinal position into the abdomen.

Sonography of the male inguinal canal for hernia is a common request. There is debate about the accuracy and even need for sonographic assessment of inguinal hernia. A clear, concise method is presented, with correlated diagrams and sonographic images, which aims to improve the ability of sonographers to easily identify inguinal herniae.

Hydrocele of the canal of Nuck also called the “female hydrocele” is a rare entity in females. The processus vaginalis peritonei is a tubular fold of peritoneum that invaginates into the inguinal canal along with the round ligament. It usually gets obliterated by birth or during early infancy, but if this communication remains patent, it may lead to the development of an indirect inguinal hernia or hydrocele. Here, we present the case of a 32-year-old female who complained of swelling in the right inguinal region. Contrast-enhanced computed tomography scan of abdomen and pelvis was suggestive of a cystic lesion in the right inguinal region which was seen extending from mons pubis up to the right iliac fossa in the retroperitoneum likely suggestive of hydrocele of the canal of Nuck. Surgical excision of the cyst was done.

Introduction and importance Amyand's hernia (AH) is a form of inguinal hernia which is consider as very rare and this type of hernia occurred up to 1% of all inguinal hernia cases. In this type of inguinal hernia, the content of hernia sac is appendix. Most patient with AH often remains asymptomatic and diagnosed intraoperatively. The diagnosis is challenging, since needs a high index of suspicion and imaging is key. Surgery is the mainstay management. We report a case of Amyand's hernia that was managed operatively in our medium complex public institution. Case presentation A 28 year's old man with normal body mass index (BMI) who had a history of right-side reducible linguino-scrotal swelling for 8 years, was admitted for elective right inguinal hernia repair. Two weeks back before admission, he noticed that swelling was slightly painful. Ultrasound of the abdomen reported normal findings. There was no history of abdominal pain and vomiting. Laboratory parameters were within normal limit. So, with a diagnosis of right sided partially reducible, incomplete, and indirect inguinal hernia, patient was operated for open hernia repair surgery, intra operatively we found dense adhesions within the sac, adhesions were released which revealed herniation of appendix into the inguinal canal. Appendix was mildly congested without gross evidence of inflammation. Hence, in view of noninflamed appendix, preperitoneal mesh (polypropylene) hernioplasty from Lichtenstein tension-free mesh repair was performed with appendicectomy. Postoperative period was uneventful, patient discharged at second day. Clinical discussion Amyand's hernia is very uncommon and characterized by the presence of the appendix in the hernia sac and it is 0.4–1% of all inguinal hernia cases, literature review also showed that incidence of Amyand's hernia is very rare, whereas only 0.1% of cases complicate into acute appendicitis due to late presentation and missed diagnosis. Conclusion Amyand's hernia (AH) makes up only a small proportion of most inguinal hernia cases, and its diagnosis is usually based on incidental finding intra-operatively. This condition may remain asymptomatic and behave like a normal inguinal hernia. Management of this type of hernia should be individualized according to appendix's inflammation stage, presence of abdominal sepsis and co-morbidity. With this approach it enables surgeons to manage more variations of Amyand's hernia. Laparoscopy for dealing Amyand's hernia is frequently diagnostic as well as therapeutic.

Background Pseudomyxoma peritonei is a disease that results from a perforated mucinous neoplasm of the appendix so that mucinous ascites and mucin-producing tumor cells are widely disseminated in a characteristic pattern throughout the abdomen and pelvis. The intraabdominal mucus can accumulate in the inguinal canal and by physical examination be indistinguishable from the usual inguinal hernia. Methods A database of patients with pseudomyxoma peritonei was used to identify patients who had an inguinal hernia prior to or at the time of cytoreductive surgery (CRS) and perioperative hyperthermic chemotherapy (HIPEC). At the time of CRS, care was taken in all patients to remove the peritoneal lining of the inguinal canal. Patients who had the inguinal hernia repaired prior to definitive treatment with CRS and HIPEC had all tissue and mesh associated with prior herniorrhaphy resected. Results In 178 pseudomyxoma peritonei patients, 17 had a new onset or previously repaired inguinal hernia that required extraction of mucus and mucinous tumor from the hernia site. No repair of the open inguinal canal was attempted at the time of CRS. No recurrent inguinal hernias were recorded and no patients required an inguinal incision at a later time to resect progressive disease within the inguinal canal. Conclusions Inguinal hernias caused by mucinous ascites and tumor were definitively treated by cytoreductive surgery plus HIPEC. Extraction of tumor and peritoneum from the inguinal canal facilitates fibrous closure of the hernia defect so that hernia recurrence was not observed.

