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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.

Highlights • Herniation of the ureter into the inguinal canal is a rare occurrence. • There have been reports of inadvertent injury to the ureter during routine inguinal hernia repair. • After an extensive search of the literature, we believe this is the 1stcase to be managed by Laparoscopic TAPP Repair. • Presence of ureter buried in a large amount of fat can be mistaken for lipoma of the cord and injured with blind clamping. • Presence of unilateral hydroureteronephrosis in a patient with inguinal hernia should prompt a surgeon to proceed with CT., Introduction Herniation of the ureter into the inguinal canal is a rare occurrence. There have been reports of inadvertent injury to the ureter during routine inguinal hernia repair. After an extensive search of the literature, we believe that this is the first case to be managed via laparoscopic Trans Abdominal Pre-Peritoneal Repair and would like to highlight the technical details of the laparoscopic procedure and is presented in line with SCARE 2018 Guidelines [1]. Presentation of case A 60-year-old male presented with left inguinal hernia. He also complained of an increase in frequency of micturition, with an occasional radiating pain from loin to the groin. Imaging revealed the left ureter coursing into the left inguinal canal, descending into the scrotum, and looping back to enter the bladder with mild hydroureteronephrosis. Patient underwent a laparoscopic repair of the inguinal hernia with reduction of ureter under ureteroscope guidance and stent placement. Discussion The presence of ureter buried in a large amount of fat can be mistaken for a lipoma of the cord or extraperitoneal fat and injured with blind clamping and division. Presence of fat without an obvious sac should alert the surgeon to the possibility of ureter being a content. Conclusion Laparoscopy is safe, technically feasible, offers good visualization of all hernial orifices, demonstrates complete reduction of ureter from inguinal canal under vision, allows manipulation of ureter under the vision for ureteroscopy and stenting, making sure there are no loops or kinking and allows placement of mesh in the preperitoneal space.

Background: Simultaneous bilateral testicular torsion in inguinal canal is a very rare condition which mandates prompt surgical intervention. Case Report: We report a case of an adolescent male presenting with complaint of severe pain in left inguinal region. Diagnosis of bilateral testicular torsion with bilateral undescended testes was made clinically and supported by Doppler study. This was followed by emergent surgical exploration requiring left orchiectomy and right orchiopexy. Conclusion: A high index of suspicion is required in any patient presenting with lower abdominal or groin pain and an empty scrotum to clinch the diagnosis and act promptly in an effort to salvage the testes. We believe, irrespective of the time elapsed since the onset of symptoms, surgical intervention should be undertaken as spontaneous torsion and detorsion might be happening, enabling testicular salvage.

A 7-year-old girl was referred to our hospital with a suspected right-sided indirect inguinal hernia. An egg-sized elastic, non-painful mass was palpated in the right inguinal region. Preoperative CT demonstrated a 30-mm simple cystic mass in the right internal inguinal canal, which we diagnosed as an abdominal cyst of the canal of Nuck. Laparoscopy revealed that the abdominal cystic component was ruptured, so we performed Pott's procedure. However, the patient's right groin swelled on postoperative day 3, necessitating re-operation. The patient's symptoms recurred again after 3 months, despite having had two surgical repairs. In the third operation, a right-sided femoral hernia was confirmed and repaired via external and laparoscopic approaches. To the best of our knowledge, there have been no reports on the combination of femoral hernia and cyst of the canal of Nuck in children. A laparoscopic approach was useful for obtaining a definitive diagnosis and conducting a safe and secure surgical repair.

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

Objectives The groin is a complex anatomic region that has traditionally been ignored by radiologists because most lesions can be diagnosed from clinical data and physical examination. Nevertheless, ultrasound examinations of the groin are increasingly being requested to confirm injury or to resolve diagnostic uncertainty. On the other hand, some conditions involving the groin are found only in paediatric patients. This article describes the key imaging findings in paediatric groin injuries, placing special emphasis on the ultrasound appearance. Conclusions Knowledge about conditions that can affect the groin in paediatric patients and the key imaging findings associated with them helps improve the diagnostic performance of ultrasound.

