Hernia vesical inguinoescrotal incarcerada: manejo quirúrgico / Incarcerated inguinoscrotal bladder hernia: surgical management

RESUMEN La hernia vesical es una entidad asociada a la hernia inguinal, con predisposición de lado derecho, en un porcentaje de 0,5 a 3%, hasta 10% en hombres, y a partir de la quinta a séptima década de vida1. La mayoría son pequeñas; la fisiopatología más común es la obstrucción mientras que la hiperplasia prostática es la principal etiología. La presentación clínica es poco específica, y el diagnóstico es en la mayoría de los casos transoperatorio. Se presenta el caso de un paciente de género masculino de 64 años, con antecedente patológico de enfermedad de Parkinson, hernia inguinal izquierda reducible hace 5 años. Acudió a consulta médica por manifestar dolor abdominal de moderada intensidad, más aumento de volumen en región inguinoescrotal izquierda. Al realizar el examen físico se constató una hernia inguinoescrotal izquierda no reducible. Con el diagnóstico de hernia inguinal incarcerada se realizó una exploración quirúrgica, con hallazgos de hernia inguinoescrotal de gran tamaño con contenido vesical y epiplón incarcerado con cambios de coloración. Se realizó entonces la reparación de la hernia. La evolución posoperatoria fue satisfactoria sin complicaciones.

ABSTRACT Bladder hernia is a condition associated with inguinal hernia, usually right-sided, in 0.5 to 3% of the cases and up to 10% in men between the fifth and seventh decade of life. Most hernias are small; the most common pathophysiology is obstruction while prostatic hyperplasia is the main etiology. The clinical presentation is unspecific, and the diagnosis is usually made during surgery. We report the case of a 64-year-old male patient with a history of Parkinson's disease and reducible left inguinal hernia 5 years before, who sought medical advice due to abdominal pain of moderate intensity, with increased volume in the left inguinoscrotal region.On physical examination a diagnosis of left-sided non-reducible inguinoscrotal hernia was made. With the diagnosis of incarcerated inguinal hernia the patient underwent surgical exploration which showed a large inguinoscrotal hernia containing the bladder and incarcerated omentum with color changes. The hernia was repaired, and the patient evolved with favorable outcome.

Técnica TAPP en manos jóvenes. Es posible reproducir los resultados de la técnica Lichtenstein para la hernia inguinal sintomática primaria unilateral / Tapp technique performed by young hands. Reproducing the results of the lichtenstein procedure for symptomatic primary unilateral inguinal hernia

RESUMEN Antecedentes: La hernioplastia inguinal es el procedimiento quirúrgico más frecuentemente realizado dentro de la Cirugía General. Se realizan anualmente 20 millones de hernioplastias; la técnica de Lichtenstein y la transabdominal preperitoneal (TAPP) mediante cirugía laparoscópica son las más utilzadas. Objetivo: El objetivo del presente estudio es valorar la factibilidad de la realización del TAPP, en un centro universitario, por parte de residentes y cirujanos jóvenes en formación. Se comparó dicho procedimiento con la técnica de Lichtenstein valorando los resultados en los primeros 30 días del posoperatorio. Las principales variables para estudiar fueron: complicaciones, dolor posoperatorio, estadía hospitalaria y costo del procedimiento. Como variables para estudiar, a largo plazo, se compararon la recidiva herniaria y el dolor crónico. Material y métodos: Se realizó un estudio observacional comparando dos técnicas quirúrgicas utilizando la base de datos del Servicio con información adquirida de forma prospectiva. Se analizaron 80 pacientes, divididos en dos grupos: hernioplastia de Lichtenstein (grupo1) y hernioplastia por TAPP (grupo 2), durante el período comprendido desde mayo de 2015 hasta mayo de 2019, en dos Centros Universitarios de Montevideo Uruguay (Hospital de Clínicas y Hospital Español). Resultados: No hubo diferencia significativa en la estadía hospitalaria y complicaciones posoperatorias. El grupo del Lichtenstein presentó una recidiva herniaria. La hernioplastia laparoscópica presentó un tiempo operatorio promedio de 20 minutos más y el costo de materiales fue mayor. Si bien el dolor posoperatorio en las primeras 24 horas fue mayor en TAPP, el dolor a las 48 horas, 7días, un mes, tres meses y seis meses fue similar en ambos grupos. Conclusión: La técnica de TAPP, para la hernia inguinal primaria unilateral, es factible de ser realizada por cirujanos jóvenes o en formación, con un porcentaje de complicaciones, dolor posoperatorio y recidivas similares al Lichtenstein, aunque con un costo de materiales y tiempo operatorio levemente mayor.