Summary Background Prune Belly Syndrome (PBS) is a rare entity, usually found in male neonates. It comprises complex urinary tract anomalies, bilateral undescended testis and absence of anterior abdominal wall muscles. Patients with unilateral abdominal wall deficiency, unilateral undescended testis and female neonates with abdominal wall laxity are classified as Pseudo Prune Belly syndrome (PPBS). Reports on PPBS do not highlight the radiological and imaging characteristics of this syndrome and the current literature on the role of newer imaging modalities, such as Magnetic Resonance Imaging (MRI), remains relatively sparse. We describe a new case of PPBS and emphasize the role of imaging, especially ultrasound and MRI in the process of diagnosis and briefly review the subject. Case Report A male infant of four months of age was referred for evaluation of left-sided cryptorchidism. Clinical examination revealed laxity of the left abdominal wall. Ultrasound examination of the abdomen, pelvis and scrotum was performed together with routine laboratory tests. Ultrasound examination was followed by intravenous urography, voiding cysto-urethrography and MRI of the abdomen. On ultrasound, the left testis was located in the inguinal canal, the right kidney was slightly enlarged and the left kidney could not be localized. Ultrasound appearances suggested chronic obstruction in the urinary bladder. Intravenous urography, voiding cysto-urethrography and MRI confirmed the ultrasound diagnosis and also revealed a left dysplastic kidney with a dilated, tortuous ureter. Clinical and imaging features were consistent with pseudo prune belly syndrome (PPBS). Conclusions We report a new occurrence of PPBS, a rare entity. The imaging approach for a comprehensive evaluation of the renal system in PPBS, especially with MRI, is emphasized.

The external oblique musculo-aponeurotic complex is an important contributor to the strength of the inguinal canal. The present case report describes the bilateral absence of the external oblique muscle in a patient. A 40-year-old male patient presented with a history of intermittent lower abdominal pain for 15 years which had increased over the past 2 years. Abdominal examination revealed bilateral reducible, incomplete, direct inguinal hernia. Elective bilateral Lichtenstein's mesh hernioplasty was planned for the patient. Intraoperatively, there was no evidence of the external oblique aponeurosis and the spermatic cord was noted deep to the membranous fascial layer. The inguinal ligament was thin and atrophic and was attached to the pubic tubercle medially and anterior superior iliac spine laterally. There was no evidence of any superior aponeurotic connection to the inguinal ligament. A postoperative ultrasound examination of the abdomen confirmed the bilateral absence of the external oblique musculo-aponeurotic complex. The isolated absence of the external oblique musculo-aponeurotic complex in adults is an exceedingly rare anomaly. The possibility of such an anomaly should be considered in patients without other risk factors for hernia.

Summary Background Acute appendicitis is an emergent surgically treated disease generally represented by right lower abdominal pain. The most common location of the appendix is descending intraperitoneal. However, it can also show atypical locations such as inguinal canal, femoral canal, subhepatic, retrocecal, intraperitoneal abdominal midline and left side in situs inversus or intestinal malrotation patients. Atypical location can lead to atypical clinical presentations. Ultrasonography is the first choice modality for imaging. However, it can be insufficient for demonstration of the appendix. Therefore, computed tomography (CT) is needed for further examination. We aim to review the CT findings of atypically located acute appendicitis with cases and remind the clinicians and radiologists the importance of the prompt diagnosis. Case Report We presented five atypically-located appendix cases, including four with acute appendicitis that presented to our emergency department with acute abdominal pain. Two of the acute appendicitis cases had normal, the other two had elevated white blood cell count, but all of them had elevated CRP. Ultrasonography imaging was performed as a first-line imaging modality. Because of the inconclusive results of both clinical-laboratory findings and ultrasonography, CT imaging was performed. Abdominal CT demonstrated all of the atypically localised appendices successfully, which were left-sided in a malrotated patient, retrocecal, subhepatic, retrocecal ascending, intraperitoneal abdominal midline localised. Conclusıons Atypically located acute appendicitis can show atypical presentation and result in misdiagnosis. If ultrasonograpgy is inconclusive, we suggest abdominal CT in such confusing, complicated cases, because misdiagnosis or delay in the right diagnosis can result in complications and increased morbidity and mortality rates.

