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Background/purpose Inguinal hernia repair and orchidopexy are among the most common operations in boys. The impact on future fertility has not been conclusively defined. This study evaluates sperm quality after previous inguinal surgery. Methods Spermiograms of men with a desire to conceive children were analyzed. History of previous inguinal surgery (hernia repair, orchidopexy, varicocele ligation) was correlated with sperm quality. Other influential factors (age, BMI, chronic medication, tobacco use) were also tested. Results A total of 333 patients were included. Overall, 12.6% of the subjects had undergone previous inguinal surgery. Of these, 17 (43%) were inguinal hernia repairs, 8 (20%) orchidopexies, and 6 (15%) varicocele ligations, while 9 (22%) could not give an exact history. Abnormal spermiograms were found in 60% (n = 24) of those with previous inguinal surgery versus 48% in controls (p = 0.16). On multivariate analysis, pathologic spermiogram parameters were associated with previous inguinal surgery, orchidopexy, use of chronic medication, and smoking, but NOT with inguinal hernia or varicocele repair alone. Conclusions Previous inguinal hernia or varicocele repair does not seem to impact negatively on quality of sperm later in life. Orchidopexy, smoking, and use of chronic medication, however, were all associated with pathologic sperm quality parameters. Type of study Prospective comparative study. Level of evidence Level II.

Background/aim How testes descend through the inguinal canal is well described, but how the ovaries appear inside an inguinal hernia remains controversial. We reviewed the literature to determine whether ovarian ‘descent' has been described. Methods The English literature from 1950 to 2014 was reviewed via PubMed, Medline and Web of Science to identify papers describing an ovary in the hernia sac: reports were examined to find whether the ovary prolapsed or ‘descended', and the anatomy of its supporting ligaments, cranial suspensory ligament (CSL) and round ligament (female gubernaculum, RL). Results In forty reports of >7140 inguinal herniotomies and/or imaging studies in females the hernia contains an ovary in 15–20%, often with the ipsilateral fallopian tube. The RL and ovary were aligned along the same path as testicular descent only rarely in Mullerian anomalies with an isolated uterine horn preceding the ovary into the sac. The ligament usually found inside the hernia sac was the CSL, not the RL. Discussion The high frequency of incarcerated ovary, along with the close proximity of the CSL to the internal ring in females is consistent with a sliding hernia pulling the CSL (and ovary) into the hernia sac, not ovarian ‘descent' by traction on the RL.

Background/Purpose Although the surgical treatment was proved to be the recommended line of management for congenital undescended testis, hormonal therapy with human chorionic gonadotrophin hormone has been started long years ago and is still used in some areas with variable degrees of success. The factors responsible for treatment failure are not well explored. In this study, we aimed to highlight the anatomical abnormalities in the congenital undescended testis that might contribute to treatment failure. Methods During the period from January 2014 to December 2015, 75 boys with congenital undescended testes received treatment with human chorionic gonadotrophin, in pediatric surgery department, Faculty of medicine, Ain Shams University. Their age ranged between 6 months and 4 years (mean 1.6 years, median 2 years). In 70 boys, the testes were palpable and in the remaining 5 boys, the testes were impalpable. Fifty boys had unilateral and 25 had bilateral undescended testes. Seven of the palpable testes were high scrotal in position and the remaining 83 were palpated in the inguinal canal. The patients were followed up for 6 months to determine the position of the testis after the treatment and surgical intervention was done for those who did not respond to the hormonal treatment either partially or completely. Results Only 7 testes showed complete descent (7%) (2 bilateral and 3 unilateral) and they were initially high scrotal in position, 8 testes showed partial descent (8%) (2 bilateral and 4 unilateral) and they were inguinal in 6 which became high scrotal and impalpable in 2 which became peeping. The remaining 85 (85%) did not respond to the hormonal treatment. Upon surgical exploration, abnormal attachment of the gubernaculum was found in 83 testes (83%), 2 testes were peeping (2%), short testicular vessels were found in 4 testes (4%), 3 testes were vanishing (3%) and a closed internal ring was found in one testis (1%). Conclusions Treatment of congenital undescended testis with human chorionic gonadotrophin hormone had low success rates. Anatomical abnormalities in the congenital undescended testis might contribute to this treatment failure. Type of the study Clinical research paper. Level of evidence level III.

Background The desire of pediatric surgeon to reduce incision related morbidity and pain while achieving good cosmetic results has recently led to the introduction of single incision pediatric endosurgery [SIPES] and needlescopic surgery. Intracorporeal suturing and knot tying during SIPES remain challenging. The aim of this study is to introduce a novel and simple technique for intracorporeal suturing of the pediatric inguinal hernia after needlescopic disconnection of hernia sac using just needles rather than laparoscopic instruments. It is an imitation of the principles of sewing machine. Methods The first author discussed the idea of the technique with the coauthors and a demonstration was done on a Silicon Pad before application of the technique on children with congenital inguinal hernia [CIH] for peritoneum closure after needlescopic disconnection of the hernia sac. The main outcome measures were feasibility of the technique, suturing and knotting time and recurrence rate. Results The sutures were snugly applied to the ridges of Silicon Pad with good approximation and the knot was firmly tightened in all experiments. After applying and mastering the technique on a Silicon Pad, we shifted to use it on 373 children with 491 hernia defects. All operations were completed by the needlescopic technique without the need for insertion of any laparoscopic instruments. The time required for suturing of the peritoneum around internal inguinal ring [IIR] and knot tying, decreased considerably from 6 min 27 s in the first operation to less than 4 min after the fifth operation and stabilized at approximately 4 min 30 s. No major intraoperative complication. There was no recurrence during a mean follow-up period of 19.6 ± 1.2 months. Conclusion The closure of the peritoneum around the IIR using needles mimicking what is happening in sewing machine suturing is a feasible, safe and effective line of treatment of children with CIH. The cosmetic results are 42 outstanding without any recurrence.

Background/Purpose Vanishing Testes Syndrome 1 (VTS) is one of the most common causes of impalpable testes in children. The role of removal of testicular nubbins owing to malignant potential in VTS is unclear. We sought to evaluate whether testicular nubbins need to be excised owing to this potential. Methods We conducted a retrospective review of children with a clinical diagnosis of impalpable testes aged 0–18 who presented to our tertiary hospital between 2007 and 2017. VTS was defined as the presence of hypoplastic vas entering a closed internal inguinal ring or remnants of gonadal tissue distally. Data collected included: age at operation, need for laparoscopy, location of nubbin and histopathological findings. Results We identified 50 consecutive children (mean age 2.4 years, range: 7 months to 12 years) with a clinical diagnosis of impalpable testis. Forty-eight of the 50 underwent laparoscopy with no testicle palpable when examined under anesthesia. Thirty-three children had VTS confirmed at laparoscopy and testicular nubbins identified with three of these being bilateral. Thirty-two children had these nubbins excised with histopathology available for 31 individual testes. Thirty were confirmed testicular nubbins with no viable testicular tissue. No malignancies were identified. Conclusion Results from this study show that testicular nubbins do not have viable germ cells and therefore do not need to be excised on the basis of malignant potential of residual testicular tissue. Level of evidence Level IV treatment study.

Background The desire to reduce incision related morbidity and pain while achieving improve cosmetic results has recently led to the introduction of single incision pediatric endosurgery [SIPES]. Over the last few years, SIPES has been increasingly used for a variety of procedures; single incision laparoscopic hernia repair [SILHR] is perhaps its common application. Intracorporeal suturing and knot tying during SIPES remain one of the most challenging tasks. The aim of this study is to present a novel technique to avoid excessive purposeless movements during SILHR in children. Patients and methods One-hundred and fifty patients with 170 hernial defects were subjected to SILHR during the period from June 2009 to October 2011. Extraperitoneal saline was injected around internal inguinal ring [IIR] in males. The opened IIR was closed by percutaneous insertion of purse string suture using Reverdin Needle (RN) with intracorporeal suture tie. The main outcome measurements were; feasibility of the technique, tightness of the suture tie, operative time, postoperative hydrocele formation, recurrence rate, and cosmetic results. Results Ages ranged between 6 months and 7 years (mean 2 ± 24.2 years). There were 101 males and 49 females. Eighty-four patients presented with right sided inguinal hernia, 46 patients with left sided hernia, and 20 patients with bilateral hernia. The mean operative time was 12.4 ± 1.7 min for unilateral cases and 18.6 ± 1.7 min for the bilateral cases. On follow-up, there were only 1 case of recurrence and 3 cases of hydrocele and the scar is nearly invisible. Conclusion The preliminary results of this study showed that our technique is very promising to achieve secure closure of IIR and reduced operative time with excellent cosmetic results.

