Paradigm shift regarding the transversalis fascia, preperitoneal space, and Retzius' space.

BACKGROUND: There has been confusion in the anatomical recognition when performing inguinal hernia operations in Japan. From now on, a paradigm shift from the concept of two-dimensional layer structure to the three-dimensional space recognition is necessary to promote an understanding of anatomy. ANATOMY AND EMBRYOLOGY: Along with the formation of the abdominal wall, the extraperitoneal space is formed by the transversalis fascia and preperitoneal space. The transversalis fascia is a somatic vascular fascia originating from an arteriovenous fascia. It is a dense areolar tissue layer at the outermost of the extraperitoneal space that runs under the diaphragm and widely lines the body wall muscle. The umbilical funiculus is taken into the abdominal wall and transformed into the preperitoneal space that is a local three-dimensional cavity enveloping preperitoneal fasciae composed of the renal fascia, vesicohypogastric fascia, and testiculoeferential fascia. The Retzius' space is an artificial cavity formed at the boundary between the transversalis fascia and preperitoneal space. In the underlay mesh repair, the mesh expands in the range spanning across the Retzius' space and preperitoneal space.

Nonobliteration of the Processus Vaginalis. Sonography of Related Abnormalities in Children.

The objective of this pictorial essay is to systematically classify processus vaginalis­ related disorders in the light of embryology and present illustrative sonograms with corresponding diagrams. Failure of the processus vaginalis to obliterate during gestation results in a wide spectrum of anomalies, including communicating and noncommunicating hydroceles and inguinal and inguinoscrotal hernias, along with other related disorders of the genital system. There are varying classifications in the literature regarding the aforementioned entities. Proper and timely diagnosis of these entities is essential, given the differences in treatment. Although physical examination can narrow the differential diagnosis, sonography plays an essential role in establishing the diagnosis.

Comparison of inguinal hernia and asymptomatic patent processus vaginalis in term and preterm infants.

INTRODUCTION: The aim of this study was to evaluate the characteristics of inguinal hernia (IH) and patent processus vaginalis (PPV) in term and preterm infants less than the age of 6months. METHOD: Between January 2004 and December 2012, 246 term and 165 preterm infants underwent laparoscopic herniorrhaphy within the first 6months of life. Preoperative clinical presentation and intraoperative anatomical findings during the laparoscopic procedure were evaluated. Additionally, initial side of hernia, laterality of IH and PPV were analyzed in term and preterm infants. RESULTS: In the group of term infants, most infants presented with a primary right-sided IH (58.5%) versus 17.9% left-sided and 23.6% bilateral IH. Babies with primary unilateral IH were found to have a contralateral PPV in 41.0% of cases. A difference between left-sided PPV and right-sided PPV could not be identified. In the group of preterm infants, initial bilateral presentation was predominant (38.8%) versus right-sided (30.3%) and left-sided IH (30.9%). Infants with primary unilateral IH were found to have a contralateral PPV in 56.4%. We identified a slight difference between left-sided PPV (54.0%) and right-sided PPV (58.8%). CONCLUSION: IH is predominantly right sided in term infants, whereas preterm infants mostly present with bilateral IH. The incidence of PPV was found to be significantly higher in the preterm group. Regarding the incidence of a contralateral PPV in term and preterm infants, no difference between initial left-sided and right-sided IH could be identified between both groups.

Inguinal hernia in premature boys: should we systematically explore the contralateral side?