Introduction: Partial deletion of distal chromosome 10q was first reported in 1978 by Lewandowski1. Interstitial deletions within bands 10q25e10q26.3 are rare. Seven such cases were reported so far2. Patient Information: A term AGA male newborn was delivered at our perinatal center with antenatal diagnosis of unbalanced translocation of chromosomes 10 and 12, and fetal cleft lip and cleft palate. Blood was sent for chromosome analysis using GTG banding method. Baby had facial dysmorphism, left cleft lip, bilateral cleft of soft and hard palate, intact nasal septum, normal ears and micrognathus. Abdominal ultrasound showed absence of right testis in inguinal canal and abdomen (anorchia). Hospital course was unremarkable except for feeding problems requiring feeding team, plastic surgery planned at 2- 3 months of age, and taping of the cleft lip. He went home on day 7. Conclusion: Here, we reported an extremely rare case of a male newborn with an interstitial deletion within the long arm of chromosome 10 between bands 10q25.1 and 10q26.1, with dysmorphic features, along with a few unreported associations (atypical Pierre-Robin sequence and bilateral dorsal horn ventriculomegaly). We added a comprehensive review of literature on chromosome 10q deletions to the case report. We also listed clinical implications of 71 RefSeq and OMIM genes noted in that ~13.3Mb 10q deletion in the Appendix. Earlier detection of both common and rare chromosomal- genetic abnormalities might prepare the family and health care team to plan optimal care to the mother, and baby.

Highlights • An interparietal inguinal hernia with undescended testis & obstructed external ring is a rare presentation. • In Interperital hernia, the sac passes between the layers of the abdominal wall. • Pre-operative diagnosis even with the help of USG & CT is really a challenging issue. • Treatment is surgical exploration which also confirms the final diagnosis., Introduction An interparietal inguinal hernia is a rare form of hernia. In this type of hernia, the sac passes between the layers of the abdominal wall of the inguinal canal area. Although its treatment is very simple but pre-operative diagnosis is really a challenging issue. Presentation of case A 62 years old male patient presented with complaint of a large swelling over right lower abdomen with absence of right testes since birth. The lump was measured 26 × 22 cm in size. Ultrasonography (USG) and Contrast enhanced computed Tomography (CECT) failed to diagnose as interparietal inguinal hernia which was proved intra-operatively. Few cases have been reported in the medical literature like this. Discussion Exploration revealed the large abdominal lump presenting as an interparietal inguinal hernia. Hernia sac was lying in between external & internal oblique muscles. The right testis was intraabdominal & atrophied. The external inguinal ring was almost completely obstructed. Conclusion An interparietal hernia with undescended testis is a very rare presentation. Even with USG & CT scan diagnosis is very challenging and final diagnosis can be made only intraoperatively.

Study Objective The purpose of this video is to demonstrate the viability of the laparoscopic approach for excision of endometriosis in the inguinal canal and the individualization of the anatomical structures in this region. Design The procedures aimed at treating symptomatic patients with cyclic groin pain, secondary to endometriosis infiltrating the inguinal canal, during a laparoscopic approach for deep endometriosis affecting the pelvis or other regions of the abdomen. All patients had a preoperative diagnosis through imaging (MRI and Ultrasound). Setting A 3D camera with 30° optics was used to provide an enlarged and suitable viewing angle of the anterior abdominal wall. Patients or Participants Between July 2019 and February 2020, 5 patients had a preoperative diagnosis (MRI and Ultrasound) and underwent a laparoscopic resection of endometriosis infiltrating the inguinal canal. 35 patients with endometriosis affecting only the internal inguinal ring were excluded. Interventions The first step was to open the peritoneum covering the internal inguinal ring, followed by the identification of the lesion inside the canal. External iliac vessels were identified and, if necessary, a double vascular bulldog interrupted venous or arterial circulation during the dissection of the vessel. Measurements and Main Results After three months all patients underwent a clinical MRI examination. They were asymptomatic and no residual lesions were identified. Conclusion A laparoscopic approach can be performed effectively and safely for the excision of endometriosis in the inguinal canal.

Summary Cryptorchidism is a fairly common pathology presented to equine surgical facilities with the cryptorchid testicle most commonly located in the abdomen or ipsilateral inguinal canal. The causes of cryptorchidism are not known, but testicular abnormalities have been suggested. Monorchidism as a cause of maldescent of one or both testicles is rare and is hypothesised to be the result of a vascular insult, similar to testicular regression in man. This case report details laparoscopic abdominal exploration of a cryptorchid horse and identification of an abnormal testicular remnant affected by ischaemic necrosis.

