Hernioplasty and testicular perfusion

An Uncommon Cause of Testicular Infarct: A Case Report and Review of the Literature of Testicular Infarcts From Laparoscopic Inguinal Hernia Repair

BACKGROUND

Testicular ischemia requires timely diagnosis and definitive management to avoid serious consequences such as orchiectomy. It is almost always caused by testicular torsion; however, there are other causes to be aware of.

CASE REPORT

A 32-year-old man developed testicular ischemia following a laparoscopic robotic-assisted inguinal hernia repair with preperitoneal mesh. The ischemia progressed to a fully infarcted testicle with no evidence of torsion on subsequent surgical exploration. He ultimately did require an orchiectomy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: While extremely rare, testicular ischemia or infarct must be considered in patients presenting with testicular pain shortly after inguinal hernia repair. Emergent surgical evaluation and loosening of the hernia mesh may be required to salvage the testicle.

Bilateral inguinal hernia repair and male fertility: a randomized clinical trial comparing Lichtenstein versus laparoscopic transabdominal preperitoneal (TAPP) technique

BACKGROUND

The effects of hernia repair on testicular function remain uncertain, regardless of the technique used. Studies that analyze testicular volume and flow after hernia repair or hormonal measurements are scarce and show contradictory results. This study aimed to evaluate the impact of bilateral inguinal hernia repair on male fertility in surgical patients in whom the Lichtenstein and laparoscopic transabdominal preperitoneal (TAPP) techniques were used.

METHODS

A randomized clinical trial comparing open (Lichtenstein) versus laparoscopic (TAPP) hernia repair using polypropylene mesh was performed in 48 adult patients (20 to 60 years old) with primary bilateral inguinal hernia. Patients were evaluated preoperatively and 90 and 180 postoperative (PO) days. Sex hormones (Testosterone, FSH, LH and SHGB) analysis, testicular ultrasonography, semen quality sexual activity changes and quality of life (QoL) were performed. Postoperative pain was evaluated using the visual analog scale (VAS).

RESULTS

Thirty-seven patients with aged of 44 ± 11 years were included, 19 operated on Lichtenstein and 18 operated on TAPP. The surgical time was similar between techniques. The pain was greater in the Lichtenstein group on the 7th PO day. The biochemical and hormonal analyses, testicular ultrasonography (Doppler, testicular volume, and morphological findings) and sperm quality were similar between groups. However, the sperm morphology was better in the Lichtenstein group after 180 days (p < 0.05 vs. preoperative) and two patients who underwent Lichtenstein hernia repair had oligospermia after 180 days. The QoL evaluation showed a significant improvement after surgery in the following domains: physical function, role emotional, bodily pain and general health (p < 0.05). On comparison of Lichtenstein vs. TAPP none of the domains showed statistically significant differences. No patient reported sexual changes.

CONCLUSION

Bilateral inguinal hernia repair with polypropylene mesh, whether using Lichtenstein or TAPP, does not impair male fertility in terms of long-term outcomes.

TRIAL REGISTRATION

Approved by the Ethics Committee for the Analysis of Research Projects (CAPPesq) of the HC/FMUSP, Number 2.974.457, in June 2015, Registered on Plataforma Brasil in October 2015 under Protocol 45535015.4.0000.0068. Registered on Clinicaltrials.gov, NCT05799742. Enrollment of the first subject in January 2016.

Fascinating history of groin hernias: Comprehensive recognition of anatomy, classic considerations for herniorrhaphy, and current controversies in hernioplasty

Groin hernias include indirect inguinal, direct inguinal, femoral, obturator, and supravesical hernias. Here, we summarize historical turning points, anatomical recognition and surgical repairs. Groin hernias have a fascinating history in the fields of anatomy and surgery. The concept of tension-free repair is generally accepted among clinicians. Surgical repair with mesh is categorized as hernioplasty, while classic repair without mesh is considered herniorrhaphy. Although various surgical approaches have been developed, the surgical technique should be carefully chosen for each patient. Regarding as interesting history, crucial anatomy and important surgeries in the field of groin hernia, we here summarized them in detail, respectively. Points of debate are also reviewed; important points are shown using illustrations and schemas. We hope this systematic review is surgical guide for general surgeons including residents. Both a skillful technique and anatomical knowledge are indispensable for successful hernia surgery in the groin.

Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults

Groin hernias include indirect inguinal, direct inguinal, and femoral hernias. Obturator and supravesical hernias appear very close to the groin. High-quality repairs are required for groin hernias. The concept of "tension-free repair" is generally accepted, and surgical repairs with mesh are categorized as "hernioplasties". Surgeons should have good knowledge of the relevant anatomy. Physicians generally focus on the preperitoneal space, myopectineal orifice, topographic nerves, and regional vessels. Currently, laparoscopic surgery has therapeutic potential in the surgical setting for hernioplasty, with laparoscopic transabdominal preperitoneal (TAPP) repair appearing to be a powerful tool for use in adult hernia patients. TAPP offers the advantages of accurate diagnoses, repair of bilateral and recurrent hernias, less postoperative pain, early recovery allowing work and activities, tension-free repair of the preperitoneal (posterior) space, ability to cover obturator hernias, and avoidance of potential injury to the spermatic cord. The disadvantages of TAPP are the need for general anesthesia, adhering to a learning curve, higher cost, unexpected complications related to abdominal organs, adhesion to the mesh, unexpected injuries to vessels, prolonged operative time, and as-yet-unknown long-term outcomes. Both technical skill and anatomical familiarity are important for safe, reliable surgery. With increasing awareness of the importance of anatomy during TAPP repair, we address the skills and pitfalls during laparoscopic TAPP repair in adult patients using illustrations and schemas. We also address debatable points on this subject.

Could polypropylene mesh impair male reproductive organs? Experimental study with different methods of implantation

PURPOSE

To evaluate the vas deferens and testicles of rats submitted to bilateral inguinotomy and polypropylene (PP) mesh placement.

METHOD

Sixty Wistar rats were randomized into three groups: Control (inguinotomy only), mesh placement over the vas deferens (Mesh-DD) or under the spermatic funiculus (Mesh-SF). The following analyses were performed: vas deferens morphometry (lumen area and wall thickness), quantification of collagen fibers, spermatogenesis, apoptosis (cleaved caspase-3 and TUNEL) and cellular proliferation (Ki67). Quantitative gene expression (qPCR) for apoptosis and inflammatory cytokines were evaluated by RT-PCR.

RESULTS

In the apoptosis pathway, Mesh-DD showed one upregulated gene (Il10) and three downregulated genes (Fadd, Tnfrsf1b and Xiap). In Mesh-SF, 17 genes were downregulated. In the inflammation pathway (Mesh-DD), one gene was upregulated (Il1r1), and one gene was downregulated (Ccl12). In Mesh-SF, three genes were upregulated (Il1r1, Tnfsf13b and Csf1), and two were downregulated (Ccl12 and Csf2). PP mesh placement preserved spermatogenesis and did not alter the vas deferens or the testicle. In the ductus deferens, there was reduced luminal area (30 days), increased wall thickness (90 days), and increased type III collagen and cell proliferation (30 and 90 days) (p < 0.05). In the testicle, cell proliferation was greater in the Mesh-DD (p < 0.05).

CONCLUSIONS

PP mesh, whether or not in direct contact with spermatic funicular structures, induces changes that were not sufficient to cause damage to the evaluated organs.

Does a bilateral polypropylene mesh alter the duct deferens morphology, testicular size and testosterone levels? Experimental study in rats

Purpose

To evaluate the effect of a PP mesh on duct deferens morphology, testicular size and testosterone levels.

Methods

Forty adult male rats were distributed into groups: 1) no surgery; 2) inguinotomy; 3) mesh placed on the duct deferens; and 4) mesh placed on the spermatic funiculus. After 90 postoperative days, the inguinal region was resected, and blood samples were collected for the measurement of serum testosterone (pg/dl). The ducts deferens were sectioned in three axial sections according to the relationship with the mesh — cranial, medial and caudal. The wall thickness and duct deferens lumen area were measured.

Results

The morphology of the duct deferens was preserved in all groups. The mesh placement did not alter this morphology in any of the analyzed segments. Surgery, with or without mesh placement, did not alter the morphology, wall thickness or lumen area (p>0.05). In all operated groups, serum testosterone levels were similar (p>0.05) but there was a decrease in testicle size (p<0.05).

Conclusion

Surgery, with or without mesh placement, did not alter the morphology of the duct deferens and, although this treatment resulted in testicular size reduction, it did not affect serum testosterone levels.

Pain and Dysfunction with Sexual Activity after Inguinal Hernia Repair: Systematic Review and Meta-Analysis

BACKGROUND

The reported incidence rates of sexual dysfunction (SD) and pain with sexual activity (PSA) after inguinal hernia repair in males vary considerably. This meta-analysis explores the rates of SD and PSA after different surgical and anesthesia types to understand patient risk after inguinal hernia repair.

STUDY DESIGN

We performed a systematic review and meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to search 3 databases (EMBASE, MEDLINE, and Cochrane Library). We identified retrospective, prospective, and randomized controlled trial studies, published on or before March 1, 2019, reporting on SD and PSA after inguinal hernia repair. We used random-effects models to calculate pooled estimates of incidence rates of SD and PSA after inguinal hernia repair. Subgroup meta-analyses and meta-regression were used to explore sources of variation.

