Inguinal endometriosis: a case series and review of the literature

BACKGROUND

Inguinal endometriosis is one of the most common forms of endometriosis. The present study introduces 8 cases of inguinal endometriosis and discusses probable theories of inguinal endometriosis by reviewing the literature.

CASE PRESENTATION

8 Iranian cases of inguinal endometriosis with a mean age of 36 years were presented. Catamenial groin pain and swelling were the most common complications. Also, patients usually had accompanying symptoms such as pelvic pain and dysmenorrhea. One-half of patients had a history of previous abdominal surgery. Ultrasound was diagnostic in 4 patients (50%), and magnetic resonance imaging was used in two patients (25%). Among 6 patients who underwent hormonal therapy, 4 experienced an endometriosis size increase. Inguinal endometriosis was right-sided in 87.5% of patients, and among 4 patients who underwent surgery, 75% had proximal site involvement of the round ligament.

CONCLUSION

According to the rarity of inguinal endometriosis, it is more likely to be a misdiagnosis with other inguinal disorders such as inguinal hernia. Inguinal endometriosis should be considered in patients who undergo inguinal herniorrhaphy, with suspected findings such as thickening of the hernia sac wall, bloody fluid inside the sac, or thickening of the extraperitoneal round ligament during the surgery.

Canal of nuck hernia with uterus and ovary presenting as inguinal swelling in a female infant

Canal of nuck hernia is rarely reported in pediatric population. We report one such case of a canal of nuck hernia in a 2-month-old girl containing uterus, ovary and small bowel diagnosed on ultrasonography, and which was later confirmed and treated surgically.

Intravenous Pyogenic Granuloma in the Inguinal Canal Mimicking Lymph Node Metastasis on PSMA PET/CT

ABSTRACT

We present a 68-year-old man with newly diagnosed high-risk prostate cancer who was referred for PSMA PET/CT after the initial CT showed a contrast-enhanced structure resembling a lymph node in the left inguinal canal. No other findings suggesting metastatic disease were seen on CT or bone scintigraphy. PSMA PET/CT showed moderate PSMA uptake in the inguinal tissue, substantiating an unexpected location of lymph node metastasis. The uncommon location warranted an excision biopsy, and an IV pyogenic granuloma was diagnosed on histological examination, emphasizing the importance of biopsy of unexpected findings.

The emerging role of MRI neurography in the diagnosis of chronic inguinal pain

INTRODUCTION

Chronic pain is a frequent and notable complication after inguinal hernia repair, it has been extensively studied, but its management and diagnosis are still difficult. The cause of chronic pain following inguinal hernia surgery is usually multifactorial. This case series highlights the utility of MRI neurography (MRN) in evaluating the damage to inguinal nerves after a hernia repair, with surgical confirmation of the preoperative imaging findings.

MATERIALS AND METHODS

A retrospective review was performed on patients who underwent inguinal mesh removal and triple denervation of the groin. Inclusion criteria included MRI neurography. All patients underwent surgical exploration of the inguinal canal for partial or complete mesh removal and triple denervation of the groin by the same senior surgeon.

RESULTS

A total of nine patients who underwent triple denervation were included in this case series. MRN was then performed on 100% of patients. The postoperative mean VAS score adjusted for all patients was 1.6 (SD p), resulting in a 7.5 score difference compared to the preoperative VAS score (p). Since chronic groin pain can be a severely debilitating condition, diagnosis, and treatment become imperative.

CONCLUSION

MRN can detect direct and indirect signs of neuropathy even in the absence of a detectable compressive cause aids in management and diagnosis by finding the precise site of injury, and grading nerve injury to aid pre-operative assessment for the nerve surgeon. Thus, it is a valuable diagnostic tool to help with the diagnosis of nerve injuries in the setting of post-inguinal hernia groin pain.

Vas Deferens and Inguinal Canal Metastasis of Prostate Cancer Revealed by 68 Ga-Prostate-Specific Membrane Antigen PET/CT

ABSTRACT

A 71-year-old man with prostate adenocarcinoma underwent 68 Ga-prostate-specific membrane antigen (PSMA) PET/CT for staging. 68 Ga-PSMA PET/CT showed the primary lesion along with bladder, rectum, bilateral seminal vesicle invasion, and metastatic pelvic lymph nodes with intense 68 Ga-PSMA uptake. Also, PET/CT showed rarely seen bilateral vas deferens invasion and metastasis to the inguinal canal. These rare metastases may be indicative of poor biological behavior and prognosis.