Background We conducted a randomized trial comparing 1 and 2-stage laparoscopic orchiopexy for intra-abdominal testes. During recruitment, it became apparent that most patients with non-palpable testes do not require vascular division. In this report, we outline the location and quality of testes found during operative exploration in patients who consented for the study but were not randomized. Methods Analysis was performed on 80 patients undergoing operative exploration for non-palpable testes between 2007 and 2014. The location and pathology of undescended testes were analyzed. Results There were 87 preoperative non-palpable testes in 80 patients that were consented but not randomized to 1 or 2 stage orchiopexy with vascular division. Forty (46%) of nonrandomized testes were atrophic or absent, and 47 (54%) were normal in appearance. Sixty eight testes were evaluated via laparoscopy. The most common location for normal (81%) and absent/atrophic (70%) testes was the inguinal canal. Atrophic testes were more often left sided (72.5%) with normal testes equally divided. Patients with atrophic or absent testicles were more likely to have a closed internal ring (p Conclusion This study demonstrates the majority of patients undergoing operative exploration for non-palpable testes will not require vascular division, and instead would be either atrophic or able to undergo traditional orchiopexy. Level of Evidence: III

Purpose To discuss an optimal surgical approach for impalpable testis in children, our own treatment results and those reported in the literature were reviewed. Materials and Methods Seventy-two impalpable testes were diagnosed in 68 patients: unilateral in 64 patients and bilateral in 4 patients. All patients underwent surgical exploration at the ages of 6 to 140months (median, 15months). The inguinal canal was initially explored, and abdominal exploration was performed with laparoscopy when an extra-abdominal testis was not identified. In addition, articles regarding surgical exploration for impalpable testis, published over the last 20years, were retrieved and the results were examined. Results Testes were detected by inguinal exploration in 28 of 72 (39%) impalpable testes: intracanalicular in 22 testes and at the internal inguinal ring (peeping or low abdominal testis) in 6 testes. All these testes were treated by conventional inguinal orchidopexy. Laparoscopic exploration was performed in 44 (61%) impalpable testes, and 4 (5.6%) high abdominal testes were detected and treated by two-stage Fowler-Stephens orchidopexy. Vanishing or absent testis was the final diagnosis in the remaining 40 testes (55.6%). The literature review showed that the ratios of intra- and extra-abdominal testes were lower in the articles that reported the results of inguinal or scrotal exploration than in those of laparoscopic exploration, although the difference was not significant. Conclusions Considering the relatively low incidence of high abdominal testis, we recommend to start with inguinal exploration for impalpable testis. When an extra-abdominal testis is not detected, transinguinal laparoscopic exploration should be indicated. Level of Evidence Treatment study, Level IV.

Background Inguinal hernia repair is one of the most frequently performed surgical procedure in infants and young children. Laparoscopic hernia repair in infancy and childhood is still debatable. There are many techniques available for laparoscopic hernia repair in pediatrics. The aim of the study is to compare laparoscopic intracorporeal purse-string suture ligation of the hernia defect leaving the sac intact versus disconnection of the hernia sac with intracorporeal suturing of proximal part. Patients and methods A prospective controlled randomized study of laparoscopic repair of congenital inguinal hernia (CIH) was conducted over a period of 2years and 8months from April 2014 to December 2016. All patients were randomized into two equal groups: Group I (n=66) received intracorporeal purse string suture ligation of the hernia sac at internal inguinal ring [IIR] leaving the sac intact; and Group II (n=66) received disconnection of the hernia sac with intracorporeal suture of proximal part at IIR. Inclusion criteria Male patient with bilateral CIH, questionable other side, cases of CIH associated with umbilical hernia and parental request. Exclusion criteria Recurrent cases, complicated cases, hernia of canal of Nuck in females, inguinal hernia with undescended testis, parental refusal. The main outcome measurements were operative time, postoperative hydrocele formation, recurrence rate. Results This study included 132 patients with 157 hernia defects. Their age ranged from 6months to 3years. Statistically significant differences regarding the demographic data of the groups. All cases were completed successfully without conversion. There was no statistically significant difference between groups regarding intraoperative complications and hospital stay. There was statistically significant difference in the operative time and post-operative complications between the studied groups. Conclusions Laparoscopic inguinal hernia repair by disconnection of the hernia sac at the IIR with peritoneal closure is safe and feasible method. It has a lower recurrence rate than the purse string suturing leaving the sac intact.

Objectives To describe our experience and illustrate the surgical procedure of synchronous bilateral testicular rerouting in high inguinal undescended testes (HIUT) by extending the use of "modified Prentiss maneuver" in bilateral situation, to establish this as a procedure of choice in bilateral HIUT and secondly to demonstrate the length gained by maneuver itself. Methods Between January 2011 and December 2012 ten boys (8months–6years) with diagnosis of bilateral HIUT were included in the study. Bilateral orchidopexy was done by "modified Prentiss maneuver" under general anesthesia. Postoperatively all patients were evaluated at 3months ,6months and 1year by physical examinations and ultrasound. Results It was possible to reroute the testes underneath inferior epigastric artery (IEA) without its mobilization and thus locate testicular pedicle through a fascial hole above pubic tubercle, well medial to IEA. The average gain in scrotal positioning was 16mm (10–22mm).No retractions, atrophy of testis, clinical weakness of anterior abdominal wall or inguinal herniation was noted in any patient up to one year follow up. Conclusions Testicular re-routing by "modified Prentiss maneuver" is a simple, feasible, safe and efficient method for bilateral orchidopexy in bilateral HIUT. Preserving the inferior epigastric artery bilaterally has physiologic advantages.

Purpose The purpose of this study was to characterize the complications associated with surgical treatment of pediatric melanoma. Methods We retrospectively reviewed all pediatric patients who received surgical treatment for melanoma at our institution between 1992 and 2010. We compared complications between three groups: wide local excision only (WLE), WLE and sentinel lymph node biopsy (SLNB), and WLE and completion lymph node dissection (CLND). Results One hundred twenty-five patients were identified: 37 patients received WLE only, 47 received WLE and SLNB, and 41 patients had WLE and CLND. Complication rates differed between the three groups: 19% in WLE, 11% in WLE+SLNB, and 39% in WLE+CLND ( P =.006). The risk of complications was significantly lower among patients having WLE+SLNB versus WLE+CLND (OR 0.19, 95% CI 0.06–0.57, P =.0032). Lymphedema was a common complication with a higher incidence in the CLND group compared to the SLNB group (19.5% vs. 2.1%, P =.01). Complications were more frequent in inguinal compared to axillary dissections (52.0% vs. 17.1%, P =.006). Conclusions In the surgical treatment of pediatric melanoma, the addition of a completion lymph node dissection significantly increases complication risk. Thus, it is critical to determine which patients truly benefit from this procedure.

