Pediatric Case Report Congenital Spigelian Hernia and Ipsilateral Cryptorchidism: Raising Awareness Among Urologists Zarine R. Balsara, Abigail E. Martin, John S. Wiener, Jonathan C. Routh, and Sherry S. Ross Spigelian hernias (SHs) are rare in the pediatric population. Although pediatric general surgeons often treat this defect, the increased association between a congenital SH and an ipsilateral undescended testis suggests that urologists may be the first provider encountering this entity. Knowledge of this condition is therefore important. We report one such case of a male infant referred to urology for an undescended testicle. Further investigation revealed the testicle to be within a congenital SH sac. Herein, we additionally review the literature concerning SHs associated with ipsilateral undescended testicles. UROLOGY 83: 457e459, 2014. 2014 Elsevier Inc.
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ongenital spigelian hernias (SHs) are exceedingly rare. As the name implies, the defect occurs through the spigelian fascia, a section of the transversus aponeurosis located between the lateral border of the rectus abdominus muscle and the semilunar line.1 The most common location of an SH is inferior to the arcuate line where the posterior rectus fascia is deficient. Reported contents of congenital SH include extraperitoneal fat, peritoneum, small intestine, sigmoid colon, and testicles.2 Herein, we report on a 3-month-old boy with an undescended testicle located within a congenital SH sac. Diagnosis was initially suggested on abdominal ultrasound and confirmed on exploratory laparoscopy. This report lends further credence to the argument that ipsilateral cryptorchidism and SH together represent a distinct clinical association.
CASE REPORT A full-term male infant with normal prenatal ultrasound was referred to urology at 2 weeks of age for evaluation of a nonpalpable left testicle. The parents also reported a palpable bulge of the baby’s left lower abdominal wall with crying and straining. There was no associated nausea, vomiting, anorexia, or pain. On examination, the left hemiscrotum was hypoplastic and there was no palpable testicle in the scrotum or inguinal canal. In the inferolateral aspect of the left lower abdominal wall just Financial Disclosure: The authors declare that they have no relevant financial interests. From the Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC; the Department of Pediatrics, Duke University Medical Center, Durham, NC; the Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, Durham, NC; and the Division of Abdominal Transplant Surgery, Department of Surgery, Duke University Medical Center, Durham, NC Reprint requests: Sherry S. Ross, M.D., Departments of Surgery and Pediatrics, Division of Urology, Duke University School of Medicine, Box 3831, Durham, NC 27710. E-mail: [email protected] Submitted: July 15, 2013, accepted (with revisions): September 27, 2013
ª 2014 Elsevier Inc. All Rights Reserved
Figure 1. Abdominal ultrasound revealed a normal-sized left testicle (white arrowhead) within the spigelian hernia sac in the left lower quadrant with loops of bowel (white arrows) surrounding the testicle. (A) Left lower abdomen transverse scan. (B) Left parasagittal longitudinal scan.
above the inguinal canal, there was a small bulging area that was easily compressible and nontender to palpation, consistent with an abdominal wall hernia. Over the next month, the ventral wall hernia increased in size but 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2013.09.032
457
Figure 2. (A) After insufflation of the abdomen, the abdominal wall hernia (white arrow) within the left lower quadrant and lateral to the rectus muscle became more pronounced. (B) The vas deferens and spermatic vessels (black arrow) are seen heading into the spigelian hernia sac. (C) The left testicle (black arrowhead) is noted within the hernia sac itself. (Color version available online.)
remained asymptomatic. An abdominal and scrotal ultrasound was performed on the boy at 2 months of age and was interpreted as an apparent dehiscence of the abdominal musculature in the left lower quadrant, with loops of bowel surrounding the left testicle contained within a hernia sac (Fig. 1). A presumptive diagnosis of a spigelian hernia (SH) with an associated undescended left testicle was made. Because of concerns over hernia enlargement, diagnostic laparoscopy was performed on the boy at 3 months of age by a pediatric urologist and a pediatric surgeon. Upon insufflation of the abdomen, an obvious abdominal wall hernia was noted lateral to the rectus muscle within the left lower quadrant, consistent with an SH (Fig. 2A). On laparoscopic exploration, the vas deferens and spermatic vessels were noted to enter the hernia sac, and the left testis was confirmed to lie within the sac itself (Fig. 2B,C). We then proceeded with left orchidopexy and hernia repair using an open approach through a transverse incision in the left lower quadrant just below the anterior superior iliac spine. Between the external oblique aponeurosis and the rectus fascia, herniation of the peritoneum was seen through the transversalis fascia. The peritoneal sac was opened and the left testicle was identified. The left testicle and spermatic cord were mobilized by carefully dissecting the peritoneal sac off the spermatic cord. There was ample length of the spermatic cord to allow the testicle to easily reach the scrotum. Left orchidopexy was performed by creating a “new” inguinal ring lateral to the 458
epigastric vessels at the inferior aspect of the hernia defect and superior to the pubic tubercle. The hernia sac was then reduced into the abdominal cavity. The internal oblique and transversus abdominus muscle were reapproximated to the lateral margin of the rectus fascia to close the fascial defect. The patient was seen at both 1 month and 7 months postoperatively and was doing well. The left testicle remained within the dependent portion of the scrotum and was normal in size. There was no evidence of recurrent hernia.