Inguinal endometriosis: A systematic review

Inguinal endometriosis is a very rare entity with uncertain pathophysiology, that poses several diagnostic and therapeutic challenges. This study aimed to summarize published literature on the diagnosis and treatment of this condition. Thus, a systematic literature search was conducted in PubMed/MEDLINE, Scopus and the Cochrane Library. An effort was made to numerically analyze all parameters included in case reports and retrospective analyses, as well. The typical and atypical features of this condition, investigations used, type of treatment and histopathology were recorded. More specifications about the surgical treatment, such as operations previously performed, type of surgery and treatment after surgery have been acknowledged. Other sites of endometriosis, the presence of pelvic endometriosis and the follow-up and recurrence have been also documented. Overall, the search yielded 61 eligible studies including 133 cases of inguinal endometriosis. The typical clinical presentation includes a unilateral inguinal mass, with or without catamenial pain. Transabdominal or transvaginal ultrasound was typically used as the first line method of diagnosis. Groin incision and exploratory surgery was the treatment indicated by the majority of the authors, while excision of part of the round ligament was reported in about half of the cases. Chemotherapy and radiotherapy were initiated in cases of coexisting endometriosis-related neoplasia. Inguinal recurrence or malignant transformation was rarely reported. The treatment of inguinal endometriosis is surgical and a long-term follow-up is needed. More research is needed on the effectiveness of suppressive hormonal therapy, recurrence rate and its relationship with endometriosis-associated malignancies.

Primary inguinal subcutaneous endometriosis accompanied with an inguinal hernia: A case report

RATIONALE

We report a case with inguinal subcutaneous endometriosis without typical cyclic dysmenorrhea and accompanied with a hernia sac treated with resection of the tumor and herniorrhaphy.

PATIENT CONCERNS

A 40-year-old woman had a painless enlarged inguinal nodule for 3 months.

DIAGNOSES

Subcutaneous endometriosis accompanied with a hernia sac.

INTERVENTIONS

Ultrasonography showed a hypoechoic lesion (3.0 cm × 2.0 cm), and an inguinal subcutaneous tumor was first suspected. After surgical exploration, a cystic lesion was excised and the hernia hole was repaired by herniorrhaphy. The immunohistochemical analysis of the small endometriotic cyst-like lesion revealed calretinin (-) in epithelial cells and CD10 (+) in stromal cells, indicative of subcutaneous endometriosis accompanied with a hernia sac.

OUTCOMES

The patient was followed up for 1 year and without recurrence.

LESSONS

Cutaneous endometriosis accompanied with a hernia sac can be presented without typical endometriosis-associated symptoms such as dysmenorrhea. Inguinal endometriosis might be the differential diagnosis of inguinal painless nodules.

Ovarian inguinal hernia

INTRODUCTION

Gynaecological structures such as the ovaries, fallopian tubes, ligaments and uterus are rarely encountered inside a hernial sac. The prevalence of groin hernias containing parts of female genitalia remains unknown. The aim of this review was to summarise the existing evidence on inguinal hernias containing ovaries with or without the other female adnexa.

METHODS

A systematic search was conducted for literature published up to February 2018 using the MEDLINE®, Scopus® and Google Scholar™ databases along with the references of the full-text articles retrieved. Papers on observational studies and case reports concerning women who were diagnosed with an ovarian inguinal hernia (pre or intraoperatively) were considered eligible for inclusion in the review.

RESULTS

Fifteen papers (13 case reports, 2 case series) comprising seventeen patients (mean age 47.9 years) were evaluated. A left-sided hernia was noted in 13 cases (77%) whereas 4 patients had a right-sided hernia. Eight patients underwent preoperative imaging with computed tomography, ultrasonography or both. This was diagnostic in five cases. In 11 patients, hernia contents were repositioned, 2 had a salpingo-oophorectomy and 2 an oophorectomy. Eight patients underwent hernia repair with mesh placement while three had a herniorrhaphy.

CONCLUSIONS

Ovarian inguinal hernias should be considered among the differential diagnoses of a groin mass or swelling. In women of reproductive age, repair of the hernia with the intent to preserve fertility is of critical importance.

Nuck canal cyst involving right femoral vein: management and therapy of a rare clinical case

We present a very rare case of a 49-year old woman suffering from Nuck canal cyst reaching and compressing femoral vein. Nuck canal cyst is very uncommon event because the pouch accompanying the gubernaculum during intrauterine descent of ovaries usually obliterates, whereas when it persists a cystic cavity containing citrine fluid develops. A gravid 0 para 0 49 old woman was admitted to Catania University Surgery Department owing to suspected lymphatic tumor compressing right femoral vein and causing groin pain with ipsilateral leg partial stasis. Patient believed right venous stasis was due to fibromatous uterus. Ultrasounds and computed tomography (CT) scan defined size (7.1 × 4.2 × 1.5 cm), structure (cystic) of mass and its relation with femoral vein, although they were not diriment for diagnosing its nature. Color Doppler detected circulatory function of compressed femoral vein. Surgery was challenging and Nuck cyst was removed after accurate separation from the right femoral venous walls. A case of Nuck cyst involving femoral vein has never been reported so far.