To assess position of mesh endoprosthesis in retroperitoneal space after TARR hernioplasty using ultrasound in early and long-term postoperative period.There were 30 patients with inguinal hernias after TARR procedure. Standard technology of laparoscopic transabdominal preperitoneal hernioplasty was used in all patients. In all cases, a large-pore monofilament polypropylene mesh 10x15 cm was used. Control examination and ultrasound of the mesh implant were performed the next day, in 1, 3, 6, 12 months after surgery. Correct position of the implant was determined by its placement at the level of pubic bone with complete overlap of posterior wall of the inguinal canal and inner ring.US-image of the implant is present in two geometric forms - linear and sinusoid. The shape of prosthesis varies depending on postoperative period and the use of fixing elements. Thus, sinusoidal shape of prosthesis was observed in patients without fixation of prosthesis the next day and in 1 month after TARR. Geometry of the implant acquired the form of a straight line after 3 months and became almost a straight line in 12 months after surgery. Linear shape of prosthesis in early postoperative period was found after intraoperative fixation of endoprosthesis. Sinusoidal shape is noted after 3 months. Ultrasonic pattern of endoprosthesis looked as a thin hyperechoic band with thickness of 1.2-3.9 mm. Mean thickness of prosthesis was 2.2±0.1 mm the next day after surgery, 2.8±0.2 mm after 1 month and 1.6±0.05 mm after 12 months.Geometry of synthetic implants after TARR hernioplasty undergoes significant changes and depends on duration of postoperative period and fixation of the prosthesis.Цель исследования - оценка положения сетчатого эндопротеза в ретроперитонеальном пространстве после трансабдоминальной преперитонеальной герниопластики с помощью ультразвукового метода в ближайшем и отдаленном послеоперационном периоде. Материал и методы. Обследованы 30 пациентов после выполнения стандартной лапароскопической трансабдоминальной преперитонеальной герниопластики по поводу паховой грыжи. Во всех случаях в качестве герниопротеза использовали крупнопористую монофиламентную полипропиленовую сетку размером 10×15 см. Контрольные осмотры и УЗИ сетчатого имплантата выполняли на следующий день и через 1, 3, 6, 12 мес после операции. Критериями правильного положения имплантата рассматривали его визуализацию на уровне лонной кости с полным перекрытием задней стенки пахового канала и его внутреннего кольца. Результаты и обсуждение. Изображение имплантата при УЗИ имеет 2 геометрические формы - линейную и синусоидную. Форма протеза изменяется в зависимости от срока послеоперационного периода и применения фиксирующих элементов. Так, у пациентов без фиксации эндопротеза в 1-е сутки и через 1 мес после трансабдоминальной преперитонеальной герниопластики он имеет синусоидную форму, а с 3-го месяца начинает приобретать вид прямой линии, к 12-му месяцу имплантат имеет форму практически полностью прямой линии. У пациентов, которым выполнена фиксация эндопротеза, в ближайшем послеоперационном периоде протез имеет линейную форму, а с 3-го месяца начинает приобретать синусоидную форму. В ходе УЗИ эндопротез выглядел в виде тонкой гиперэхогенной полосы, толщина которой варьировала от 1,2 до 3,9 мм. В первые сутки после операции толщина протеза составляет в среднем 2,2±0,1 мм, через 1 мес после операции толщина увеличивается до 2,8±0,2 мм, затем отмечается уменьшение толщины до 1,6±0,05 мм к 12-му месяцу наблюдений. Заключение. Геометрическая характеристика синтетических имплантатов, используемых при выполнении трансабдоминальной преперитонеальной герниопластики, претерпевает значительные изменения, которые зависят от сроков послеоперационного периода, а также от наличия либо отсутствия фиксации протеза.

In most mammals the testes migrate from their original site in the abdomen alongside the lumbar spine down into the scrotum [1, 2]. Exceptions are elephants, whales, and rhinoceros, whose testes remain in the abdomen. In most mammals, however, including humans, they pass through the abdominal wall into the evagination of the peritoneum that forms the scrotum (Figs. 2.1, 2.2, and 2.3). The descent of the testis occurs in two morphologically and hormonally distinct phases termed as transabdominal and inguinoscrotal phases. During the first phase, the testis remains anchored to the retroperitoneal inguinal area by the swollen gubernaculum, which prevents its ascent as the fetus enlarges. The gubernaculum is a cylindrical structure attached to the inguinal canal. During the third trimester of development, the testis slips down the posterior abdominal wall dragging its neurovascular bundle and descends from the inguinal area into the scrotum guided by the gubernaculum (Fig. 2.4). By birth, or shortly thereafter, the testis has moved into its definitive extra-abdominal location and is covered by the processus vaginalis of the peritoneum (Fig. 2.5).