Background/aim Testicular ectopia is rare, but the large range of anatomical locations described in the literature has spawned an abundance of possible theories to explain etiology. However, as the anatomical characteristics of normal testicular descent have only been elucidated recently, many of the theories of testicular ectopia do not incorporate this new perspective. In this study we aimed to determine what was in the literature about ectopic testis since 1980, and then try to explain the different anatomical variants in the light of current knowledge about testicular descent. Methods A literature search was performed and all articles in English published since 1980 about testicular ectopia using several key words were identified. Results A total of 271 articles in English were found, of which 31 addressed the pathophysiology and are the primary focus of this study. Case reports and reviews described perineal ectopia (× 4), transverse testicular ectopia (× 11), and abdominal ectopia (× 2), along with 3 reviews/case reports addressing diagnosis and management. A range of proposed causes were found, including obstructed ‘third inguinal ring’ at neck of scrotum, abnormal CGRP function, aberrant distal gubernacular attachment, mechanical hindrance from retained Mullerian ducts, defective gubernacular formation or disruption of the gubernacular attachment to the testis. Conclusion After reviewing the proposed theories, we propose a unifying theory, based on current knowledge of testicular descent, where testicular ectopia can be explained by a) anomalous attachment of the gubernaculum to the anterior abdominal wall during transabdominal descent, or b) aberrant migration of the gubernaculum during the inguinoscrotal phase of testicular descent.

Background The use of transinguinal laparoscopy for contralateral groin exploration during unilateral inguinal hernia repair has gained popularity. Controversy exists, however, regarding its use in older children. We report a large, single-surgeon series describing the safety and effectiveness of this procedure. Methods A retrospective review was completed of all cases of open inguinal hernia repair from 1997 to 2009 performed by the senior author. Patients were explored laparoscopically through the ipsilateral hernia sac to assess the contralateral groin. Exclusion criteria were an inadequate sac or preoperatively diagnosed bilateral inguinal hernia. Results A total of 649 children underwent open inguinal hernia repair. A preoperative diagnosis of bilateral hernia was made in 18% (n = 117), and of the 532 unilateral cases, an inadequate sac was present in 15% (n = 79). Transinguinal laparoscopic exploration was performed on the remaining 453 children. A hernia or contralateral patent processus vaginalis (CPPV) was found in 38% of children (n = 173). In children older than 8 years, 32% demonstrated a hernia or CPPV on laparoscopic exploration. No complications occurred because of laparoscopy. Conclusion Transinguinal laparoscopic exploration is safe and effective and should be routinely performed in pediatric patients of all ages because of the high prevalence of contralateral hernia and CPPV.

Background/Aims Recent work both from our laboratory and in marsupial models of testicular descent suggests a strong connection between the mammary line and gubernacular migration. This study investigated the relationship between the mammary fat pad (MFP) that underlies the mammary line and the developing gubernaculum by fluorescent immunohistochemistry. Methods Rats at E17 and E19 were fixed and processed for immunohistochemistry. Sagittal sections of male fetuses were stained with antibodies against androgen receptor (AR), prolyl-4 hydroxylase β , Desmin, activated Notch-1, Jagged-1, and Ki-67. These were analyzed by fluorescent confocal microscopy. Results At E17 and E19, the MFP anlage forms a continuous distribution of fibroblasts passing immediately adjacent the gubernaculum to the future scrotum. Within this exists a distinct subpopulation of fibroblasts expressing AR distributed over the path of inguinoscrotal descent of the gubernaculum. Proliferation and Notch-1 signaling were similar throughout the MFP with differential Notch-1 signaling in the E19 gubernaculum. Conclusion This investigation has identified the presence of a distinct AR-expressing subpopulation of MFP fibroblasts over the path of inguinoscrotal descent during the key androgenic programming window of this phase. This unique developmental pattern is consistent with a prime role for the MFP in testicular descent.

Background In patients with a non-palpable testis (NPT) on physical examination, the testis is assumed either to be situated intra-abdominally or to be hypoplastic or absent. Diagnostic laparoscopy in these boys is considered the preferable first step. In this study the diagnostic value of pre-operative ultrasound for NPT is assessed in comparison with laparoscopy. Methods All boys aged under the age of 17years who were diagnosed with an NPT by a pediatric surgeon from 2000 till 2012 were evaluated. All patients of whom clinical, ultrasonographic, and operative findings were available were included. Results Ninety-six boys with 117 NPTs were included. With ultrasound 67 testes were detected in the inguinal canal, which was confirmed peroperatively for 61 testes. Of the 15 testes with an intra-abdominal position on ultrasound, 10 were found intra-abdominally during surgery. The positive predictive value of the ultrasonography is 91% for inguinally located testes and 67% for intra-abdominally located testes. Conclusion Ultrasonography has a high positive predictive value for inguinally located testes. When ultrasound locates a testis in an inguinal location, a primary inguinal exploration can be considered, preventing an unnecessary diagnostic laparoscopy.

Background/Purpose: Inguinoscrotal testicular descent is controlled by androgens and the genitofemoral nerve, but the trigger for what makes the gubernaculum become a migratory organ like a limb bud remains unknown. Recent observations in the flutamide-treated rat suggested a link with the mammary line. We aimed, therefore, to reassess histologic anatomy in 2 different rodent models of androgen blockade, the testicular feminisation mouse (TFM) and the flutamide-treated rat. Methods: Neonatal TFM mice and fetal and neonatal rats after pretreatment of dams with an antiandrogen, flutamide (75 mg/kg; sunflower oil; days 16-19), were prepared for histologic analysis of the inguinal region and compared with fetal and neonatal controls. Results: Fetal control rats (E15.5 days) showed a mammary bud just outside the future inguinal canal adjacent to the gubernaculum. Neonatal TFM mice showed persistence of the inguinal breast bud supplied by the genitofemoral nerve. Flutamide-treated rats (D2) showed the gubernaculum surrounded by a persisting breast bud. Conclusions: The inguinal mammary line is adjacent to the gubernaculum in fetal rodents, and after androgen blockade, the gubernaculum becomes connected to the breast. The male mammary line, which is hidden in plain sight outside the inguinal canal, is made visible by androgen blockade. It may be the missing link in testicular descent, regulating gubernacular migration.

Introduction/Background Ectopic nephrogenic rests (ENR) are rare. The incidental discovery of these lesions in children has particular clinicosurgical implications, especially given the association between ENR and the development of extrarenal Wilms' tumors (ERWT). Methodology We reviewed the hospital records of patients with ERWT and ENR treated at our hospital over a 10-year period to identify those patients with histopathologically confirmed ENR and/or ERWT. Results Ninety-five children with Wilms' tumor (WT) were identified, but only 1 case of ENR and ERWT. This patient was a 14-month-old boy who was incidentally found to have a mass in the left inguinal canal during orchiopexy. After histology, a provisional diagnosis of ENR was made. Six months later, the child went on to develop an ERWT at the same site. Periodic postsurgical follow-up has been uneventful. Discussion and conclusions This was the only case of ENR and ERWT in child in a 10-year review of patients with WT at our hospital. Our experience stresses the importance of including ENR in any working differential diagnosis of unexpected masses in the inguinal canal in children and underscores why careful long-term follow-up is mandatory. The reasons for the malignant transformation of ENR into primary ERWT are unknown, but our experience lends support for the theory that ENR are precursor lesions to the development of WT even in ectopic sites. The case also provides an example of the kind of technical difficulties presented by paratesticular masses during laparoscopy.

Aim Inadequate androgen activity is a likely cause of cryptorchidism in humans, affecting inguinoscrotal testicular descent. Flutamide, a nonsteroidal antiandrogen, produces cryptorchidism in rats. We aimed to determine the anatomical and histologic effects of flutamide. Methods Time-mated Sprague-Dawley female rats were injected subcutaneously with flutamide (75 mg/kg in sunflower oil) on days 16 to 19 of pregnancy. Embryonic (E) and postnatal (P) male offspring were collected (E16, E19, P0, P2, P4, P8) in control and flutamide-treated groups (n = 5-10). Samples were fixed in 4% paraformaldehyde. Five-micrometer-thick sections were prepared for hematoxylin and eosin, trichrome and immunohistochemical stains (Desmin, TuJ1, Ki67). This identified muscle and neural cells and areas of cell proliferation. Results Postnatally, the gubernaculum in flutamide-treated rats had more mesenchyme and muscle than controls. Gubernacular eversion failed, and mammary tissue persisted around the gubernaculum in flutamide-treated rats. Flutamide had no effect on embryonic gubernacular anatomy and histology. Conclusions Prenatal androgens altered postnatal gubernacular anatomy and histology in the postnatal period. Our findings indicate that the failure of gubernacular differentiation and migration may be because of the ongoing presence of mammary tissue in the region of the external inguinal ring.