OBJECTIVE: Bilateral surgery has been largely advocated in premature boys with unilateral inguinal hernia owing to the high incidence of contralateral patent processus vaginalis. Recently, the potential morbidity of herniotomy in low birth-weight babies and the progress in pediatric anesthesia questioned this attitude. This study aims to evaluate the incidence of contralateral metachronous hernia in a large series of premature boys and to compare the morbidity of preventive versus elective surgery. METHODS: This retrospective multicenter analysis of 964 premature boys presenting with unilateral inguinal hernia operated from 1998 to 2012 included 557 infants who benefited from a unilateral herniotomy and 407 from a bilateral herniotomy (median follow-up 12months). RESULTS: Contralateral metachronous hernia after unilateral surgery occurred in 11% (n=60) without significant difference according to the initial symptomatic side (9.5% on right vs 13% on left, p>0.05). Postoperative morbidity on the contralateral side was higher after preventive surgery than elective surgery with metachronous hernia (2.45% versus 0.9%, p=0.05) especially for secondary cryptorchidism (1% vs 0%, p=0.03). Despite the risk of metachronous incarcerated hernia, elective surgery did not increase the rate of testicular hypotrophy on the opposite side (0.7%, vs 0.7%, p>0.05). CONCLUSION: Systematic bilateral herniotomy is unnecessary in almost 90% of patients and has a significant morbidity. Secondary surgery for metachronous hernia does not increase the risk of testicular lesion and even reduces the risk of secondary cryptorchidism. These results, along with the risk of hypofertility reported after bilateral surgery, may justify treating only the symptomatic side in premature boys.

The epidemiology and risk factors for recurrence after inguinal hernia surgery.

BACKGROUND: Recurrence after inguinal hernia surgery is a considerable clinical problem, and several risk factors of recurrence such as surgical technique, re-recurrence, and family history have been identified. Non-technical patient related factors that influence the risk of recurrence after inguinal hernia surgery are sparsely studied. The purpose of the studies included in this PhD thesis, was to describe the epidemiologic characteristics of inguinal hernia occurrence and recurrence, as well as investigating the patient related risk factors leading to recurrence after inguinal hernia surgery. Four studies were included in this thesis. METHODS AND RESULTS: Study 1: The study was a nationwide register-based study combining the Civil Registration System and the Danish National Hospital Register during a five-year period. We included a total of 46,717 persons operated for a groin hernia from the population of 5,639,885 people (2,799,105 males, 2,008,780 females). We found that 97% of all groin hernia repairs were inguinal hernias and 3% femoral hernias. Data showed that inguinal hernia surgery peaked during childhood and old age, whereas femoral hernia surgery increased throughout life. Study 2: Using data from the Danish Hernia Database (DHDB), we included all male patients operated for elective primary inguinal hernia during a 15-year period (n = 85,314). The overall inguinal hernia reoperation rate was 3.8%, and subdivided into indirect inguinal hernias and direct inguinal hernias, the reoperation rates were 2.7% and 5.2%, respectively (p <0.001, chi-square). In the multivariate Cox proportional hazards analysis of factors predicting reoperation, we found that a direct inguinal hernia at primary operation was a substantial risk factor for recurrence with a Hazard ratio of 1,90 (CI 95% 1.77-2.04) compared with an indirect inguinal hernia at primary operation (p < 0.001). We found that there was a significant relationship between the type of hernia at the primary operation and reoperation, when controlling for the effect of the operation method, r = 0.45 (p < 0.001). This corresponded to odds ratios (OR) of 7.1 (CI 95% 6.0-8.4) of being reoperated for a direct inguinal hernia if the hernia at the primary operation was a direct inguinal hernia, and an OR of 3.0 (CI 95% 2.7-3.3) of being reoperated for an indirect inguinal hernia if the primary operation was for an indirect inguinal hernia. As subsequent findings, we saw that the frequency of laparoscopic hernia repair increased during the study period and that the laparoscopic repair of indirect inguinal hernias recurred more often than indirect inguinal hernias operated by Lichtenstein's technique (p < 0.001). Study 3: Using data from the DHDB, we included all female patients operated for elective primary inguinal hernia during a 15-year period (n = 5,893). Of those, a total of 305 operations for recurrences were registered (61 % inguinal recurrences, 38 % femoral recurrences, 1 % no hernial), which corresponded to an overall crude reoperation rate of 5.2%. A noticeable difference was found in reoperation rates after primary operation for direct inguinal hernias (DIH), indirect inguinal hernias (IIH) and combined IIH+DIH of 11.0%, 3.0%, and 0.007% respectively (p < 0.001, chi-square). In the multivariate Cox proportional hazards analysis of factors predicting reoperation, we found that a direct inguinal hernia at primary operation was a substantial risk factor for recurrence with a Hazard ratio of 3.1 (CI 95% 2.4-3.9) compared with an indirect inguinal hernia at primary operation (p < 0.001). Laparoscopic operation was found to give a lower risk of recurrence with a Hazard ratio of 0.57 (CI 95% 0.43-0.75) compared with Lichtenstein's technique (p < 0.001). We found that all femoral recurrences (n = 116) occurred after Lichtenstein's procedure and none occurred after laparoscopic operation (p < 0.001, Log Rank test). Study 4: This study was a systematic review and meta-analysis of non-technical patient-related risk factors for recurrence after inguinal hernia surgery. From a total of 5,061 potentially relevant records we included 40 studies in the review covering 719,901 procedures in 714,167 patients and of those 14 studies covering 378,824 procedures in 375,620 patients were included into meta-analysis of eight risk factors (gender, age, hernia type, hernia size, re-recurrence, bilaterality, mode of admission and smoking). We found that female gender (RR 1.38, 95% CI 1.28-1.48, I2 = 0%), direct inguinal hernias at primary procedure (RR 1.91, 95% CI 1.62-2.26, I2 = 10%), operation for a recurrent inguinal hernia (RR 2.2, 95% CI 2.0-2.42, I2 = 6%), and smoking (OR 2.53, 95% CI 1.43-4.47, I2 = 0%) were risk factors for recurrence after inguinal hernia surgery. Furthermore, emergency admission; connective tissue composition and degradation; and positive family history were found to have an impact on the risk of recurrence, while post-operative convalescence and age had no impact on the risk of recurrence. CONCLUSION: The studies included in the thesis have studies the natural history of groin hernias on a nationwide basis; have identified the epidemiologic distribution of groin hernias and the non-technical risk factors associated with recurrence. Data showed that non-technical patient-related risk factors have great impact on the risk of recurrence after inguinal hernia surgery. The reason to why inguinal hernias recur is most likely multifactorial and lies in the span of technical and non-technical patient-related risk factors and it is possible that the different groin hernia subtypes have different pathophysiology. This knowledge should be implemented into clinical practice in order to reduce the risk of recurrence and in future research design examining recurrence after inguinal hernia surgery as outcome.