Surgical treatment of cyst of the canal of Nuck and prevention of lymphatic complications: A single-center experience

The canal of Nuck is a residue of the peritoneal evagination that runs along the round ligament through the inguinal canal in women. Its partial or total patency can lead to a cystic lymphangioma (CL). CL of the canal of Nuck in an adult female is a rare entity and its clinical diagnosis can be difficult or incorrect. Ultrasonography can be useful to identify the nature of groin masses. A potential CL of the canal of Nuck should always be considered in the differential diagnosis of inguinal swelling in adult females. Even if it is possible to consider conservative treatment, the optimal therapeutic option is surgical excision of the cystic mass and closure of the inguinal ring by an anterior approach. In this study, we report a case series of four women affected by a cyst of the canal of Nuck to underline the surgical treatment's therapeutic role of this pathological condition and the importance of preliminary identification of lymphatic vessels with BPV (Blue Patent Violet) in order to prevent lymphatic injuries such as lymphorrea and lymphocele in the groin after surgery due to the disruption of inguinal lymph nodes and lymphatics.

Evaluation of hernia of the male inguinal canal: sonographic method

Sonography of the male inguinal canal for hernia is a common request. There is debate about the accuracy and even need for sonographic assessment of inguinal hernia. A clear, concise method is presented, with correlated diagrams and sonographic images, which aims to improve the ability of sonographers to easily identify inguinal herniae.

Inguinal canal spermatic cord leiomyoma presenting as an incarcerated inguinal hernia

Leiomyoma is a benign neoplasm originating from smooth muscle cells and is most commonly seen in the uterus, followed by the small bowel and oesophagus. We report a rare case of a 41-year-old male patient with a spermatic cord leiomyoma that presented as an inguinal canal mass mimicking an irreducible inguinal hernia without scrotal involvement. This report highlights the rare presentation and workup of an inguinal mass, importance of intraoperative decision making based on operative findings and the significance of postoperative pathology findings.

Hydrocele in the Canal of Nuck - CT appearance of a developmental groin anomaly

Hydrocele in the Canal of Nuck is a condition of female fetal development. The Canal of Nuck is a patent tubular peritoneal fold that travels with the round ligament to its attachment on the labia major. Failure of complete obliteration of the Canal of Nuck during fetal development predisposes females to development of a hydrocele or an inguinal hernia during post-pubertal or adult stages. We present a case of a 21 year old female with a tender reducible labial mass diagnosed as a Hydrocele in the Canal of Nuck.

The role of pelvic bone anatomy in the pathogenesis of inguinal hernia

BACKGROUND

a small number of reports have suggested that inpatients with inguinal hernia, certain pelvic anatomical traits prevail, which are characterized by the low position of the groin, resulting in a marked verticality of the inguinal fold.Based on this notion we investigated a possible correlation of this anatomical characteristic with hernia development, by applying a simple clinical research protocol.

METHODS

two groups were formed. A study group including 25 adult patients with a history of inguinal hernia or aclinically proven inguinal hernia and a control group of 10 individuals of the same age and sex distribution with the study group, but with no history of inguinal hernia. On anteroposteriorpelvic plain x-rays, we measured Radoievitch'€™s angle which is formed by the interspinal line and the line passing from the anterior superior iliac spine and the pubic tubercle.Mean values of Radoievitch'€™s angle were then compared between the two groups.

RESULTS

patients with inguinal hernia had greater values concerning Radoievitchâ€'s angle in a statistically significant manner when compared to controls (p=0.004).

CONCLUSIONS

individual variability in the configuration of the adult bony pelvis is an important factor in the development of inguinal hernia. Pelvimetry could affect the choice of hernia repair and radiological pelvimetry could be included in the preoperative planning of hernia repair.

[Atypical debut of symptoms of fallopian tube cancer]

Fallopian tube cancer is rare and accounts for 0.3-1% of all gynaecological cancers. We describe a case of undiagnosed fallopian tube cancer presenting as a swollen inguinal lymph node and later diagnosed with PET-CT. Final histology revealed a serous adenocarcinoma of the fallopian tube with metastases to both ovaries and one inguinal lymph node. Recent studies suggest that serous borderline tumour of the ovaries originate from the fallopian tubes. The present case confirms this hypothesis. PET-CT is an important tool in diagnosing ovarian and fallopian tube cancers.