ABSTRACT Background: Inguinal hernia repair is one of the most common procedures in general surgery. Each year, 20 million surgeries for inguinal hernia repaired are performed; the most common techniques used are the Lichtenstein procedure and the transabdominal preperitoneal (TAPP) laparoscopic approach. Objective: The aim of the present study is to evaluate the outcomes of the TAPP approach performed by residents and young surgeons in training in a university center. TAPP was compared with the Lichtenstein and the outcomes at 30 days were compared. The variables considered were complications, postoperative pain, length of hospital stay and procedure-related costs. The long-term variables analyzed were recurrence and chronic pain. Material and methods: We conducted an observational study comparing two surgical techniques, using prospectively acquired information from the database of our department. The cohort was made up of 80 patients undergoing inguinal hernia repair in two university-based hospitals in Montevideo, Uruguay (Hospital de Clínicas and Hospital Español), between May 2015 and May 2019. The patients were divided into two groups: Lichtenstein procedure (group 1) and TAPP procedure (group 2). Results: There were no significant differences in length of hospital stay and postoperative complications. One patient in the Lichtenstein group presented hernia recurrence. Mean operative time was 20 minutes longer with laparoscopic hernia repair, and the cost of the materials was higher. Postoperative pain at 24 hours was greater in the TAPP group, but was similar at 48 hours, 7 days, one month, three months and six months in both groups. Conclusion: The use of TAPP technique for unilateral primary inguinal hernia is feasible to perform by young surgeons or surgeons in training, and the percentage of complications, postoperative pain and recurrences is similar to that of the Lichtenstein technique, although the cost of materials and operative time are slightly higher.

Vasitis: a clinical confusion diagnosis with inguinal hernia

Abstract Vasitis or inflammation of the vas deferens is a rarely described condition categorized as either generally asymptomatic vasitis nodosa or the acutely painful infectious vasitis. Vasitis nodosa, the commonly described inflammation of the vas deferens, is benign and usually associated with a history of vasectomy. Clinically, patients present with a nodular mass and are often asymptomatic and require no specific treatment.

Avaliação da acurácia do exame ultrassonográfico em pacientes portadores de hérnia inguinal / Accuracy of the ultrasound examination in patients with inguinal hernia

RESUMO Objetivo: avaliar a acurácia da ultrassonografia no diagnóstico de hérnia inguinal no pré-operatório de pacientes submetidos à herniorrafia inguinal. Métodos: estudo retrospectivo descritivo, analítico, baseado em dados obtidos dos prontuários de pacientes submetidos à herniorrafia inguinal entre janeiro de 2016 e dezembro de 2017 e que realizaram ultrassonografia no período pré-operatório. A amostra foi composta por 232 pacientes e foram comparados os resultados da ultrassonografia com as queixas, exame físico e achados intraoperatórios desses pacientes. Resultados: a ultrassonografia apresentou concordância com a queixa de hérnia inguinal em 52% dos pacientes (p=0,019). Houve discordância entre a porcentagem de pacientes que apresentaram hérnia ao exame físico não confirmada pelo exame ultrassonográfico (28,57%) e a porcentagem de hérnias identificadas somente ao exame complementar (8,93%), com significância estatística (p=0,0291). Quando comparados os resultados ultrassonográficos com achados intraoperatórios, 32,70% dos pacientes que apresentavam hérnia tinham ultrassonografia normal com significância estatística para discordância (p=0,001). Conclusão: a ultrassonografia mostrou-se método não confiável para auxiliar no diagnóstico em casos duvidosos de hérnia inguinal e dispensável quando o diagnóstico era confirmado por queixas típicas e exame físico compatível.

ABSTRACT Objective: to evaluate the accuracy of ultrasonography in the diagnosis of inguinal hernia in the preoperative period of patients submitted to inguinal herniorrhaphy. Methods: we conducted a retrospective, descriptive, analytical study, based on data obtained from the charts of patients submitted to inguinal herniorrhaphy between January 2016 and December 2017 and who underwent ultrasonography in the preoperative period. The sample consisted of 232 patients, and we compared the results of the ultrasonography with the complaints, physical examination and intraoperative findings. Results: ultrasonography was in agreement with inguinal hernia complaint in 52% of patients (p=0.019). There was a disagreement between the percentage of patients who presented a hernia at the physical examination not confirmed by the ultrasound examination (28.57%) and the percentage of hernias identified only by the complementary examination (8.93%), with statistical significance (p=0.0291). When comparing the ultrasound findings with the intraoperative ones, 32.70% of patients presenting with hernia had normal ultrasonography, with statistical significance for discordance (p=0.001). Conclusion: ultrasound was an unreliable method to help diagnosis in dubious cases of inguinal hernia, and dispensable when the diagnosis was confirmed by typical complaints and compatible physical examination.