Assessment and management of inguinal hernia in infants.

Inguinal hernia repair in infants is a routine surgical procedure. However, numerous issues, including timing of the repair, the need to explore the contralateral groin, use of laparoscopy, and anesthetic approach, remain unsettled. Given the lack of compelling data, consideration should be given to large, prospective, randomized controlled trials to determine best practices for the management of inguinal hernias in infants.

Pediatric inguinal hernias, hydroceles, and undescended testicles.

Pediatric inguinal hernias are extremely common, and can usually be diagnosed by simple history taking and physical examination. Repair is elective, unless there is incarceration or strangulation. Hydroceles are also quite common, and in infancy many will resolve without operative intervention. Undescended testicles harbor an increased risk of infertility and malignancy, and require orchiopexy in early childhood.

An evidence-based approach for laparoscopic inguinal hernia repair: lessons learned from over 1,000 repairs.

In this educational article, we aim to provide a literature review on laparoscopic anatomy of the inguinal region. We share the lessons learnt from the 1,194 laparoscopic hernia operations we have performed in 16 years of experience, trying to provide an anatomical and physiological basis for surgeons. The current study reports a personal experience with a transabdominal preperitoneal (TAPP) hernioplasty procedure. A literature review using the keywords "hernia," "laparoscopic approach," and "hernia repair" was performed using the electronic biomedical database PubMed, Medline Extra, Embase, Biosis, Science Citation Index, Ovid and text books. Between January 1994 and December 2010, a total of 1,194 patients, males and females (average age, 56.7 years), underwent laparoscopic TAPP inguinal hernia repair. Following reduction of the hernia sac and creation of the preperitoneal flap, a polypropylene mesh (10 × 16) and four spiral tacks were placed. TAPP is easy to learn and perform. Through this approach, a much better view from the inguinal anatomy is achieved, and the procedure also offers a brief learning curve. Our patients reported minimal postoperative pain and returned to work after 5-10 days, which is in accordance with the general anesthesia series. During the follow-up period, 10% of seromas, 3% of scrotal hematomas, 1% of hemorrhages, and 3% of recurrent hernias were observed. It should be emphasized that we have not observed abscess formation or acute infection related to the presence of mesh.