Crossed testicular ectopia with preoperative ultrasound

Crossed testicular ectopia/transverse testicular ectopia is a rare congenital anomaly. It is most commonly identified intraoperatively in the setting of inguinal hernia repair with contralateral cryptorchidism. We report a case of crossed testicular ectopia identified in a 3-month-old male who presented with right cryptorchidism. Preoperative ultrasound revealed no testicle on the right and two testicles on the left - one within the left hemiscrotum and one within the left inguinal canal. Laparoscopy at 7 months of age revealed a closed right external ring and right ectopic testicle at the left external ring. Bilateral orchiopexy was performed.

[Application of ultrasound in paediatric abdominal trunk blocks]

Although relatively few studies have compared US guidance with established "blind" techniques, the available evidence suggests that the use of US guidance is a safe and effective way to facilitate correct needle placement and adequate spread of LA for abdominal wall nerve blocks. It improves block effectiveness and safety by reducing LA doses and by detecting anatomic variants or unsuspected pathologies. Different techniques are described and discussed: the transverse abdominal nerve blocks, the paraombilical block, the inguinal field block and the fascia transversalis block. Matched with improving technology, the use of US has significant benefits over conventional techniques to perform classic and new abdominal wall nerve blocks in children. However, more studies are required to evaluate the potential of US to support this finding.

Impalpable testis: Laparoscopy or inguinal canal exploration?

OBJECTIVE

There is great controversy regarding the best approach to impalpable testis. In this retrospective study we evaluated the accuracy of intraperitoneal laparoscopy, inguinal canal exploration and ultrasound in the diagnosis of impalpable testis.

MATERIAL AND METHODS

Over a 2-year period (2004-06), 76 patients with a diagnosis of uni- or bilateral clinically impalpable testis were referred to our center. A preoperative ultrasound evaluation was done and all patients underwent intraperitoneal laparoscopy. An inguinal canal incision and exploration was done in all cases except for patients with high intra-abdominal testes (> 2 cm above the internal ring), for whom laparoscopic dissection, mobilization and orchidopexy were necessary.

RESULTS

The mean age of the patients was 15.36 years (range 1-39 years). The undescended testis (UDT) was right-sided in 25% of patients, left-sided in 41% and bilateral in 34%. Intraperitoneal laparoscopy, inguinal canal exploration and ultrasound detected 70.6%, 78.4% and 15.6% of testes, respectively.

CONCLUSIONS

Laparoscopy changed the management protocol of impalpable UDT in only 21% of cases. Inguinal canal exploration alone was sufficient in the majority of our cases. We recommend laparoscopy for those patients with impalpable UDT in whom an initial inguinal canal exploration proves negative.

Female hydrocele of the canal of Nuck: a case report

This is a case report of a congenital right labia majora hydrocele in a 13-year-old adolescent girl. Hydrocele of the canal of Nuck is a rare condition in females. A small invagination of the parietal peritoneum that fails to obliterate during the first year of life, can result in either an indirect hernia or a hydrocele of the canal of Nuck.

[Ultrasound of inguinal hernias: morphological classification for a potentially conservative treatment in asymptomatic patients]

PURPOSE

By using a standardized ultrasound procedure, it is possible to identify 3 types of hernias, which provide relevant information about the risk of incarceration based on morphological data. Therefore, conservative treatment is possible in asymptomatic patients. The aim of this paper is to demonstrate how the different hernia types are distributed, to evaluate the assessment for the risk of incarceration and to compare this management with "watchful waiting".

MATERIALS AND METHODS

Over the last 16 years we performed ultrasound examinations in over 7000 patients with preoperatively inguinal hernia and compared the findings to the intraoperative situs. From 1 / 1 / 2002 - 12 / 31 / 2007 we operated on 2758 patients with an inguinal hernia and treated 425 patients conservatively. Asymptomatic patients were checked annually and symptomatic patients were checked immediately.

RESULTS

In all cases there was an exact correlation between the ultrasound description and the intraoperative finding in relation to the 3 hernia types: type A (bulge) 23 %, type B (tube) 55 %, type C (sandclock) 22 %. No case in the conservatively treated group required emergency operation.

CONCLUSION

Preoperatively inguinal hernias can be differentiated into 3 types by using sonomorphological criteria. Therefore, safe assessment of the need for operation is possible in asymptomatic patients. This procedure seems to be safer than "watchful waiting".

Sonographic findings of inguinal endometriosis

OBJECTIVE

The purpose of this series was to describe the sonographic findings of inguinal endometriosis.

METHODS

This was a retrospective analysis of 3 cases of inguinal endometriosis. The following gray scale and color Doppler sonographic features were analyzed: size, shape, echogenicity, and blood flow within inguinal endometriosis.