This video article demonstrates an inguino-abdominal combined approach for laterally extended pelvic resection, a major surgical procedure for locally advanced primary or recurrent gynecological cancer infiltrating the pelvic sidewall, for which palliative therapy is the only alternative.1 After local institutional review board approval (protocol No CICOG 02/03/62), we made a step by step surgical video of an inguino-abdominal combined approach for laterally extended pelvic resection , defined as an en bloc resection of a pelvic tumor with pelvic sidewall structures, including the iliopsoas and/or obturator internus muscles.2 3 The patient, a 48-year-old woman, diagnosed with single pelvic platinum resistant recurrence after five lines of chemotherapy for serous ovarian cancer G3, International Federation of Gynecology and Obstetrics (FIGO) stage IIIC, BRCA wild type. The preoperative positron emission tomography/computed tomography scan detected uptake on the right side at the level of the external iliac region and obturator fossa: the tumor surrounded the right external iliac vessels by more than 50% of their circumferences, with possible involvement of the vascular wall and venous vascular compression (Tinelli’s score=4).4 The tumor extended towards the obturator fossa, with possible involvement of the inguinal canal. Due to an uncertain pathological response, the size of the recurrence, and its close contiguity with the ureter and bowel, we decided to avoid radiation therapy as it could result in a ureteral or intestinal fistula. We performed a laterally extended pelvic resection, as shown step by step in the video.The procedure was conducted until complete removal of recurrence (R0). Estimated blood loss was 1000 mL and total operative time was 240 min. The patient was discharged after 15 days; we reported a urinary infection, a likely postoperative complication. The pathology report described a lymphnodal relapse of ovarian cancer (diameter=6 cm) with infiltration of surrounding tissue and in the sano margins. Six months after surgery, the patient is alive without evidence of relapse.The borders of pelvic surgical anatomy are continually extending, requiring surgeons to use a personalized approach and to continually update their anatomic knowledge. In this context, laterally extended pelvic resection could be a feasible surgical procedure, representing a salvage treatment in recurrent or persistent primary gynecological malignancies infiltrating the pelvic sidewall, when other approaches have failed. However, additional clinical trials are needed to confirm these results.3

INTRODUCTION Breast cancer-related extremity lymphedema is a potentially devastating condition. Vascularized lymph node transfer (VLNT) has shown benefit in lymphedema treatment. Due to concerns over potential iatrogenic complications, various donor sites have been described. The current study aims at defining the deep inferior epigastric lymph node basin as a novel donor site for VLNT. METHODS A retrospective study was performed on patients undergoing routine abdominal-based breast reconstruction. Resection of all perivascular adipose and lymphatic tissue surrounding the proximal deep inferior epigastric pedicle was performed at the time of pedicle dissection and submitted for Pathologic evaluation. Patient demographics and pertinent medical/surgical history was obtained from medical records. RESULTS Specimens were obtained from 10 consecutive patients. Seven patients underwent bilateral reconstruction for a total of 17 specimens obtained. Mean patient age and BMI were 48 years ± 9.4 and 27 ± 4.2, respectively. Fourteen out of 17 (82%) specimens contained viable lymph nodes displaying a thin fibrous connective tissue capsule overlying an unremarkable subcapsular sinus with a cortex and paracortex containing germinal centers composed of B lymphocytes, tangible body macrophages, and T-cells. The medullary sinus space displayed a fatty unremarkable hilum. The mean number and size of lymph nodes were 2.6 ±1.2 nodes/specimen and 3.67 mm ± 2.3, respectively. All patients experienced an uneventful postoperative course without evidence any of compromised flap viability. CONCLUSION Lacking previous description, the deep inferior epigastric lymph node basin is a readily accessible donor site with significant anatomic advantages for potential VLNT during autologous breast reconstruction.