Prospective ultrasonographic study of blood flow and testicular volume in patients submitted to surgical repair of inguinal hernia without using prosthesis

Abstract Purpose: To evaluate the behavior of arterial circulation and testicular volume in patients submitted to conventional inguinal hernia repair without the use of a synthetic prosthesis to reinforce the posterior wall. Methods: A prospective observational clinical trial was performed on 26 male patients with unilateral inguinal hernia types I and II by the Nyhus classification, who underwent surgical correction using the modified Bassini technique. Bilateral Doppler ultrasonography was performed preoperatively, at the third and at the sixth postoperative month. The studied variables were: systolic peak velocity (SPV), diastolic peak velocity (DPV), resistance index (RI), pulsatility index (PI) and testicular volume. Results: There were no statistically significant changes over time in the variables studied on the operated side: SPV (p = 0.916), DPV (p = 0.304), RI (p = 0.879), PI (p = 0.475), and testicular volume (p = 0.100). The variables on the control side also did not change statistically until the sixth postoperative month: SPV (p = 0.784), DPV (p = 0.446), RI (p = 0.672), PI (p = 0.607), and testicular volume (p = 0.413). Conclusion: Surgical correction of the inguinal hernia without the use of a prosthesis does not cause alterations in vascularization and testicular volume in the first six months postoperatively.

Un recorrido por la pared abdominal: evaluación de las hernias por tomografía computada multidetector / A tour of the abdominal wall: assessment of hernias by multidetector computed tomography

Si bien el diagnóstico de hernias de la pared abdominal es clínico y el estudio más indicado es la ecografía, en una gran cantidad de casos es difícil su evaluación o no se sospecha su presencia debido al biotipo del paciente, la ausencia de síntomas, la aparición de complicaciones o corresponde a algún tipo de hernia poco frecuente. Además, la debilidad de la pared abdominal generada por una cirugía predispone a la eventración de órganos, a veces poco habituales, como el hígado, la vejiga o el apéndice. La utilización de la tomografía computada multidetector (TCMD) brinda grandes ventajas cuando resulta dificultoso establecer el diagnóstico por otros métodos. También puede ser un hallazgo incidental a tener en cuenta por sus posibles complicaciones futuras. En el presente trabajo describimos los principales hallazgos por TCMD de las hernias y eventraciones de la pared abdominal (como la umbilical, epigástrica, hipogástrica, inguinal, de Spiegel, lumbar, obturatriz, intercostal e incisional) y su contenido.

Although the diagnosis of abdominal wall hernias is clinical, and the most appropriate study is ultrasound, in a lot of cases they are difficult to evaluate, or their presence is not suspected because of the biotype of the patient, the absence of symptoms, the presence of complications, or the appearance of rare hernias. Surgery weakness generated in the wall leads to organ hernia, sometimes unusual, as in the liver, bladder, or appendix. The use of multidetector computed tomography (MDCT) is a great advantage in these situations where the diagnosis can be difficult to determine with other methods. It also can be an incidental finding to consider eventual complications. In this paper, the main MDCT findings in abdominal wall hernias are described, including umbilical, epigastric, hypogastric, inguinal, Spiegel, lumbar, obturator, intercostal, and incisional, as well as their content.

Íleo biliar: reporte de un caso de fístula colecistoduodenal asociada a hernia inguinal izquierda / Gallstone ileus: a case report of cholecystoduodenal fistula associated with leftinguinal hernia

Biliary ileus, first described byThomas Bartholin in the year1654, is a rare cause of mechanical ileus (small bowel obstruction) (1-3% in patients younger than 65 years), increasing significantly from that age (25%). The necessarycondition forthis pathologyis the presence ofa fistula between the gallbladderandthe gastrointestinaltract. Simple abdominal X-ray and ultrasonography are widely available and of relatively low cost, together presenting a sensitivity of 74% when they show the classic signs of Rigler’s triad (pneumobilia, ectopic gallstone and dilated loops of small intestine), but computed tomography of the abdomen is considered the gold standard, with a sensitivity and specificity higher than 90%. The aim of this article is to present a case of radiological diagnosis of biliary ileus in a patient with vesicular lithiasis + cholecystoduodenal fistula, associated with inguinal hernia on the left.

El íleo biliar, descrito por primera vez por Thomas Bartholin en el año 1654, constituye una causa poco frecuente de íleo mecánico (1-3% en menores de 65 años) aumentando significativamente a partir de esa edad (25%). La condición necesaria para esta patología es la presencia de una fístula entre la vesícula biliar y el tracto gastrointestinal. La radiografía simple de abdomen y la ecografía son de amplia disponibilidad y coste relativamente bajo, presentando en conjunto una sensibilidad del 74% cuando manifiestan los signos clásicos de la tríada de Rigler (neumobilia, lito biliar ectópico y dilatación de asas de intestino delgado), pero se considera que la tomografía computada de abdomen es el gold standard, con una sensibilidad y especificidad superiores al 90%. El objetivo de este artículo es presentar un caso de diagnóstico radiológico de íleo biliar en un paciente con litiasis vesicular + fístula colecistoduodenal asociadas a hernia inguinal izquierda.