Despite the introduction of sentinel node biopsy in patients with vulvar cancer, still approximately 50% of all patients have to undergo an inguinofemoral lymphadenectomy. This is associated with a high incidence of postoperative complications, which may be influenced by inguinal drain management. The aim of this study was to investigate the feasibility of a new surgical technique regarding drain management with an inguinoperitoneal drainage. A retrospective analysis of 21 vulvar cancer patients with inguinofemoral lymphadenectomy was conducted. A silicone drain was circularly placed with the perforated end in the groin and the other end in the space of Douglas. The removal after 3 months was performed under local anesthesia. All patients were questioned during clinical follow-up regarding their personal experiences with the procedure, the occurrence of complications, and side effects using a clinical questionnaire. In 100% of the patients, the procedure was feasible. Regarding the number of groin punctures due to lymphocyst formation, 15 (71.4%) patients did not need any intervention and 3 (14.3%) patients needed 1–3 punctures. The patient satisfaction with the internal drainage was ranked as good by 17 (81.0%) patients and as moderate by 1 (4.8%) patient. In 3 (14.3%) patients, information about the number of groin punctures and the patient satisfaction were missing. Inguinoperitoneal drainage after inguinofemoral lymphadenectomy in vulvar cancer patients is feasible and safe and a patient satisfaction of 81% is promising. For definitive conclusions regarding the efficacy of this technique, further investigations and prospective multicenter trials are needed.

Inguinal hernia repair is one of the most commonly performed surgical procedures. Postoperative neuropathic groin pain is a potentially disabling complication and can be due to a neuroma of the ilioinguinal, iliohypogastric, and/or genitofemoral nerves. In this article, we present our operative technique-a retroperitoneal approach to the ipsilateral ilioinguinal, iliohypogastric, and genitofemoral nerves with neurectomy and proximal transposition of these nerves-for management of neuropathic pain. A retrospective review was performed of 12 of the patients who underwent this surgery at our institution. Three of 12 patients underwent a selective neurectomy, whereas 9 of 12 underwent a triple neurectomy; 3 of the 9 patients who underwent triple neurectomy also had a retroperitoneal peripheral nerve stimulator placed at the time of neurectomy. Pain visual analog scores (VASs) demonstrated significant improvement after neurectomy (preoperative pain VAS of 85 ± 11 vs postoperative pain VAS of 47 ± 32, P = 0.0027). Eight of 12 patients experienced partial or complete pain relief, whereas 4 of 12 patients had no pain relief. There were no major complications, and the minor complication rate was low for all patients and primarily related to peripheral nerve stimulator placement. This retroperitoneal approach to triple neurectomy for treatment of refractory groin pain in postoperative inguinal hernia repair patients is safe and effective for an otherwise devastating problem.

Introduction Gynaecological structures such as the ovaries, fallopian tubes, ligaments and uterus are rarely encountered inside a hernial sac. The prevalence of groin hernias containing parts of female genitalia remains unknown. The aim of this review was to summarise the existing evidence on inguinal hernias containing ovaries with or without the other female adnexa. Methods A systematic search was conducted for literature published up to February 2018 using the MEDLINE®, Scopus® and Google Scholar™ databases along with the references of the full-text articles retrieved. Papers on observational studies and case reports concerning women who were diagnosed with an ovarian inguinal hernia (pre or intraoperatively) were considered eligible for inclusion in the review. Results Fifteen papers (13 case reports, 2 case series) comprising seventeen patients (mean age 47.9 years) were evaluated. A left-sided hernia was noted in 13 cases (77%) whereas 4 patients had a right-sided hernia. Eight patients underwent preoperative imaging with computed tomography, ultrasonography or both. This was diagnostic in five cases. In 11 patients, hernia contents were repositioned, 2 had a salpingo-oophorectomy and 2 an oophorectomy. Eight patients underwent hernia repair with mesh placement while three had a herniorrhaphy. Conclusions Ovarian inguinal hernias should be considered among the differential diagnoses of a groin mass or swelling. In women of reproductive age, repair of the hernia with the intent to preserve fertility is of critical importance.

Introduction. Angiomyolipomas represent neoplasms of mesenchymal origin, made up of abnormal thick-walled blood vessels, smooth spindle muscle cells, and mature adipose cells. The most common site of origin are kidneys, and other localizations are extremely rare. We represent a case of a spermatic cord angiomyolipoma misdiagnosed as incarcerated inguinoscrotal hernia, and to our prudence this is second described case of an angiomyolipoma localized in the spermatic cord. Case outline. We present a case of a 63-year-old man presented with high fever and difficulty in walking due to pain and swelling in the right groin. According to the clinical examination and laboratory tests, presumptive diagnosis was incarcerated inguinoscrotal hernia, so the patient was immediately operated on. The exploration of the inguinal canal showed a timorous mass, 9 ? 9 cm in size, with the origin from the spermatic cord, so radical inguinal orchiectomy was performed with the removal of the tumor mass. Histopathological and immunohistochemistry examination suggested angiomyolipoma of the spermatic cord. The postoperative course was uneventful. Conclusion. Although rare, an angiomyolipoma of the spermatic cord must be included in the differential diagnosis of scrotal masses. Also, we advocate additional diagnostic procedures (ultrasound or computed tomography) for every inguinoscrotal mass before undertaking surgery, since a variety of different causes can be found. After definitive angiomyolipoma diagnosis is obtained, further investigation is needed, especially brain computed tomography due to possible tuberous sclerosis coexistence.