RESULTS

The size of inguinal endometriosis ranged from 3.1 to 4.2 cm (mean, 3.7 cm). All 3 cases were cystic lesions. Two of 3 cases were lesions with internal septa. On color Doppler sonography, 1 of the 3 cases showed a few flow signals within the lesion, whereas in 2 of the 3 lesions, no blood flow could be identified within the lesions.

CONCLUSIONS

Although the sonographic features of inguinal endometriosis may be variable, endometriosis should be included in the differential diagnosis when unilocular and multilocular cystic masses are seen on sonography.

Elective clinical target volumes for conformal therapy in anorectal cancer: a radiation therapy oncology group consensus panel contouring atlas

PURPOSE

To develop a Radiation Therapy Oncology Group (RTOG) atlas of the elective clinical target volume (CTV) definitions to be used for planning pelvic intensity-modulated radiotherapy (IMRT) for anal and rectal cancers.

METHODS AND MATERIALS

The Gastrointestinal Committee of the RTOG established a task group (the nine physician co-authors) to develop this atlas. They responded to a questionnaire concerning three elective CTVs (CTVA: internal iliac, presacral, and perirectal nodal regions for both anal and rectal case planning; CTVB: external iliac nodal region for anal case planning and for selected rectal cases; CTVC: inguinal nodal region for anal case planning and for select rectal cases), and to outline these areas on individual computed tomographic images. The imaging files were shared via the Advanced Technology Consortium. A program developed by one of the co-authors (I.E.N.) used binomial maximum-likelihood estimates to generate a 95% group consensus contour. The computer-estimated consensus contours were then reviewed by the group and modified to provide a final contouring consensus atlas.

RESULTS

The panel achieved consensus CTV definitions to be used as guidelines for the adjuvant therapy of rectal cancer and definitive therapy for anal cancer. The most important difference from similar atlases for gynecologic or genitourinary cancer is mesorectal coverage. Detailed target volume contouring guidelines and images are discussed.

CONCLUSION

This report serves as a template for the definition of the elective CTVs to be used in IMRT planning for anal and rectal cancers, as part of prospective RTOG trials.

Inguinal canal recurrence of colorectal adenocarcinoma following cytoreductive surgery and intraperitoneal hyperthermic chemotherapy

Peritoneal carcinomatosis, the second most common cause of death among patients with colorectal carcinoma, may be managed with cytoreductive surgery and adjuvant intraoperative peritoneal hyperthermic chemotherapy (IHPC). We present the case of a 35-year-old male with locally recurrent colorectal adenocarcinoma in the inguinal canal and testis following intraperitoneal debulking and IPHC. When communicating with the peritoneal cavity, the inguinal canal may act as an anatomic sanctuary site and allow peritoneal carcinomatosis to escape the effects of intraperitoneal chemotherapy.

Hydrocele of the canal of Nuck: sonographic and MRI appearances

Hydrocele of the canal of Nuck is a rare disorder in females. A 50-year-old female presented with the complaint of swelling and occasional pain in the right groin. Sonographic examination revealed a proximal dilatation at the inguinal canal with a 3-cm ovoid, septated cystic lesion at the distal end. The mass appeared as a simple cyst on MRI. Valsalva's maneuver during real-time sonography helped differentiate the hydrocele of the canal of Nuck from an inguinal hernia.

Radiologic Anatomy of the Inguinofemoral Region: Insights from MDCT

OBJECTIVE

We set out to reexamine the radiologic anatomy of the inguinofemoral region using volume data sets obtained with an MDCT scanner.

MATERIALS AND METHODS

We conducted a systematic prospective review of CT scans of 20 consecutively enrolled patients, 10 men and 10 women chosen retrospectively from our CT database. An experienced radiologist and a senior trainee surgeon conducted an image review to maximize recognition of relevant anatomic detail.

RESULTS

The inferior epigastric artery and femoral canal were identified in all planes in all patients. On axial views a spur on the pubic bone was visible in 17 (85%) of the patients, but the inguinal ligament was not reliably identified in any. The round ligament or spermatic cord was visible in only 15 (75%) of 20 patients. In contrast, on coronal and sagittal views, the inguinal ligament, which is vital to reliable identification and accurate classification of groin hernias, was visible in 19 (95%) of the 20 patients. Scans in the sagittal plane best depicted the gutter-like aspect of the ligament, the canal and contents being clearly visible in 95% of the patients. On sagittal views, the internal ring was identifiable in 90% and the round ligament or spermatic cord in 95% of the patients. On coronal images, the internal ring was identified in all and the conjoint tendon in 95% of the patients. The round ligament or spermatic cord was not seen in 10% of the patients.