COMMENT SH represents 0.1%-2% of all reported abdominal wall hernias.1 The majority of SHs affect adults with only 3% of SHs occurring in children.3 To date, there have been approximately 55 pediatric cases of SH reported, with the majority being diagnosed in infants
C
ongenital spigelian hernias (SHs) are exceedingly rare. As the name implies, the defect occurs through the spigelian fascia, a section of the transversus aponeurosis located between the lateral border of the rectus abdominus muscle and the semilunar line.1 The most common location of an SH is inferior to the arcuate line where the posterior rectus fascia is deficient. Reported contents of congenital SH include extraperitoneal fat, peritoneum, small intestine, sigmoid colon, and testicles.2 Herein, we report on a 3-month-old boy with an undescended testicle located within a congenital SH sac. Diagnosis was initially suggested on abdominal ultrasound and confirmed on exploratory laparoscopy. This report lends further credence to the argument that ipsilateral cryptorchidism and SH together represent a distinct clinical association.
CASE REPORT A full-term male infant with normal prenatal ultrasound was referred to urology at 2 weeks of age for evaluation of a nonpalpable left testicle. The parents also reported a palpable bulge of the baby’s left lower abdominal wall with crying and straining. There was no associated nausea, vomiting, anorexia, or pain. On examination, the left hemiscrotum was hypoplastic and there was no palpable testicle in the scrotum or inguinal canal. In the inferolateral aspect of the left lower abdominal wall just Financial Disclosure: The authors declare that they have no relevant financial interests. From the Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC; the Department of Pediatrics, Duke University Medical Center, Durham, NC; the Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, Durham, NC; and the Division of Abdominal Transplant Surgery, Department of Surgery, Duke University Medical Center, Durham, NC Reprint requests: Sherry S. Ross, M.D., Departments of Surgery and Pediatrics, Division of Urology, Duke University School of Medicine, Box 3831, Durham, NC 27710. E-mail: [email protected] Submitted: July 15, 2013, accepted (with revisions): September 27, 2013
ª 2014 Elsevier Inc. All Rights Reserved
Figure 1. Abdominal ultrasound revealed a normal-sized left testicle (white arrowhead) within the spigelian hernia sac in the left lower quadrant with loops of bowel (white arrows) surrounding the testicle. (A) Left lower abdomen transverse scan. (B) Left parasagittal longitudinal scan.
above the inguinal canal, there was a small bulging area that was easily compressible and nontender to palpation, consistent with an abdominal wall hernia. Over the next month, the ventral wall hernia increased in size but 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2013.09.032
457
Figure 2. (A) After insufflation of the abdomen, the abdominal wall hernia (white arrow) within the left lower quadrant and lateral to the rectus muscle became more pronounced. (B) The vas deferens and spermatic vessels (black arrow) are seen heading into the spigelian hernia sac. (C) The left testicle (black arrowhead) is noted within the hernia sac itself. (Color version available online.)
remained asymptomatic. An abdominal and scrotal ultrasound was performed on the boy at 2 months of age and was interpreted as an apparent dehiscence of the abdominal musculature in the left lower quadrant, with loops of bowel surrounding the left testicle contained within a hernia sac (Fig. 1). A presumptive diagnosis of a spigelian hernia (SH) with an associated undescended left testicle was made. Because of concerns over hernia enlargement, diagnostic laparoscopy was performed on the boy at 3 months of age by a pediatric urologist and a pediatric surgeon. Upon insufflation of the abdomen, an obvious abdominal wall hernia was noted lateral to the rectus muscle within the left lower quadrant, consistent with an SH (Fig. 2A). On laparoscopic exploration, the vas deferens and spermatic vessels were noted to enter the hernia sac, and the left testis was confirmed to lie within the sac itself (Fig. 2B,C). We then proceeded with left orchidopexy and hernia repair using an open approach through a transverse incision in the left lower quadrant just below the anterior superior iliac spine. Between the external oblique aponeurosis and the rectus fascia, herniation of the peritoneum was seen through the transversalis fascia. The peritoneal sac was opened and the left testicle was identified. The left testicle and spermatic cord were mobilized by carefully dissecting the peritoneal sac off the spermatic cord. There was ample length of the spermatic cord to allow the testicle to easily reach the scrotum. Left orchidopexy was performed by creating a “new” inguinal ring lateral to the 458
epigastric vessels at the inferior aspect of the hernia defect and superior to the pubic tubercle. The hernia sac was then reduced into the abdominal cavity. The internal oblique and transversus abdominus muscle were reapproximated to the lateral margin of the rectus fascia to close the fascial defect. The patient was seen at both 1 month and 7 months postoperatively and was doing well. The left testicle remained within the dependent portion of the scrotum and was normal in size. There was no evidence of recurrent hernia.
COMMENT SH represents 0.1%-2% of all reported abdominal wall hernias.1 The majority of SHs affect adults with only 3% of SHs occurring in children.3 To date, there have been approximately 55 pediatric cases of SH reported, with the majority being diagnosed in infants