Objective The aim of the study is to specify diagnostic MRI and ultrasound criteria for a sports hernia in order to verify its diagnosis in football players. Patients and methods Materials and methods: The study included 50 professional and amateur football players aged 15 to 34 from 2016 to 2019. The criteria for inclusion in the study were: the presence of groin pain in football players, which prevented them from continuing to actively participate in sports activities. Results Results: The findings of the study revealed that during MRI the two factors, which had the strongest influence, were "increased MR signal intensity on PDfs observed from the structures of the inguinal canal" and "increased MR signal intensity on PDfs observed from bone marrow of superior ramus of the pubic bone". During ultrasound of the inguinal area, the main criterion for a sports hernia diagnosis was "increased size of the inguinal canal". The verification of the diagnosis was carried out on the basis of the presence of a protrusion in the posterior wall of the inguinal canal. For a sports hernia diagnosis the MRI sensitivity is 91.67% (95% CI 77.5 - 98.2), specificity -78.57% (95% CI 49.2 - 95.3) and the sensitivity of ultrasound is 88.89% (95% CI 73.9 - 96.9), the specificity - 50% (95% CI 23.0 - 77). Conclusion Conclusions: The combination of MRI and ultrasound makes it possible to accurately detect the presence of a sports hernia in the football player. Based on the findings of our study, we formulated MRI and ultrasound criteria for a sports hernia diagnosis.

Background: Inguinal hernia in children is currently treated through a groin incision with access to the inguinal canal and handling of the spermatic cord. In the face of the growing utili...

Groin hernias occur in 27–48% of men and 3–6% of women during lifetime. Among the causes are inherited or age-related connective tissue or muscular dysplasia, lack of diverticular obliteration in fetal parietal peritoneum, pre-peritoneal lipomas migrating into the hernia ring, and congenital, postpartum, or postoperation dilation of the femoral ring. Physical examination and examination of the preperitoneal space reveals hernia in 93% and 100%, respectively, yet ultrasound examination, computed tomographic peritoneography, magnetic resonance imaging are also employed to confirm the diagnosis. An established technique for the treatment of groin hernias includes opening the inguinal canal, high ligation of the hernia sac, and repair of the inguinal canal, altogether termed herniorrhaphy. Suprapubic or inguinal incision permits closure of the hernia sac without involving the inguinal canal (herniotomy). Implementation of synthetic meshes led to the increase in hernioplasty, i.e. reinforcement of the inguinal canal upon the inguinal canal repair. Laparoscopic transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) hernioplasty became widely used along with the development of endoscopic surgery. In these techniques, mesh is placed between the peritoneum and transversalis fascia, closing both inguinal canal and femoral ring. Overall, modern surgical techniques reduced the time of treatment, disability and disease recurrence to 1.4–2%.

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)).

Seventy-five percent of all abdominal wall hernias are found in the groin, making it the most common location for an abdominal wall hernia. Of all groin hernias, 95% are hernias of the inguinal canal, with the remainder being femoral hernia defects. Inguinal hernias are nine times more common in men than in women. Although femoral hernias are found more often in women, the inguinal hernia is still the most common hernia in women. The overall lifetime risk of developing a groin hernia is approximately 27% in males and 3% in females. Over a period of one and half year patients selected with inguinal hernia as per inclusion and exclusion criteria were included in this prospective study Patients were randomly divided into two groups’ i.e. Group 1(Control group): were subjected to Lichtenstein Tension free mesh repair, Group 2(Study group): were subjected to Desarda repair. In the present study 2 patients from both group had seroma collection and 2 patients of LTF group had wound infection one patient of Desarda group had wound infection with Ischemic Orchitis for which re-exploration was done. Rests of the complications were not seen in both groups.

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.