CONCLUSION

MDCT produces images of the inguinal region in detail not possible with previous generations of scanners. In our small series, 100% identification of key anatomic structures was achieved when information from all three views was combined. We found subtle differences between imaging findings and standard anatomic teaching.

[Inguinal pain in sportmen: clinical and radiological examinations]

Pain of the inguinal region is a frequent but difficult diagnostic problem. It may be induced by accidents, overload due to sports or profession as well as daily life activities. Numerous anatomic structures of the inguinal or hip region may be injured, but one should also think about adjacent structures as the bowel, uro-genital system, spine and nerves. The goal of this article is to describe which clinical and imaging parameters allow to establish a correct diagnosis for each patient.

The role of peritoneal scintigraphy in the detection of continuous ambulatory peritoneal dialysis complications

While continuous ambulatory peritoneal dialysis (CAPD) offers several advantages over hemodialysis in patients with end-stage renal disease, several complications have been recognized. The intraperitoneal instillation of dialysate increases intra-abdominal pressure and consequently predisposes the patient to leaks and herniations through defects in the abdominal wall. The use of an intraperitoneal radiolabeled colloid has been previously described to image entities such as hernias, patent processus vaginalis, abdominal wall, and diaphragmatic leakage. This study shows a simple, non-invasive method of determining the site of dialysate leak and its importance to assist further patient management. There has been a continuing increase in the number of end stage renal disease patients maintained on chronic peritoneal dialysis (CPD). Many patients choose CPD as their preferred chronic dialysis treatment, though approximately 20% of patients who drop out transfer to hemodialysis annually.[1] Although peritonitis remains the major reason for transfer to hemodialysis, other factors such as exit site infections, catheter-related problems, abdominal wall and inguinal hernias, loss of ultrafiltrations, and poor clearance contribute to CPD technique failure.[2] In order to permit the continuation of long-term therapy with CPD, these complications should be resolved. Routine laboratory evaluation or physical examination can detect some CPD-related problems; however, some patients require more complicated investigations to evaluate their problems properly.

Angiomyofibroblastoma-like tumor (cellular angiofibroma) in the male inguinal region

Angiomyofibroblastoma-like tumor is a rare mesenchymal tumor involving the male genital tract. We report a case of an angiomyofibroblastoma-like tumor that arose in the subcutaneous tissue of the left inguinal region in a 50-year-old man. Ultrasonography of the region demonstrated a well-circumscribed subcutaneous mass. Intralesional fat was revealed on magnetic resonance images. Although these imaging features are nonspecific, radiological findings enable considering the diagnosis of angiomyofibroblastoma-like tumor.

Sonographic diagnosis of a round ligament cyst in the inguinal area

We report a case of a 37-year-old female with a mesothelial cyst of the round ligament presenting as a palpable mass. The mass appeared sonographically as a fusiform structure with several cystic anechoic areas and was misdiagnosed preoperatively as herniation of the right ovary.

Nonpalpable testes: is there a relationship between ultrasonographic and operative findings?

BACKGROUND

Ultrasonography (US) as a diagnostic tool in the work-up of boys with nonpalpable testes (NPT) is still controversial.

OBJECTIVE

To evaluate the relation between US and operative findings in boys with NPT.

MATERIALS AND METHODS

During a 7-year period we saw 135 boys with 152 NPT. All were examined by the referring physician or a paediatric surgeon, underwent US examination, and were then re-examined afterwards by a specialist. Finally, all boys were surgically explored for testicular position.

RESULTS

US located 103 NPT (68%), 16 within the abdomen and 87 in the inguinal canal. With knowledge of the US result, 37 testes were palpable on re-examination. The sensitivity of US was 97% for inguinal and 48% for abdominal viable testes. Of the 49 testes (32%) missed by US, 16 were viable in either the abdominal (n=14) or the inguinal (n=2) position.

CONCLUSION

All boys with presumed NPT should be referred to a specialist. US is useful to determine localization of NPT, which facilitates planning the surgical procedure. An inguinal exploration is called for when US identifies the testis in the inguinal canal. Because the sensitivity of US for viable abdominal testes is only 48%, we now always perform laparoscopic exploration when US is negative.

Ultrasound guidance for ilioinguinal/iliohypogastric nerve block: a pilot study

BACKGROUND

Ilioinguinal/iliohypogastric nerve block combined with general anaesthesia facilitates inguinal herniorrhaphy in an ambulatory setting by improving analgesia and reducing opioid requirements. Case reports in children indicate the possibility of colonic puncture and associated morbidity with blind ilioinguinal and iliohypogastric blockade.

AIMS

To investigate the feasibility of ultrasound guided ilioinguinal/iliohypogastric nerve block.