RESULTS

A total of 4,884 patients from 12 studies were identified. Study-level median age at the time of repair was 52.3 years old, and study-level median follow-up was 10.5 months. Definitions of SD and PSA focused on completion of intercourse for the former and pain with erection/ejaculation for the latter. The overall incidence of new-onset, postoperative SD was 5.3% (95% CI 3.6% to 7.9%) and of PSA was 9.0% (95% CI 5.8% to 13.6%). Rates of SD associated with minimally invasive surgical (MIS) and open repair were, respectively, 7.8% (95% CI 5.4% to 11.3%) and 3.7% (95% CI 2.0% to 6.8%); rates of PSA were 7.4% (95% CI 4.7% to 11.5%) and 12.5% (95% CI 6.4% to 23.3%), respectively.

CONCLUSIONS

Sexual dysfunction and PSA are not rare after inguinal hernia repair. They should be included in preoperative discussions and as standard metrics in reporting outcomes of repair in large cohorts or trials.

Bilateral endoscopic totally extraperitoneal (TEP) inguinal hernia repair does not impair male fertility

PURPOSE

Endoscopic totally extraperitoneal (TEP) hernia repair with polypropylene mesh has become a well-established technique. However, since the mesh is placed in close contact with the spermatic cord, mesh-induced inflammation may affect its structures, possibly resulting in impaired fertility. The aim of this observational prospective cohort study was to assess fertility after bilateral endoscopic TEP inguinal hernia repair in male patients.

METHODS

Fifty-seven male patients (22-60 years old) with primary, reducible, bilateral inguinal hernias underwent elective bilateral endoscopic TEP hernia repair with use of polypropylene mesh. The primary outcome was testicular perfusion; secondary outcomes were testicular volume, endocrinological status, and semen quality. All patients were assessed preoperatively and 6 months postoperatively.

RESULTS

Follow-up was completed in 44 patients. No statistically significant differences in measurements of testicular blood flow parameters or testicular volume were found. Postoperative LH levels were significantly higher [preoperative median 4.3 IU/L (IQR 3.4-5.3) versus postoperative median 5.0 IU/L (IQR 3.6-6.5), p = 0.03]. Levels of inhibin B were significantly lower postoperatively [preoperative median 139.0 ng/L (IQR 106.5-183.0) versus postoperative median 27.0 ng/L (IQR 88.3-170.9), p = 0.01]. No significant changes in FSH or testosterone levels were observed. There were no differences in semen quality.

CONCLUSIONS

Our data suggest that bilateral endoscopic TEP hernia repair with polypropylene mesh does not impair fertility, as no differences in testicular blood flow, testicular volume, or semen quality were observed. Postoperative levels of LH and inhibin B differed significantly from preoperative measurements, yet no clinical relevance could be ascribed to these findings.

A comparison of preoperative and postoperative testicular volume and blood flow in patients with inguinal hernia, hydrocele, and cord cyst: A prospective cohort study

OBJECTIVE

To evaluate the effect of inguinal operations performed with a modified Ferguson technique upon testicular volume and blood flow.

METHODS

This study involved 23 children receiving surgery for inguinal hernia, hydrocele, and cord cyst. This was a prospective study performed between April 2016 and June 2016 in a medical faculty pediatric surgery unit. The color Doppler ultrasound (CDUS) was used to assess testicular volume and blood flow before and after a modified Ferguson technique surgery. The pre- and post operative testicular volume and blood flow were compared with the contralateral testes. SPSS software was used to statistically analyze the data arising; the Mann-Whitney U test and Friedman test were used to compare samples, and P<0.05 was accepted as statistically significant.

RESULTS

Preoperative and postoperative testicular volumes were not statistically different when compared to contralateral testes. In patients with right sided inguinal pathology, testicular blood flow on the right side was significantly lower than that on the left side (P=0.023). The testicular blood flow was not statistically different compared with the contralateral testes during the first week evaluation and first month evaluation. The blood flow, probably reduced due to the pressure caused by inguinal pathology, was normalized through surgery.

CONCLUSIONS

The modified Ferguson technique do not change the testes volume and blood flow.

Early results of dual approach hernioplasty (DAH): an innovative laparoscopic inguinal hernioplasty technique

BACKGROUND

In this study, the proposed technique is combining the invented method of extraperitoneal dissection utilizing gas insufflation through Veress needle introduced from the groin with the transabdominal approach. Such a combination minimizes operative demands, achieves major goals, and reduce operative time in an attempt to improve laparoscopic hernioplasty techniques.

METHODS

The study recruited 211 patients having primary reducible inguinal hernia upon first diagnosis. Abdominal ultrasound examination achieved to exclude any additional pathology and confirming clinical diagnosis. The new technique is applied on all patients without any modification through the whole series.

RESULTS

Patients' epidemiology, operative characteristics, and follow-up are all tabulated. Results showed no complications nor conversion to open procedure.

CONCLUSIONS

The proposed procedure showed preliminary encouraging results regarding technique, clinical outcome, time-saving, and patients' safety. Combination of extraperitoneal gas-derived dissection, transabdominal field review, and preperitoneal mesh application offers an innovative and promising laparoscopic hernioplasty technique. The study is introducing the technique and as well invites further trials on wider scale to verify the technique.