Abdominoscrotal hydrocele (ASH) is an unusual condition characterized by a large scrotal hydrocele which communicates in an hourglass fashion with an abdominal component through the inguinal canal. Based on previous clinical observations, we believed that ASH is a condition that begins as a large scrotal hydrocele during the neonatal period and later expands first into the inguinal canal and finally into the abdominal cavity during the next few months of life. We report a case series of ASH and point out its distinctive characteristics.

To achieve satisfactory surgical and cosmetic results with minimal surgical invasiveness without laparoscopic assistance in childhood inguinal hernia repair, a novel technique, the selective sac extraction method (SSEM), was devised. The technical feasibility of this method was retrospectively examined.The method was applied to 162 consecutive hernia repairs in 153 patients, 79 boys and 74 girls, excluding patients with incarcerated or irreducible hernia, sliding hernia of the ovary (hernia with palpable ovary at repair), or hernia associated with an undescended testis. Hernia repair was performed by several young surgeons under the guidance of one teaching surgeon.Patients' ages ranged from 1 month to 12 years (median, 3 years), and their body weights ranged from 2.9 to 41 kg (median, 14.4 kg). The SSEM was accomplished in 149 (92%) of 162 repairs, and lengths of incision at the end of the procedure were less than 10 mm in all repairs. The success rate was 72 (88%) of 82 repairs in male patients and 77 (96%) of 80 repairs in female patients. In the remaining 13 (8%) repairs in 13 patients, 10 males and 3 females, the procedure was converted to a conventional open method by extending the incision to 10 mm or longer. The ages of the 13 patients ranged from 1 month to 8 years (median, 3 months), being significantly younger than patients whose repair was accomplished by the SSEM (P = .006). The reason for conversion in 9 repairs was a huge or thickened sac that could not be extracted from the small incision, of which 6 involved male infants younger than 11 months. Obesity (the body mass index was 22.2 and97th percentile for the patient's age) and thick subcutaneous tissue characteristic of early infancy were also reasons, both of which hindered the approach to the inguinal canal. Other reasons included malpositioning of the skin incision and difficulty in sac identification. The lengths of incision at the end of the 162 repairs ranged from 4.5 to 13.0 mm (median, 7.0 mm). Those in female patients, 4.5 to 11.5 mm (median, 6.5 mm), were significantly shorter than in male patients, 5.0 to 13.0 mm (median, 7.5 mm) (P.001). The median length of the operation was 25 minutes. A follow-up interview revealed that there was no hernia recurrence with a median follow-up time of 20 months (range, 12-29 months). No postoperative complications were reported by the parents. As for the parents' satisfaction with wound cosmesis, 93% of them rated it as good or excellent.Inguinal hernia repair with the SSEM through a minimal skin incision is technically feasible, with very satisfactory surgical and cosmetic results. As it has the potential to be a standard method for inguinal hernia repair in children, a prospective study to confirm the safety of the procedure should be carried out.

Objective Reoperative orchidopexy is a technical challenge to pediatric surgeons. The laparoscopy-assisted procedure is described for securing the testis in the scrotum in patients with a past history of open orchidopexy and testes in an unsatisfactory position. Patients and Methods Thirty-one patients with 35 abnormally positioned testes (4 bilateral) were evaluated. All patients had a past history of inguinal surgery, and ages ranged between 2.5 and 13 years (mean, 5.5 years). Previous surgical procedures included 32 orchiopexies and 3 testicular detorsion of undescended testis. If needed, inguinal dissection was performed to loose the adherence between the cord and inguinal canal. Laparoscopic orchidopexy was applied to allow the testis to remain in the scrotum without tension. Patients underwent follow-up every 3 months after the operation with physical and ultrasound examinations. Results Ten low inguinal testes were treated directly with open inguinal redo orchidopexy, whereas laparoscopy-assisted orchidopexy was possible in 23 (92%) of the remaining 25 reoperations. In 2 (8%) of these cases, severe scarring was present between the cord and the inguinal canal impeding the laparoscopy-assisted orchidopexy. For laparoscopy-assisted procedure, the operation time was 42 to 67 minutes (mean = 52 min). After the laparoscopy-assisted reoperations, 23 (92%) testes remain within the scrotum after a mean follow-up of 22 months (range, 6-32 months). Conclusion When feasible, laparoscopy-assisted orchiopexy is a simple and effective technique for securing testicles in reoperative orchiopexy procedures.

Background The gubernaculum is crucial for testicular descent, and in the second, or inguinoscrotal, phase of descent it has no caudal attachments. Cranially, it is attached to the testis, but its caudal free tip migrates to the scrotum controlled by the genitofemoral nerve. Recent studies show active proliferation in the tip. We hypothesized that the gubernacular tip may grow like a limb bud. Methods We performed whole-mount in situ hybridization studies on male and female fetal mice (ages, E14.5-E18.5; n=162) looking for limb bud regulatory factors. Results Our results showed that a member of the fibroblast growth factor (Fgf) family, Fgf10 , and Hoxa10 were both expressed in the male gubernaculum at E14.5, and Hoxa10 was also expressed in the E16.5 mice. Weak staining was seen in the female gubernaculum for Hoxa10 on days E14.5 and E16.5, whereas no staining for Fgf10 was seen in the female gubernaculums. Conclusions These studies, although preliminary, suggest limb bud regulators are essential for gubernacular growth. Hox genes and Fgfs may be fruitful areas of research to unravel the molecular control of gubernacular migration during testicular descent.

Background Extrapolation of rat testicular descent studies to humans has been criticized because of anatomical differences of the cremaster muscle. Human cremaster is described as a thin strip rather than a large, complete sac as in rats, which is proposed to be more important in propelling the testis during descent. This study investigated cremaster muscle anatomy and ontogeny in both normal and cryptorchid rat models. Methods Gubernacula from 4 groups of neonatal rats were sectioned longitudinally and transversely: normal Sprague-Dawley, capsaicin pretreated, flutamide pretreated, and congenital cryptorchid rats. Gubernacula were stained with hematoxylin-eosin, Masson trichrome, and desmin immunohistochemistry to study muscle development. Results Myoblasts are more numerous at the gubernacular tip, whereas the most differentiated muscle is proximal. Rat cremaster develops as an elongated strip rather than a complete sac derived from abdominal wall muscles. Flutamide and capsaicin pretreatment disrupts development. Conclusion Rat cremaster muscle develops as a strip, bearing close resemblance to human cremaster muscle, permitting extrapolation of cremaster function to human testicular descent. The cremaster muscle appears to differentiate from the gubernacular tip during elongation to the scrotum, and requires intact sensory innervation and androgen.

Patent processus vaginalis (PPV) might be incidentally diagnosed during laparoscopy. The aims of this study were to determine the prevalence and the natural history of PPV, i.e. its possible development into symptomatic inguinal hernia.children16years undergoing laparoscopy for pathologies other than processus vaginalis (PV) related, from 10/2000-10/2005.past or present history of PV-related pathologies. The internal inguinal rings were documented during laparoscopy. Follow-up was provided by phone inquiry and clinical examination if needed. Median follow-up was 10.5years (range 7.1-12.8).416 patients were included. Median age at laparoscopy was 12.4years (range 3days-18.1years). Forty-three PPV (33 unilateral, 5 bilateral) were found in 38 patients (9.1%). Four children with PPV presented later with an ipsilateral inguinal hernia (10.5%, 95%CI [3%; 25%]), at a median age of 16.0years (range 11.8-17.3), at a median of 22.5months (range 12-50) after initial laparoscopy, as compared to no patient in the population with obliterated PV (0%, 95%CI [0%; 1%]).9.1% of the observed pediatric population showed an asymptomatic PPV, and 10.5% of these children later developed an inguinal hernia. None of the children with obliterated PV developed a hernia.