METHODS

Pilot study of four patients where ultrasound imaging was used to identify the ASIS, anterior abdominal muscle layers, the peritoneum and to guide local anaesthetic infiltration in patients undergoing inguinal hernia surgery and appendicectomy.

RESULTS

All patients had successful blocks, without complications. Mean visual analogue scores were 2/10 in the post anaesthesia care unit. Mean opioid consumption was 10 mg of intramuscular morphine in the first 24 h.

CONCLUSIONS

Ultrasound guidance for ilioinguinal and iliohypogastric nerve block in the inguinal region is both feasible and a promising technique.

Accuracy of magnetic resonance imaging of inguinofemoral lymph nodes in vulval cancer

Inguinofemoral lymphadenectomy contributes to the high morbidity related to surgical treatment of vulval cancer. The objective of this study was to assess the accuracy of magnetic resonance imaging (MRI) in predicting inguinofemoral lymph nodes metastasis in women with vulval cancer. We reviewed the clinical, MRI, surgical, and pathologic findings of 59 women with vulval cancer who were treated at our institution from January 2000 to June 2004. Histology was available for 39 women who had undergone inguinofemoral lymphadenectomy. Clinical and MRI findings were compared with histology result to assess test accuracy. MRI had a positive likelihood ratio (LR+) of 4.8 (95% confidence interval of 2.7-8.6) and negative likelihood ratio (LR-) of 0.17 (0.06-0.49). It had a sensitivity of 85.7% (63.7-97), specificity of 82.1% (69.6-91.1), positive predictive value (PPV) of 64.3% (44.1-81.4), and negative predictive value (NPV) of 93.9% (83.1-98.7). Clinical examination had an LR+ of 6.1 (1.8-21.6) and LR- of 0.69 (0.5-0.96). It had a sensitivity of 35% (15.3-59.4), specificity of 94.3% (84.3-98.8), PPV of 70% (34.7-93.3), and NPV of 79.4% (67.3-88.5). Kappa statistics for interobserver and intraobserver agreement were 0.9091 and 0.8475, respectively. MRI assessment was accurate in predicting negative nodal status that is clinically useful in identifying women who can be spared inguinofemoral lymphadenectomy. It is noninvasive and is superior to clinical assessment. In clinical practice, this should encourage toward nodal sparing surgery, thus lowering surgical-related patient morbidity.

Non-developed external oblique aponeurosis in inguinal hernia repair: a case report and discussion of the literature

Open inguinal hernia repair is one of the most commonly performed operations in the world. It relies heavily on the presence of an inguinal canal formed by the external oblique aponeurosis and conjoint tendon. Variations of the anatomy of this region are rarely described. We describe a patient with bilateral inguinal hernias and missing external oblique aponeurosis. The patient underwent open repair secondary to previous abdominal surgery and the inability to obtain laparoscopic access. A medline search was performed and we provide a synopsis of the literature. At operation, no clear external oblique aponeurosis could be identified and large defects of the transversalis fascia were corrected. CT images of the anatomic variations are provided. To the best of our knowledge, combined abnormalities of the external oblique aponeurosis and transversalis fascia have not been described before.

Nominal free air in the left inguinal fossa due to perforation of the sigmoid colon in a case of blunt abdominal trauma: CT diagnosis

We present a case of perforation of the sigmoid colon due to blunt abdominal trauma. Computed tomography showed nominal free air in the inguinal fossa. The distribution of free air may be a clue to the site of an injured intestine. Early detection of intestinal injury is difficult, but repeated computed tomography after several hours may reveal increased free air.

Fluoroscopic localization of the femoral head as a landmark for common femoral artery cannulation

We sought to determine the reliability of frequently used landmarks for femoral arterial access in patients undergoing cardiac catheterization. The common femoral artery (CFA) is the most frequently used arterial access in cardiac catheterization. Arterial sheath placement into the CFA has been shown to decrease vascular complications. Some authors recommend locating the inferior border of the femoral head using fluoroscopy due to the relationship of the femoral head and the bifurcation of the CFA. We performed a descriptive study in a prospective design of 158 patients undergoing catheterization from the femoral approach. A femoral angiogram was performed, and the CFA bifurcation location was recorded in relation to the inguinal ligament, middle and inferior border of the femoral head, and the inguinal skin crease. The CFA bifurcation was distal to the inguinal ligament, middle femoral head, and inferior femoral head in most patients with mean distances (cm +/- SD) of 7.5 +/- 1.7, 2.9 +/- 1.5, and 0.8 +/- 1.2, respectively. The inguinal skin crease was below the bifurcation in 78% of patients (-1.8 +/- 1.6 cm). The CFA overlies the femoral head in 92% of cases. The femoral head has a consistent relationship to the CFA, and localization using fluoroscopy is a useful landmark.