Ten-year review of groin laparoscopy in 1001 pediatric patients with clinical unilateral inguinal hernia: an improved technique with transhernia multiple-channel scope.

PURPOSE: The purpose of this 10-year review of data is to verify the effectiveness, safety, and appropriate age group for using a multichannel scope during inguinal herniorrhaphy in pediatric patients with clinical unilateral inguinal hernia to evaluate for contralateral patent processus vaginalis (CPPV). METHODS: The data evaluated are age, sex, negative findings, positive findings, false positives, false negatives, recurrences, date of recurrence, and complications. Patients who clinically had bilateral hernias or were born prematurely were excluded. A 5-mm, 30° multichannel scope was used through the ipsilateral open hernia sac to explore the contralateral internal ring. A Fogarty catheter was used through one of the channels of the scope to probe the contralateral side in instances of questionable patent processus vaginalis. RESULTS: One thousand one patients were studied, and a total of 237 CPPVs (23%) were identified. The highest incidence of CPPV was found in those patients younger than 1 year (44%). Contralateral patent processus vaginalis was identified and ligated in 34% of patients younger than 2 years, 20% in patients 2 to 8 years old, and 17% of patients 9 to 18 years old. There were no false positives and 6 false negatives (0.6%) of the contralateral side. There were 3 (0.3%) recurrent inguinal hernias of the ipsilateral side and no complications. CONCLUSIONS: The use of a multichannel scope through the ipsilateral open hernia sac during inguinal herniorrhaphy in pediatric patients with clinical unilateral inguinal hernia to evaluate for CPPV proved to be effective, cost-effective, and safe. Our procedure eliminated any additional scars and the cost of trocars and permitted us to probe the contralateral internal ring. Unnecessary open exploration was spared in 56% of children younger than 1 year and proved to be useful in all pediatric patients up to the age of 18 years.

[Prenatal diagnosis of an inguino-scrotal hernia in a fetus with trisomy 18]. / Pränatale Diagnose einer Skrotalhernie bei einem Feten mit Trisomie 18.

In spite of its prevalence in neonates, an inguino-scrotal hernia is a rarely detected condition in prenatal life. The sonographic findings, i. e., a scrotal mass with intestinal peristalsis, the differential diagnosis, and possible associations between a scrotal hernia and chromosomal aberrations are described by presenting the case of a fetus with trisomy 18 and major structural anomalies.

Prenatal evaluation of a scrotal mass using a high-frequency probe in the diagnosis of inguinoscrotal hernia.

Whereas inguinal hernia is a common pediatric disease, fetal inguinal hernia is rarely diagnosed because intra-abdominal pressure usually occurs only after birth. We report a case of prenatal diagnosis of a scrotal mass at 35 weeks' gestation. The initial differential diagnosis included hydrocele, testicular teratoma and testicular torsion, but inguinoscrotal hernia was considered the most likely diagnosis when further ultrasound imaging using a high-frequency probe demonstrated bowel loop movements around the mesenteric artery. This diagnosis was confirmed postnatally.

Rol de la ultrasonografía en el diagnóstico y manejo de la hernia inguinal en pacientes pediátricos / Role of ultrasonography in the diagnosis and management in pediatric patients with inguinal hernia

La ultrasonografía (US) puede jugar un rol importante, tanto en la confirmación diagnóstica de hernia inguinal como en la detección preoperatoria de hernia inguinal contralateral.

Obliteration of processus vaginalis: aberrations in the regulatory mechanism result in an inguinal hernia, hydrocele or undescended testis.