Subcutaneous endoscopically assisted ligation (SEAL) is a technique for high ligation of the patent processus at the internal ring without a groin incision or dissection of the vas and vessels. Under endoscopic visualization through a single umbilical port, a suture is guided extraperitoneally around the internal ring, avoiding the vas and vessels. The safety, efficacy (recurrence risk), and cost-effectiveness of this unproven procedure must be tested against standard open repair in a trial.

Background/purpose To analyze the value of ultrasound scan (US) in the preoperative identification of a contralateral patent processus vaginalis (CPPV), the authors investigated the presence of CPPV by US in children with clinically diagnosed unilateral inguinal hernias. Methods Three hundred forty-eight patients (168 boys and 180 girls) with unilateral inguinal hernia underwent US examination using a 7.5-MHz linear transducer. If a CPPV was visible as a hydrocele owing to the inflow of physiologic ascites into a processus vaginalis on straining, then US scanning was performed while the patient was at rest and while inducing straining by standing or crying. A groin with a hydrocele in the inguinal canal on straining was diagnosed as a CPPV and was explored bilaterally through surgery. The US findings were compared with surgical results. Results In 348 patients, 78 cases (22.4%) were diagnosed by US as patients with a CPPV; these patients underwent bilateral surgery. Seventy-four of 78 cases (94.9%) were confirmed surgically as patients with CPPV. Conclusions A CPPV was detected correctly by US in 74 of 348 patients (21.3%) with clinically diagnosed unilateral inguinal hernias. US is a noninvasive and accurate method for evaluating the presence of a CPPV.

Background/Purpose: Acquisition of clinical skills in medical education requires repeated practice. Current medical education mandates simulator-based clinical skills training programs. The details of our simulator-based clinical skills training on inguino-scrotal disorders (ISD) of the childhood, and the feedbacks obtained from the trainees are reported Methods: From 1999 to 2001, simulator-based skill training on ISD is given to second- and fourth-year students (n = 207 and n=128, respectively) and to primary health care physicians during postgraduate continuing medical education program (n = 80). Feedback forms filled out by each participant after the training were evaluated. Results: A total of 55% to 66% of the second-year medical school students had judged 5 points, whereas 6% to 9% of them had judged 1 point on their feedback forms. A total of 79% to 84% of the fourth-year students had judged 5 points, whereas 1% to 5% of them had judged 1 point on their feedback forms. A total of 87% to 91% of the primary health care physicians had judged 5 points, whereas 1% to 2% of them had judged 1 point on their feedback forms. Conclusions: Simulated models of inguino-scrotal disorders constructed from readily available materials are effective in clinical skills training.

Background/purpose Preoperative sonographic studies of the groins have become a routine evaluation of inguinal hernia in children. Its value is not only to confirm the clinical diagnosis, but also to accurately assess the opposite side and to prevent an unnecessary exploration or additional operation at a later stage. The purpose of this study is to report more definitive criteria of inguinal hernias (IH) and patent process vaginalis (PPV) established from 1,284 groin examinations. Methods From January 1999 to October 2000 the authors compared prospectively the sonographic dimensions of the inguinal canal to the operative findings as reported by the surgeons (blinded to the results) for 642 pediatric patients (ages 1 to 176 months) undergoing inguinal hernia repairs. Results A normal inguinal canal was found at operation when a preoperative sonographic groin width of 3.6 +/- 0.8 mm, on average, was detected. A PPV was found when a groin width of 4.9 +/- 1.1 mm was detected. A full hernia was found when a groin width of 7.2 +/- 2.0 mm was detected. A large hernia was found when a groin width of 12.8 +/- 3.6 mm was detected, and a hydrocele was found along with a groin width of 4.8 +/- 2.2 mm. Conclusions Establishing accurate sonographic criteria for inguinal hernia and patent processus vaginalis is an important tool for the pediatric surgeon to plan the approach before groin surgery.

Background/Purpose: With the improvement in long-term outcome from childhood malignancy, the expected quality of life is important. This study was to assess the value of reverse orchidopexy in patients requiring radiotherapy to the groin or pelvic area. Methods: The details of 6 boys (age 2 to 13 years) who had malignancy necessitating groin or pelvic radiotherapy were reviewed. Each had reverse orchidopexy of the contralateral testis for the course of the radiotherapy treatment. Brief case summaries are presented. The testis was replaced in the scrotum 4 to 12 months after the reverse orchidopexy. Results: The protected testis continued to grow and was considered normal at 1 to 7 years later. One individual had fathered a child. Conclusion: Reverse orchidopexy is a promising method of preserving testicular function in boys who require radiotherapy to the groin or pelvis area. J Pediatr Surg 37:236-239. Copyright © 2002 by W.B. Saunders Company.

Background/Purpose The purpose of this study is to present a summary of paediatric Spigelian hernia (SH) reported to date, and discuss possible aetiology of SH associated with ipsilateral ectopic testis (SH-ET). Methods Search of PubMed, Medline, Embase, and CINAHL was performed using keywords "Spigelian hernia". The following were extracted from articles describing paediatric SH: demographics, site and contents of SH, comorbidities, proposed aetiology, presence of ipsilateral inguinal canal (IC) and gubernaculum (G). Results There were 78 patients with 88 hernias (69 male, 19 female), including 55 male (19 left, 22 right, 7 bilateral) and 16 female (5 left, 5 right, 3 bilateral) nontraumatic SHs. In nontraumatic male SH, 29 hernias contained testis (10 left, 11 right, 4 bilateral), 15 did not, 10 had no data. Of 29 SH-EH, 15 were lacking IC and G, 3 were missing IC (no G data) and 2 had absent G (no IC data). The combination of SH and cryptorchidism is increasingly recognised as a distinct syndrome. However, there is controversy as to the pathogenic mechanism of this association. We hypothesise SH-ET develops because the G, and therefore IC and line of descent, become cranially ‘mislocated' along the mammary line, which overlies the Spigelian fascia. Conclusion SH is rare in children. SH-ET may result by testicular descent to an ectopic site along the embryological mammary line.

Purpose: The caliber of processus vaginalis is accepted to define the clinical outcome to be an inguinal hernia or hydrocele not based on any evaluation. The caliber of sacs and length of inguinal canals of boys and girls were evaluated to define the relation of sex, age, and the diagnosis with caliber of the sac and the length of inguinal canal. Methods: A total of 217 inguinal canals in 24 girls and 112 boys with inguinal hernia, 30 boys with hydrocele or hydrocele of the cord, and 31 boys with undescended testis have been evaluated. Twenty patients had bilateral involvement. The length of inguinal canal, and the circumference of the sac were measured. A formula was developed to predict the length of inguinal canal according to the age and sex. The circumferences of the sacs, length of inguinal canals, and the ratios of the circumference to the length were compared according to the clinical pictures. Results: The regression model of the relationship between the age and the length of the inguinal canal is an equation of third degree (inguinal canal in millimeters) = 0.0000119 × age 3 (months) − 0.00292 × age 2 (months) + 0.3168 × age (months) + 19.979 (r 2 = 0.47). Inguinal canal is longer in boys (25.133 and 27.996 mm; P =.018), and length does not differ among diagnoses but differs according to age showing a linear growth after 24 months. Although the circumference as a sole parameter could classify only 55.3% of boys correctly, the ratio of length of inguinal canal to circumference of the sac has been the significant parameter in classifying boys into 1 of 3 groups including inguinal hernia, undescended testis, and hydrocele with a 70.2% success rate. Conclusions: Inguinal canal that shows a linear growth after 24 months of age is longer in boys. Caliber is not the unique factor that determines the clinical outcome. Although the ratio of length of inguinal canal to the circumference of the sac defines the clinical picture best, even this parameter cannot classify the cases correctly. Therefore, some factors in addition to the caliber and length of inguinal canal might have roles in determining the clinical outcome. J Pediatr Surg 35:1165-1169. Copyright © 2000 by W.B. Saunders Company.