Hernia de Amyand, reporte de un caso / Amyand's hernia, a case report

Introducción: La hernia de Amyand es la presencia del apéndice cecal en el interior de una hernia inguinal, observándose en el 0,5-1% del total de hernioplastías en los adultos. Presentación del caso: Mujer de 81 años ingresó al servicio de urgencias por dolor en fosa iliaca derecha de una semana de evolución, de intensidad progresiva, asociado a aumento de volumen inguinal derecho, redondo de 10 centímetros de diámetro, sensible a la palpación, no reductible y sin signos de irritación peritoneal. Se decidió realizar intervención quirúrgica por sospecha de hernia inguinal derecha complicada, evidenciándose contenido purulento entre asas intestinales, el cual se drenó, descubriéndose el apéndice cecal en el interior del saco herniario, de aspecto necrótico y perforado, procediéndose a realizar apendicectomía más hernioplastia. La paciente evoluciona en el postoperatorio con cuadro bronquial obstructivo, el cual se trató con antibioticoterapia, respondiendo favorablemente, otorgándose el alta 13 días después de la cirugía. Discusión: El 6,7% de las causas de abdomen agudo en adultos mayores se deben a cuadros apendiculares, mientras que un 13,3% se deben a hernias complicadas. Sin embargo es extremadamente infrecuente encontrar el apéndice cecal inflamado intraherniano, lo que ocurre aproximadamente en el 0,1% de todas las apendicectomías. El cuadro clínico consiste en síntomas inespecíficos con confirmación usualmente intraoperatoria. Se ha descrito el diagnóstico pre-quirúrgico imagenologico con tomografía computarizada (TC). El tratamiento consiste en dos procedimientos: apendicectomía con aseo de la cavidad y la reparación del defecto herniario.

Introduction: Amyand's hernia is the presence of cecal appendix within an inguinal hernia, observed in 0.5-1% of total hernioplasties in adults. Case Report: 81 year old woman admitted to the emergency room for pain in the right iliac fossa, one week of evolution, progressive in intensity associated with an increase in right round inguinal volume, 10 centimeters (cm) in diameter, sensitive to palpation, non reducible without signs Peritoneal irritation. It was decided to undergo surgery for suspicion of complicated right inguinal hernia, showing purulent contents between the intestinal loops, which managed to drain, discovering the cecal appendix in the sack of necrotic and perforated inguinal hernia, proceeding to the subsequent appendectomy of hernioplasty. Postoperatively, the patient developed bronchial obstruction, which was treated with antibiotics, responding favorably, granting discharge 13 days after surgery. Discussion: 6.7% of the causes of acute abdominal pain in older adults are due to appendiceal pictures, while 13.3% are due to complicated hernias. However it is extremely rare to find the intraherniano inflamed cecal appendix, which occurs in approximately 0.1% of all appendectomies. The clinical picture is nonspecific symptoms usually intraoperative confirmation. It described the pre-surgical diagnosis imaging with computed tomography (CT). Treatment consists of two procedures: appendectomy with toilet cavity and repair of the hernia defect

Imaging Findings of Angiomyxolipoma of the Spermatic Cord Mimicking Inguinal Hernia

We report the case in a 72-year-old man who presented with a right inguinal mass and with a one month history that was initially interpreted as an inguinal hernia. Ultrasonography (US) and computed tomography (CT) demonstrated a right inguinal mass, including myxoid and fat component, extending from the right spermatic cord to the right inguinal subcutaneous layer. Mass excision was performed, and the diagnosis turned out to be angiomyxolipoma. Angiomyxolipoma is a rare tumor and the preoperative diagnosis of this disease is very difficult. However, angiomyxolipoma of the spermatic cord should be considered in the differential diagnosis in patients with an irreducible inguinal mass. Imaging diagnosis, such as US and CT may help to make a preoperative diagnosis.

FDG Uptake in PET by Bladder Hernia Simulating Inguinal Metastasis

A 70-year-old man with past history of hemicolectomy due to colon cancer underwent a follow-up abdominal/pelvic CT scan. CT revealed a right adrenal metastasis and then he underwent FDG-PET/CT study to search for other possible tumor recurrence. In PET images, other than right adrenal gland, there was an unexpected intense FDG uptake at right inguinal region and at first, it was considered to be an inguinal metastasis. However, correlation of PET images to concurrent CT data revealed it to be a bladder herniation. This case provides an example that analysis of PET images without corresponding CT images can lead to an insufficient interpretation or false positive diagnosis. Hence, radiologists should be aware of the importance of a combined analysis of PET and CT data in the interpretation of integrated PET/CT and rare but intriguing conditions, such as bladder herniation, during the evaluation of PET scans in colon cancer patients.