Radiographic inguinal curl may indicate paraspinal misplacement of percutaneously inserted central venous catheters: report of three cases

BACKGROUND

Misplacement of percutaneously inserted central venous catheters (PCVCs) into the paraspinal venous plexus can result in devastating outcomes. Several cases have been reported in the literature together with an explanation of the mechanism.

OBJECTIVE

To describe three premature babies with their PCVCs inserted through the left saphenous vein that ended up in the lumbar spinal dural venous plexus.

RESULTS

Plain radiographs obtained to check positions showed an unusual 360 degrees curl of the PCVC in the left inguinal area.

CONCLUSION

We believe that misplacement of the catheter into the paraspinal venous plexus could be diagnosed with great accuracy if such a curl is seen.

Surgery for posterior inguinal wall deficiency in athletes

This study retrospectively evaluated the outcome for patients undergoing herniorraphy for chronic groin pain due to posterior inguinal wall deficiency, and correlated the outcome with preoperative investigation findings. There were 47 patients (with a total of 52 herniorraphies) who were contacted by phone between six and 50 months post surgery. Subjects had a diagnosis of posterior inguinal wall deficiency made on history and clinical examination. Thirty seven patients had an ultrasound scan prior to the surgery (three bilateral) with a total of 40 symptomatic groins scanned. There were 26 abnormal scans (22 posterior inguinal wall deficiency and four hernias) and 14 normal scans. Twenty nine patients had a technetium-99m bone scan with 22 having increased uptake at the symptomatic pubic tubercle, while 13 had increased uptake at other sites in the groin. Seventy seven percent of patients had a full return to sport after surgery and the average time to return to sport was four months. There was no significant difference in outcome between subjects who had an abnormal ultrasound scan on the symptomatic side and those who had a normal scan. There was a significant difference in outcome between patients who had a bone scan with increased uptake at the symptomatic pubic tubercle and those who did not (p < 0.04). Our study supports previous research that good results can be obtained with surgery when posterior inguinal wall deficiency is the sole diagnosis. Ultrasound scan does not appear to aid in predicting surgical outcome, while the role of isotope bone scanning requires further study.

Inguinal canal as an anatomic sanctuary site of relapse in peritoneal carcinomatosis previously treated with intraperitoneal chemotherapy

Early postoperative intraperitoneal chemotherapy (EPIC) and intraoperative peritoneal hypertermic chemotherapy (IPHC) are used in addition with cytoreductive surgery to treat with curative intent peritoneal carcinomatosis arising from colorectal adenocarcinomas. Three patients with such a disease were treated with perioperative intraperitoneal chemotherapy in addition to cytoreductive surgery and presented isolated local recurrence located in the inguinal canal (round ligament in two and spermatic cord in one). All these patients were treated by local surgical excision. No patient showed evidence of intra-abdominal recurrence at the last follow-up, but one developed pulmonary metastasis. When communicating with the peritoneal cavity, the inguinal canal may act as a sanctuary site for peritoneal carcinomatosis, since it is not totally soaked by the intraperitoneal chemotherapy solution. A local recurrence is thus possible. New clinical presentations such as this one have first to be described in order to improve patient follow-up.

[Osteotomy of the iliac fossa in the treatment of a hip dislocation associated with a two-column acetabular fracture. Modification of the ilioinguinal approach to avoid an extended surgical approach]

Open reduction and internal fixation is the treatment of choice for displaced acetabular fractures. The surgical approach depends on the fracture type, concomitant injuries, and general condition of the patient. The ilioinguinal approach provides a good exposure to the medial wall and is associated with an acceptable degree of surgical trauma. Exposure of the joint surface, however, is difficult when using the ilioinguinal approach. We report a case of a polytraumatized 39-year-old patient who sustained a posterior hip displacement and a two-column acetabular fracture. An osteotomy of the iliac ala was performed via an ilioinguinal approach to fragments of the acetabular surface that were displaced distally. Thereby, reposition of a craniolateral fragment was achieved without the need to extend the surgical approach or to perform a second incision.

Hydrocele of the canal of Nuck in a girl: ultrasound and MR appearance

Hydrocele of the canal of Nuck is a rare condition in females. A small evagination of parietal peritoneum forms the canal of Nuck. Failure of complete obliteration of the canal results in either an indirect inguinal hernia or a hydrocele of the canal of Nuck. We present a case in a 7-year-old girl. On ultrasound, there was a comma-shaped cyst with the tail directed cranially toward the inguinal canal. The cyst had no internal echoes and demonstrated increased through transmission. Coronal and axial MR showed a thin walled cystic mass.