Inguinal endometriosis is a very rare entity with uncertain pathophysiology, that poses several diagnostic and therapeutic challenges. This study aimed to summarize published literature on the diagnosis and treatment of this condition. Thus, a systematic literature search was conducted in PubMed/MEDLINE, Scopus and the Cochrane Library. An effort was made to numerically analyze all parameters included in case reports and retrospective analyses, as well. The typical and atypical features of this condition, investigations used, type of treatment and histopathology were recorded. More specifications about the surgical treatment, such as operations previously performed, type of surgery and treatment after surgery have been acknowledged. Other sites of endometriosis, the presence of pelvic endometriosis and the follow-up and recurrence have been also documented. Overall, the search yielded 61 eligible studies including 133 cases of inguinal endometriosis. The typical clinical presentation includes a unilateral inguinal mass, with or without catamenial pain. Transabdominal or transvaginal ultrasound was typically used as the first line method of diagnosis. Groin incision and exploratory surgery was the treatment indicated by the majority of the authors, while excision of part of the round ligament was reported in about half of the cases. Chemotherapy and radiotherapy were initiated in cases of coexisting endometriosis-related neoplasia. Inguinal recurrence or malignant transformation was rarely reported. The treatment of inguinal endometriosis is surgical and a long-term follow-up is needed. More research is needed on the effectiveness of suppressive hormonal therapy, recurrence rate and its relationship with endometriosis-associated malignancies.

Lipomas of the cord are common and generally associated with an indirect hernia sac, but not always, as the lipoma may be the only pathology identified during groin exploration. Missed lipoma of the spermatic cord is unfortunately not infrequent and may lead to persistence of post-operative groin pain, with confirmation of unresected cord lipoma on postoperative ultrasound, often necessitating reoperation. We present an interesting case of a 40-years-old male with symptomatic re-recurrent left inguinal hernia following previous open and subsequent endoscopic totally extraperitoneal (TEP) mesh repair. At laparoscopy, the previously inserted extraperitoneal mesh seemed well integrated with no evidence of recurrent hernia sac. Further transabdominal preperitoneal (TAPP) approach identified a moderate-size cord lipoma that had been missed twice before. His postoperative recovery was uneventful, and his previous symptoms completely subsided. This is of significant value as lipomas of the cord may sometimes represent the only source of chronic groin pain in patients with no other clinical findings. Consequently, they should be viewed and treated as “true” inguinal hernias as per the European Hernia Society (EHS). During every inguinal hernia case, the surgeon must perform rigorous exploration of the inguinal canal, looking for any herniated adipose tissue that can be easily cleared by either reduction or resection. This is further supported by both the European Association of Endoscopic Surgery (EAES) and the International Endohernia Society (IEHS) who recommend an active search for spermatic cord lipomas in all laparo-endoscopic inguinal hernia repairs.

Amyand’s hernia, presence of the appendix within an inguinal hernial sac, is a rare condition. We report a case of a 68-year-old woman who presented during the COVID-19 pandemic with an acute right groin pain due to a tender incarcerated inguinal hernia. Cross-sectional imaging confirmed an Amyand’s hernia. She proceeded to open appendectomy via the inguinal canal and primary suture repair of her inguinal hernia. Patient was discharged the following day. Surgical management of Amyand’s hernia varies depending on the resources, clinical findings and personal experience. In our opinion and experience, open hernia reduction, appendectomy and primary tissue repair repairs the most effective and appropriate approach especially during the COVID-19 pandemic.

OBJECTIVE To compare mean postoperative pain post-Lichenstein open hernioplasty with and without ilioinguinal neurectomy at six months. STUDY DESIGN Randomised controlled trail. PLACE AND DURATION OF STUDY Surgical Unit-I, Benazir Bhutto Hospital, Rawalpindi, from August 2014 to February 2015. METHODOLOGY Adult male patients with unilateral reducible inguinal hernia, who consented to the study between the age range of 18-80 years, were included. Recurrent, irreducible or strangulated, or large inguinal-scrotal hernia and those with previous abdominal incision, impaired cognition, peripheral neuropathy, limited mobility and females were excluded. Patients were equally randomised to nerve-preservation and excision groups. Mann-Whitney U-test was applied to find out difference in inguinodynia at 1 and 6 months. RESULTS There was significant difference in pain at 1 month in the nerve-preservation group (Md=6.00, IQR=4, n=90) and nerve excision group (Md=3.50, IQR=4, n=90), U=2308.00, z=-5.017, p

Groin pain in athletes is a common problem and can have extensive consequences for professional athletes. The anatomical and functional complexity of the groin as well as radiating pain from remote anatomical regions can make the differential diagnosis a challenge and requires special attention. As there are a wide variety of possible causes for groin pain, a multidisciplinary approach is required. The treating orthopedic surgeon needs to pay special attention to pre-arthritic hip deformities to avoid irreversible damage of the hip joint. By a meticulous patient history and identification of the pain character, followed by clinical, sonographic and radiographic investigations, a differential diagnosis can usually be achieved. Besides typical orthopedic causes, pathological findings particularly in the area of the groin need to be considered, clarified and adequately treated; therefore, a clear terminology of the different diseases is necessary. Sportsmen's groin is not a hernia but should be perceived as a separate entity due to its typical pain character and detection of a measurable protrusion of the posterior wall of the inguinal canal by ultrasound.