Background/Purpose: Controversy exists whether to explore the contralateral groin in boys during unilateral herniorrhaphy. Proponents claim there is minimal risk of injury to the cord structures and developing testicle with contralateral exploration. However, findings have shown testicular atrophy occurred in 1% to 2% of patients after herniorrhaphy, and vasal damage is possible after routine manipulation of the spermatic cord. This study investigated the effect of routine surgical exploration of the prepubertal groin on testicular development and future fertility. Methods: Twenty-four prepubertal Wistar rats were divided equally into 2 groups. Group 1 (sham) rats underwent unilateral inguinoscrotal incision only. Group 2 (experimental) rats underwent unilateral inguinoscrotal exploration with manipulation of the cord structures as in human inguinal exploration. At maturation, the fertility and fecundity of the males were assessed. After mating, testes were examined for mass, volume, mean seminiferous tubule diameter (MSTD), and mean testicular biopsy score (MTBS). The vasa were examined for histological injury and vasal diameter. Statistical comparisons were made by paired t test and Mann-Whitney rank sum test. Results: There was a difference between the volumes of the testes when comparing the operative and nonoperative side of the 2 groups (experimental, Δvol = −0.063 ± 0.123; sham, Δvol = +0.067 ± 0.137; P =.029). There also was a trend toward a smaller testicular mass when comparing the two sides (experimental, Δmass = −0.045 ± 0.101; sham, Δmass = +0.048 ± 0.123; P =.057) but did not reach significance. The MSTD and MTBS were similar between the ipsilateral and contralateral testes in both groups. Likewise, the MSTD and MTBS were similar when comparing the 2 groups. All male rats in both groups were fertile. The number of offspring produced and the number of female rats impregnated were similar between the 2 groups. There was no histological evidence of vasal injury in any of the experimental spermatic cords. The vasal diameters were similar between the 2 groups. Conclusion: Surgical manipulation of the prepubertal spermatic cord imparts a small, but statistically significant morphological change in testicular size without a deleterious effect on testicular development, fertility, or fecundity. J Pediatr Surg 35:327-330. Copyright © 2000 by W.B. Saunders Company.

Persistent mullerian duct syndrome (PMDS), characterized by the presence of mullerian structures in a virilized male, frequently presents as undescended testis, either intraabdominal or within a hernial sac. We describe a 10-month-old infant with PMDS successfully managed by the laparoscopic approach. At the age of 1.5 months, the patient presented with a left inguinal hernia and bilateral nonpalpable gonads in another center and underwent left inguinal exploration. The uterus and a gonadlike structure along with the hernia sac were found in the inguinal canal. Left inguinal herniotomy was performed after reduction of the uterus and gonadlike structure. No gonadal biopsy was obtained. The patient was further investigated in the same center. His karyotype was 46,XY. Magnetic resonance imaging of the abdomen and pelvis revealed a uterinelike structure posterior to the urinary bladder, but neither testis nor ovaries were visualized. At 10 months of age, he was referred to our department for further management. A laparoscopic single-stage orchiopexy was performed. Both testes were identified and brought to the scrotum by splitting the uterus in the midline and then bringing the testes with the vas and attached uterine tissue into the scrotum. The aim of placement of well-vascularized testes in the scrotum was achieved as confirmed on follow-up color Doppler ultrasound study 6 months postoperatively, which showed normal vascularity. Laparoscopic surgical techniques for this condition are also discussed.

Crossed testicular ectopia is a rare congenital anomaly in which both testes descend through a single inguinal canal. The typical presentation is that of ipsilateral inguinal hernia and contralateral cryptorchidism. This is a case report of crossed testicular ectopia in a 6-month-old male infant with depiction of herniorrhaphy and laparoscopic intraabdominal findings.

The cremaster muscle (CM) has been considered to participate in regulation of blood flow and temperature of the testis. Its contribution to testicular descent has been suggested. However, there is limited information about the CM in physiological and pathological states. Therefore, an experimental study has been conducted to evaluate and compare the contractile and electrophysiological properties of CM in boys with descended or undescended testes.Identical CM strips were obtained from eight boys who underwent orchidopexy with a mean age of 3+/-2.2 years and from eight boys who underwent herniorrhaphy with a mean age of 4+/-1.3 years. Muscle strips of 3 x 8 mm were vertically attached to an isometric force displacement transducer, and direct muscle contractions were elicited by rectangular electrical pulses. Direct isometric muscle contractions were recorded in an organ bath containing mammalian Ringer's solution. In electrophysiological experiments, conventional microelectrode techniques were used.Direct electrical stimulation of CM strips obtained from patients with descended and undescended testes elicited muscle twitches and frequency-dependent contractile responses. Tetanic contractions of undescended testes at 100 Hz were 67% greater in amplitude than that of descended testes (P.002). Muscle strips of both groups exhibited increased twitch amplitudes by 105%+/-37% when the temperature of the bathing solution was increased from 22 degrees to 37 degrees C (P.001). The electrophysiological findings were similar.Contrary to other striated muscles, elevated temperature increases the contractility of CM. If the increased contractility by an increase in temperature is a property unique for CM, it should reflect the attempts at regulating testicular blood flow or temperature. The increased amplitude of contractions encountered among the CM of boys with undescended testis suggests the CM to have a role on the location of the testis.

Background With the increasing number of open surgical procedures shifting to laparoscopy, laparoscopic suturing and knot tying are becoming integral parts of the skills that any laparoscopist must acquire. It is the most difficult step in laparoscopic surgery, especially in single incision pediatric endosurgery (SIPES). It needs special laparoscopic skills and very long learning curve. The aim of this study is to introduce a new simplified technique for single instrument intracorporeal suture tying during single incision laparoscopic hernia repair (SILHR). Patients and methods This study was conducted at Al-Azhar University Hospitals between June 2008 and June 2010. Three-hundred and eighty three patients with 402 congenital inguinal hernias were subjected to SILHR using percutaneous insertion of purse string suture by Reverdin Needle (RN) with single instrument intracorporeal suture knot tie. Description of the technique Under general endotracheal tube anesthesia, a 0.8–1.2-cm. longitudinal transumilical skin incision was done for insertion of the umbilical port and a 3-mm Maryland forceps. RN was used for insertion of a purse string suture with single instrument intracorporeal suture tie around internal inguinal ring (IIR). The purse-string knot airtightness was stress-tested by raising the intraperitoneal CO 2 pressure to 16–24mm Hg for about 30seconds. Results A total of 383 patients with 402 congenital inguinal hernias were subjected to SILHR. They were 304 males and 79 females with a mean age of 2.2±2.25years. A single instrument technique was used for intracorporeal suture knot tie and all cases were completed laparoscopically without conversion. The mean operative time was 12.5±3.3minutes for unilateral hernia repair and 17±4.37 for bilateral cases. All patients achieved full recovery without intraoperative or postoperative complications. Conclusion Single instrument intracorporeal suture tie is feasible, simple, and rapid as it resulted in marked decrease of operative time. It is of low cost, secure and gives great help during SIPES surgery without struggling. It is a good alternative option to extra corporeal knot tying.