Objective Traditional repair of the disrupted pubic symphysis includes application of pointed clamps to the pubic tubercles and/or pubic body for fracture reduction. Recent studies have reported rates of sexual dysfunction of 42%-90% after repair of these injuries. The purpose of this study is to define the anatomy of the spermatic cord relative to the pubic tubercle and other local structures to assess the risk of sustaining an iatrogenic injury during clamp placement. Methods Eight intact lower-half fresh male human cadavers were dissected. A window of skin and subcutaneous tissue was excised to expose the low abdominal wall and penile root. Pubic tubercles were identified by palpation and marked. The spermatic cord was identified at the superficial inguinal ring and followed into the scrotum, and any anatomical abnormalities were recorded. The relationship and distance of the spermatic cord to the pubic tubercle, insertion of the inguinal ligament and abdominal wall musculature, and pubic symphysis were recorded. Photographs were taken of the superficial and deep anatomy. Results Spermatic cords were found to follow a consistent course after exiting the inguinal canal at the lower abdomen: they coursed inferior and medial to a position lateral to the pubic tubercles. In all cases, the spermatic cord lay adjacent, directly lateral to the tubercle with an average separation of 0.8 mm (range, 0-2 mm). The average distances from the lateral aspect of the tubercle and the medial border of the spermatic cord to the pubic symphysis were 26 and 27 mm, respectively. Qualitatively, even with direct visualization, it was not feasible to apply a pointed tenaculum to the pubic tubercles without piercing the spermatic cord, unless one manually retracted the latter. Conclusions The spermatic cord is located lateral and immediately adjacent to the pubic tubercle after it exits the inguinal canal and passes into the scrotum. As such, the spermatic cord seems to be at a significant risk of sustaining injury when pointed forceps are placed on the tubercles, as is often recommended during the repair of pubic diastasis.

This report describes an extremely rare case of extrarenal Wilms' tumor in a 4 year-old girl who presented with abdominal mass and pain. Computed tomography (CT) scanning revealed a well-defined mass lesion measuring 10 cm on the right side of her lower abdomen and pelvic cavity. The mass was surgically removed. Histologically, the tumor showed a triphasic pattern, consisting of stromal, epithelial and blastemal components. Immunohistochemistry showed that the tumor was positive for cytokeratin, vimentin and CD99. The histopathological diagnosis was extrarenal Wilms' tumor arising in the retroperitoneum and inguinal canal. The patient was administered adjuvant chemoradiotherapy due to subsequent pulmonary and peritoneal metastases. Follow-up 4 years later showed that she was doing well, with no recurrence of the tumor.

Laparoscopic inguinal hernia repair in children is in evolution. Multiple methods of passing the suture around the peritoneum at the level of the internal inguinal ring exist. Cauterization of the peritoneum at the internal ring is thought to increase scarring and decrease recurrence. We have employed a sutureless, cautery only, laparoscopic single port repair of inguinal hernias and patent processus vaginalis (PPV) in girls.After institutional ethical review was obtained, a retrospective review of sutureless laparoscopic inguinal hernia repairs in girls by 4 surgeons at separate institutions was performed. Patient demographics, intraoperative findings, and postoperative outcomes were recorded and analyzed. The technique involves an umbilical 30° camera and either a separate 3 mm stab incision in the midclavicular line or a 3 mm Maryland grasper placed next to the camera, and the distal most portion of the hernia sac is grasped and pulled into the abdomen and cauterized obliterating the sac.Eighty inguinal hernias were repaired using this technique in 67 girls between July 2009 and September 2015. The ages and weights ranged from 1 month to 16 years and from 2 to 69 kg, respectively. There was one conversion to open approach because an incarcerated ovary was too close to the ring. A single umbilical incision was utilized in 85%. Fifty-seven percent patients had hernias on the right whereas 42% had hernias on the left. Of the patients with presumed unilateral hernias, 22 patients were found to have PPV and were treated through the same incisions, 17/22 were found during a contralateral hernia surgery and 5/22 were found incidentally during appendectomy. Average operative time for unilateral and bilateral hernias was 22 minutes (5-38 minutes) and 31 minutes (11-65 minutes), respectively. No patient required a hospital stay because of the hernia repair. At an average of 25 months follow-up (1.6-75 months), there were no recurrences. The only complication was a single lateral port site hernia on a 2 kg, former 24 week postmenstrual age girl before adapting the technique to single-site surgery for all.Laparoscopic sutureless inguinal hernia repair is safe and effective in girls of all ages. The single-site modification allows for superior cosmetic result and lower complication profile. The Burnia allows for adequate treatment of unilateral and bilateral inguinal hernias with a single incision in the umbilicus.