The testis is descended through the processus vaginalis via propulsive force generated by the muscles derived from the gubernaculum. After propelling the testis, the smooth muscle should undergo programmed cell death for obliteration of the processus vaginalis. Achievement of programmed cell death mandates a transient decrease in sympathetic, but an increase in parasympathetic, tonuses. Since the sympathetic tonus is androgen-dependent, the decrease in androgen levels during the third trimester appears to be responsible for the process. Alterations in timing, intensity or duration of the decrease in sympathetic tonus under the control of the central nervous system give rise to hernia, hydrocele or abnormal testis localizations. The persistence of decrease causes undescended, retracted, or ascended testis. Absence or inadequacy of the decrease in sympathetic tonus results in rescue of more smooth muscle, thus inhibiting the obliteration. Inadequacy in the intensity or duration rescues less smooth muscle and gives rise to a hydrocele. Persistence of signals towards inducing programmed cell death contributes to decrease in fertility, and provides a basis for epididymo-vasal anomalies. The reduction in the central regulatory mechanism that involves catecholaminergic activity explains the blunting of luteinizing hormone (LH) response to gonadotropin-releasing hormone (GnRH). The explained mechanism precisely defines the role of all factors, and links all of the associations related to the process of descent.

Atypical sonographic presentation of fetal unilateral inguinoscrotal hernia in a multiple gestation.

Ultrasonographic demonstration of bowel peristalsis within the fetal scrotum has been described as a pathognomonic sign of inguinoscrotal bowel herniation. We present the sonographic features and neonatal outcome of a fetus with a scrotal mass seen at 34 weeks of gestation in a twin pregnancy. This mass was diagnosed postnatally as a non-reducible inguinoscrotal hernia, in which bowel peristalsis had not been observed by real-time ultrasound in utero.

A reevaluation of the structures accepted to represent the postnatal gubernaculum.

INTRODUCTION: The structure called the residual gubernaculum (G) has been evaluated to define its origin. MATERIALS AND METHODS: Girls operated for inguinal hernia (n = 7) and boys operated for undescended testis (n = 12), inguinal hernia (n = 7), hydrocele of the cord (n = 1), and ectopic (n = 1) and entrapped (n = 1) testes were evaluated. Attachments of the structures coursing distally from the sacs were identified, and they were removed en block. Three samples, first from the distal part of the sac with the beginning of the fibrous structure, second from the midportion, and third from the most distal part, were prepared and stained with hematoxylin-eosin, trichrome and elastic van Gieson. Histologic structures within the samples were determined and compared with Mann-Whitney U test. RESULTS AND CONCLUSIONS: Structures called the residual G differed from the walls of accompanying sacs by only the absence of mesothelial lining. Therefore, the structure called the residual G in boys with an undescended testis and the round ligament in girls actually represent the obliterated processus vaginalis.

Scrotal and inguinal masses in the newborn period.

Scrotal or inguinal masses may represent inguinal hernias, hydroceles, or testicular torsion and are common findings in the newborn period. The clinician is challenged to differentiate between normal, abnormal, atypical, and pathologic findings and to seek urgent surgical consultation when compromised bowel, testis, or ovary is suspected. This issue of Focus on the Physical offers a review of the embryologic development of the processus vaginalis and testicular attachments to enhance the clinician's understanding of the development of these conditions. Systematic advanced physical assessment techniques will be provided along with pictures of common clinical findings. A brief discussion of the diagnostic studies that aid in differentiation of scrotal and inguinal masses and the clinical implications of each of these conditions will be discussed.

Pathology of the pediatric regio inguinalis: mysteries of the hernia sac exposed.

Inguinal hernia repair is one of the most common surgeries performed on children. However, the value of routine histologic examination of hernia sac tissues continues to be debated. Although the surgical pathology of herniorrhaphy tissues is usually simple, occasional examples have unexpected findings that potentially lead to inappropriate management or that have added clinical implications. These along with surgical-quality assurance issues need to be considered in cost-benefit arguments. This article reviews basic histology, common potential pitfalls, and significant unexpected conditions encountered in the surgical pathology of the inguinal hernia sac in children.