Purpose There is a tendency for the majority of surgeons to open the inguinal canal in children over two years old when performing inguinal hernia repair. On the other hand, in small children, most surgeons perform the herniotomy superficially to the external ring, as in Mitchell-Banks' technique (MBT). Our aim was to compare the Ferguson hernioplasty (FH) and Mitchell-Banks' technique in terms of recurrence and complication rates in older children. Methods We retrospectively reviewed the office medical records of children who were at least two years old and who underwent a herniotomy procedure for inguinal hernia between 1997 and 2012. Results The 4520 inguinal herniotomy procedures in boys who were over two years old were included in this study. Of these cases, 1607 cases (40.2%) were operated on by a FH with opening the inguinal canal, and 2388 cases (59.8%) by MBT superficially to the external ring. The median ages were 5.1years (range, 2.0–16.2) in the FH group and 4.6years (2.0–14.6) in the MBT group. The total complication rates were 2.3% in the FH group and 2.9% in the MBT group ( P >.05). Early complications such as wound infection, scrotal edema, and hematoma were seen in 13 (0.8%), 15 (1%), and 10 (0.6%) in the FH group, and 12 (0.5%), 18 (0.7%), and 15 (0.6%) in the MBT group, respectively ( P >.05). Late complications such as recurrence, trapped undescended testis, and testicular atrophy were seen in 2 (0.12%), 1 (0.06%), and 2 (0.12%) in the FH group, and 3 (0.12%), 1 (0.04%), and 2 (0.08%) in the MBT group ( P >.05). Conclusion The Mitchell-Banks technique is a simple and safe procedure in older boys.

Laparoscopic evaluation of the contralateral side (LECS) in children with unilateral inguinal hernia (UIH) has been criticized because of the abdominal trocar risk and costs. LECS was modified to avoid abdominal trocar insertion by using the open hernia sac for instrumentation (OHLECS). This study was performed to determine the utility, safety, and effectiveness of this technique.During a 15-month period, 80 children with unilateral hernia underwent attempted OHLECS. All ordinarily would have undergone open contralateral exploration. The indications were UIH in boysor = 2 years of age and girlsor = 4 years of age (n = 53) or high clinical suspicion (but not certainty) of contralateral hernia in older children with UIH (n = 27). Endotracheal intubation was not used unless otherwise indicated. Reusable 3-mm blunt trocars and 3-mm 30 degrees or 70 degrees laparoscopes were employed, with and 6 to 8 mm of insufflation pressure. No urethral catheter was used. The ipsilateral hernia sac was dissected, opened, and instrumented, and the contralateral side was evaluated for patency. Concurrent external palpation of the contralateral inguinal canal is an important diagnostic adjunct. Positive results were visible patency of processus vaginalis or bubbles or fluid and/or gas expressed from the processus by palpation. Only if the evaluation was positive was contralateral incision and repair performed. OHLECS added no more than 2 minutes of operating time. The operating room cost is similar to that of opening the contralateral side. Only reusable laparoscopic instruments are used, and less operating time, anesthetic time, suture material, and dressings are required if the contralateral side is not opened.In 10 patients (all6 months old) OHLECS was aborted because the hernia sac was smaller than 3 mm at the internal ring. OHLECS was successful in 70 (88%) patients-56 boys and 14 girls, aged 2 mo to 12 years (mean, 2.6 years). The presenting hernia was right-sided in 46 (66%) and left-sided in 24 (34%). Overall, 43 (61%) OHLECS results were negative and 27 (39%) were positive. The OHLECS results were positive for 22 (39%) boys and 5 (36%) girls. Their mean age was 1.9 years (range, 2 months to 10 years). There were no false-positives and one false-negative. There have been no complications during follow-up (mean, 1.14 years; range, 6 months to 2 years). No additional costs were incurred because nondisposable equipment was used.Laparoscopic evaluation of the contralateral side via the open ipsilateral hernia sac is feasible, quick, safe, cost effective, and requires no additional incisions. The rate of positive findings is comparable with that of open exploration. Long-term follow-up is required to determine the ultimate effectiveness of the technique.

Purpose The management of the contralateral region in a child with a known inguinal hernia has been debated by surgeons for more than 50 years. However, the perspective of the child's parents has not been sought, and this study was designed to evaluate parental views on this topic. Methods After IRB approval, all patients less than 10 years of age with a unilateral inguinal hernia seen by the senior surgeon were studied prospectively from November 2001 through February 2003. A study sheet was given to the parents about the nature of an inguinal hernia, the incidence of 20% to 40% of a contralateral patent processus vaginalis (CPPV), and the possible surgical options (perform repair of the unilateral inguinal hernia only, repair the unilateral inguinal hernia with contralateral exploration and repair if indicated, or unilateral inguinal hernia repair with laparoscopy through the ipsilateral hernia sac and repair of a CPPV if discovered). The parents of the last 113 patients requesting contralateral inspection were asked their motives (convenience or anesthesia concerns) regarding their decision. Results One hundred sixty-seven patients comprise the study group. Twelve parents chose unilateral repair alone, 13 chose bilateral incisions with contralateral repair if a CPPV was found, and 142 chose unilateral hernia repair with laparoscopic contralateral inspection followed by repair if needed. Regarding their motives, 90 of the last 113 parents requesting contralateral inspection indicated that convenience was the primary motive. Surprisingly, only 21 exhibited concerns about their child undergoing a second anesthesia. Conclusions When presented options regarding management of a unilateral inguinal hernia, parents preferred laparoscopic inspection and repair of the contralateral region, if needed, more for convenience than for concerns about a second procedure and anesthesia.

Purpose The purpose of this study was to determine the incidence and predictive factors associated with a contralateral patent processus vaginalis in boys with a unilateral palpable undescended testis. Methods We retrospectively reviewed the records of 77 consecutive boys (median age, 15 months; range, 5 months to 17.7 years) who had undergone orchiopexy for a unilateral palpable testis. At inguinal orchiopexy, an 8F feeding tube and a 70° adult cystoscope lens were placed into the peritoneum through the hernia sac, and the contralateral internal ring was inspected. The clinical factors that might predict the presence of a contralateral patent processus vaginalis were determined. Results The overall rate of a contralateral patent processus vaginalis was 34% in those with a significant ipsilateral hernia sac. After considering age, side, prematurity, location, and volume of the undescended testis, only the boys with a testis distal to the external ring compared with those with testes lying within the inguinal canal had statistically increased odds of a patent contralateral processus vaginalis (odds ratio, 3.1; 95% confidence interval, 1.08-9.08). Conclusion Approximately one third of boys with a unilateral palpable undescended testis will have a contralateral patent processus vaginalis as determined by transinguinal laparoscopy. The rate is higher (52%) if the undescended testis was distal to the external ring. Both the etiology and significance of this contralateral finding are unknown.

Background/Purpose: Operations for the treatment of inguinal diseases are the most frequent in childhood. Bleeding owing to trauma to the spermatic vessels is frequent and can cause testicular atrophy. The goal of this work was to determine the effects of the trauma to the spermatic vessels in the prepubertal and postpubertal histopathologic alterations in an experimental model in Wistar rats. Methods: Eighty albino Wistar rats were divided in 4 groups for the histopathologic analysis. In group A, they were submitted to digital compression of the spermatic vessels for 45 seconds; in group B, the spermatic vessels were clamped with hemostats for 5 seconds; in group C, the spermatic vessels were cauterized for 2 seconds. Group D was the control group, in which the animals were submitted to inguinotomy solely. Results: The prepubertal histopathologic alterations were significantly decreased in group A for testicular weight (0.97 ± 0.10); in group B, for testicular weight (0.81 ± 0.24), testicular volume (0.522 ± 0.192), and mean testicular biopsy score (7.2 ± 2.7); and in group C, for the 5 parameters studied, testicular weight (0.69 ± 0.28), testicular weight per 100 g of body weight (0.498 ± 0.188), testicular volume (0.765 ± 0.308), mean seminiferous tubular diameter (236.6 ± 62.5), and mean testicular biopsy score (6.9 ± 3.1). The postpubertal histopathologic alterations were not significant for any of the 5 parameters studied, in the 3 groups. Conclusions: The prepubertal histopathologic alterations were more intense in the group submitted to cauterization of the spermatic vessels, intermediate in the group submitted to clamping of the spermatic vessels with hemostats, and less severe in the rats submitted to digital compression of the spermatic vessels. The postpubertal histopathologic alterations demonstrated the capability of the young testicle to recuperate from a vascular trauma.

Background/Purpose No straightforward theoretical descriptions explaining the discrepant incidences of metachronous contralateral hernia and positive contralateral patent processus vaginalis (cPPV) exist. The indications for contralateral groin repair are still not clearly defined. Methods During laparoscopic herniorrhaphy, the intraoperative appearances of the internal inguinal rings (IIRs) were characterized and classified in 211 children with symptomatic unilateral inguinal hernias. A total of 125 boys and 86 girls with 130 right-sided and 81 left-sided indirect inguinal hernias were examined. The morphological appearances of the IIRs in patients with cPPV were compared before and after the ligation of the symptomatic IIRs. Results Of 211 children, 108 (51%) had positive cPPV findings. The cPPVs had significantly smaller orifices and shorter lengths than those on the side of the symptomatic hernia. Among these children, 24 (22%) patients exhibited morphological changes in their cPPVs, characterized by an upward movement of the overlying peritoneal veil after the closure of the symptomatic hernia. Conclusion Metachronous contralateral hernia might occur because of morphological changes to the cPPV resulting from closure of the symptomatic IIRs. The predicted incidence of contralateral hernia in this series was 11.2%.

Background Testicular descent occurs in several stages, but the exact mechanism remains obscure. Sympathetic nerves have been proposed to have a role by a possible action on developing cremaster muscle, following observations of sympathetic dysfunction in cremaster from boys with cryptorchidism. This study aimed to see if chemical sympathectomy affected testicular descent in rats. Methods Sprague-Dawley dams were injected with 6-hydroxydopamine (days 15-19; 75 μ g/kg) or control vehicle alone, and male pups examined at 0 to 10, 20, 30, and 60 days of age. The length of the processus vaginalis was measured and sections taken for histology. Results No difference in processus vaginalis growth was found between experimental and control groups, both macro- and microscopically. Chemical sympathectomy was confirmed by loss of adrenergic fibres in the adrenal cortex of experimental, but not control, animals. Conclusions These studies suggest that sympathetic innervation is not an important part of testicular descent in the rat but does not exclude a pathologic role in undescended testes or effects in humans only.

Various approaches to the management of the impalpable testis in cases of cryptorchidism have been advocated. The authors' experience over the past 13 years was reviewed to try to determine an optimal approach. Of 1,305 patients with undescended testicles seen between February 1982 and December 1995, 157 boys (12.03%) had impalpable testes with 17 having bilateral impalpable testes for a total of 174 impalpable testes. A hernia sac was present in 155 impalpable testes with a testicle present in all cases. No hernia sac was found in 19 impalpable testes, five of which had no testicle present. This was confirmed by either open exploration or laparoscopy. One hundred forty-eight boys underwent groin exploration as initial treatment, 13 of these had bilateral impalpable testes. In addition to the five absent testicles with no hernia sac, one patient with a hernia sac and no testicle evident benefited from subsequent laparoscopy to identify an intraabdominal testicle. All other patients underwent routine orchidopexy or orchidectomy (one case with grossly malformed testicle). Nine boys underwent laparoscopy as initial treatment, four of these had bilateral impalpable testes. Two abnormal testicles were found and removed. Groin exploration and subsequent orchidopexy was definitive treatment in all other cases. The association of a hernia sac with an impalpable undescended testicle is very significant (P < .00001 Fisher's Exact test). The absence of a sac therefore may reflect an alternate diagnosis. When no sac is found with a testicle in the groin, this may represent an ectopic testicle. When no sac is found with no testicle, this may represent a vanishing testicle. From this experience the authors conclude that groin exploration should be the initial approach to impalpable testes. The presence of a hernia sac with an absent testicle demands further exploration; the absence of a hernia sac with an absent testicle suggests a vanishing testicle and may need no further exploration.

The contralateral internal inguinal rings of 333 children were examined with a laparoscope during repair of unilateral inguinal hernia. The nonpuncture laparoscopy technique was used so that no extra wound was created. The morphology of the rings was classified as follows: type 1, flat and covered tightly with peritoneum; type 2, shallow with a visible base under an elevated peritoneal fold; type 3, deep ring that represented a patent processus vaginalis. The incidence of types 1, 2, and 3 rings was 45%, 23%, and 32%, respectively. The incidence of type 1 internal rings was similar for different age groups. The incidence of type 2 rings increased with age, and that of type 3 decreased with age. This observation is compatible with autopsy studies and the experience of contralateral exploration of childhood inguinal hernias.

The authors report 2 cases of pediatric emergencies caused by fishbone ingestion. In the first case, 2 fishbones within the sac of an inguinal hernia were detected during an emergency operation for suspected testicular torsion; in the second case, a big fishbone was found in the omentum covering an inflammed appendix during an emergency appendicectomy. In some cases this three foreign bodies can be detected with a simple abdominal X-ray; the relationship between the fish species involved and the diagnosis is discussed.

The authors report on 2 neonates with irreducible inguinal hernia in whom a Pfannenstiel skin incision followed by lower abdominal midline fasciotomy were used to open the abdomen during emergency operation. By using this approach, the inguinal canal could also be opened and the hernia sac ligated. Bowel resection followed by anastomosis in one case and appendectomy in the other case could be performed safely intraabdominally because of the better exposure provided by using our approach compared with an inguinal incision alone. A Pfannenstiel incision followed by a midline fasciotomy decreases the risks associated with surgical intervention by enhancing exposure and contributing to good outcome by improving wound cosmesis.

It has been proposed that testicular descent is controlled indirectly by androgens acting on the central nervous system to mediate migration of the gubernaculum to the scrotum. Accumulating evidence suggests that the genitofemoral nerve may release a newly described neurotransmitter, calcitonin gene-related peptide (CGRP) to stimulate gubernacular motility during migration. This study aimed to determine whether exogenous CGRP could stimulate gubernacular migration in mice with complete androgen resistance (testicular feminization mouse [Tfm]). CGRP was injected into the right groin of neonatal Tfm mice at 2-day intervals until 2 weeks of age, when the length of the processus vaginalis was measured under a dissecting microscope. The processus vaginalis length in normal male littermates was 5.9 +/- 1.8 mm (mean +/- SD) while in the female it was 1.2 +/- 0.9 mm. Exogenous CGRP had no effect on either of these. In Tfm males CGRP caused a significant increase in the length of the processus vaginalis on the injected side (2.3 +/- 0.8 mm) compared with the uninjected side (1.4 +/- 1.0 mm). These results are consistent with the hypothesis that CGRP can replace, at least partially, the effect of androgens on gubernacular migration.

A 5-month-old boy presented with bilateral hydroceles since birth and right leg edema. An ultrasound of the pelvis showed a 4-cm cystic mass that was diagnosed as a teratoma or cystic hygroma. Magnetic resonance imaging was performed, which showed a dumbbell shaped contiguous, fluid filled mass extending intraabdominally through the inguinal canal from the scrotum. The cystic portion in the right iliac fossa was lying on the right iliac vessels, which were patent. A bilateral hydrocelectomy was performed, and the intraperitoneal sac was completely excised through the inguinal incision. The edema of the right leg disappeared a few days after surgery.

A prospective evaluation of the value of magnetic resonance imaging (MRI) for localizing the nonpalpable undescended testis was performed in 17 boys aged 1 year to 5 years 4 months who had a clinical diagnosis of nonpalpable testes. The results were compared between the MRI, ultrasonographic, clinical, and definitive surgical diagnosis in all patients. Nine nonpalpable undescended testes were identified in the inguinal canal or just proximal to the inguinal ring by MRI, and these were confirmed by surgical findings. Six nonpalpable testes were not observed by MRI, and the absence of these testes was surgically confirmed. Like scrotal testes, all the undescended testes showed a low intensity on sequences with a short repetition time (TR) and echo time (TE), and a high intensity on long TR/TE sequences. Undescended testes were observed better on coronal images than on axial images. MRI promises to become an important diagnostic tool in the detection of nonpalpable undescended testes.