Case Report Pantaloon Hernia: Obstructed Indirect...

Case ReportPantaloon Hernia Obstructed Indirect Component andDirect Component with Cryptorchidism

Mohan Kumar Kariappa Vivek Harihar Ashwini Rajareddy Kothudumand Vivekanand Kedarlingayya Hiremath

Department of Surgery Sri Devaraj Urs Medical College and Research Centre Kolar 563101 India

Correspondence should be addressed to Vivek Harihar hariharvivekgmailcom

Received 13 April 2016 Accepted 22 May 2016

Academic Editor Christoph Schmitz

Copyright copy 2016 Mohan Kumar Kariappa et alThis is an open access article distributed under the Creative CommonsAttributionLicense which permits unrestricted use distribution and reproduction in anymedium provided the originalwork is properly cited

Cryptorchidism is a condition in which one or both testes have not passed down into the scrotal sac It is categorized as trueundescended testis in which testes are present in the normal path of descent and as ectopic testis in which testes are present atabnormal site Common complications of cryptorchidism are testicular torsion subfertility inguinal hernia and testicular cancerHere we present a rare case of pantaloon hernia of obstructed indirect component and direct component with cryptorchidism

1 Case Report

A 40-year-old male patient presented to the emergencydepartment of RLJ Hospital with history of pain and swellingin the right inguinoscrotal region following lifting heavymetal pipe since 1 day

2 OE

The following was noticed

(i) Abdomen was soft and diffuse tenderness in thelower abdomen was present

(ii) There was irreducible swelling measuring 6 times 4 cmwhich was present in right inguinoscrotal regionand was firm in consistency Skin is erythematousstretched and shiny

Regarding the external genitalia

(i) right testis was not palpable(ii) left testis is palpable and penis is normal (Figure 1)(iii) in the rest of the examination nothingwas significant

A diagnosis of right irreducible inguinal hernia with unde-scended testis was made

3 Preoperative Findings

Surgical exploration revealed an indirect hernia of incom-plete type (Figure 2) with pregangrenous bowel loop andatrophic testis (Figure 3) After releasing the neck bowel loopwas viable therefore reduced and sac ligation followed byexcision was done

Another direct type sac was noted with omentum ascontent which was reduced (Figure 4) In view of age andatrophic testis high orchidectomy with hernioplasty wasdone (Figure 5)

Patient tolerated the procedurewell and the postoperativeperiod was unremarkable

4 Histopathology

Histopathology report confirmed the presence of Leydigcells seminiferous tubule and Sertoli cells without TesticularGerm Cell Tumors (TGCT) (Figure 6)

5 Discussion

An undescended testis sometimes called a cryptorchid testiscan be found in 3 of the term newborns and in 05ndash10 of adults [1] Cryptorchidism is more commonly seenin premature males and associated to genetic disorders in

Hindawi Publishing CorporationCase Reports in SurgeryVolume 2016 Article ID 1461425 3 pageshttpdxdoiorg10115520161461425

2 Case Reports in Surgery

Figure 1 Preoperative picture

Figure 2 Hernia with sac

10 of the cases The causes of cryptorchidism are prema-turity spina bifida hormonal disorders testicular absenceor retractile testes Smoking more than 10 cigarettes a dayduring pregnancy increased the risk of cryptorchidism [2] Itis concluded that the second inguinoscrotal stage of testiculardescent is clearly androgen-dependent [3] The diagnosisof cryptorchidism is made by physical examination Thediagnosis of cryptorchidism should be considered whennonpalpable testis and inguinal hernia are present Howevereach patient may experience symptoms differently Nonethe-less for inguinal hernia the clinical presentation variesdepending on the contents of the hernial sac and the degreeof herniation Because of its varied presentation clinicalexamination is often inconclusive [4] The correct diagnosisof inguinal hernia is usually made during an inguinal herniarepair although ultrasonography and computerized tomog-raphy have been used to identify an inguinal hernia [5]

The complications of unrepaired cryptorchidism aremainly testicular torsion infertility inguinal hernia andtesticular cancer The testicles begin to lose the process ofspermatogenesis if they are not in the scrotum because thescrotum is a ldquocooler locationrdquo This process explains the linkbetween cryptorchidism and infertility In our case inspiteof old age histopathology report confirmed the absence of

Figure 3 Pregangrenous bowel with atrophic testis as contents ofindirect sac

Figure 4 After sac ligation and excision

tumor Because the incidence of testicular cancer generallyincreases in cryptorchid testes careful follow-ups are essen-tial [6 7]

Usually cryptorchidism resolves without any interven-tion before the age of 6 months Surgical repair for cryp-torchidism will be carried out if the testicles have notdescended Studies have shown that individuals who hadcorrective surgery after the age of 13 years had an incidencerate of 54 whereas those who were treated before 13years had an incidence rate of 223 [8] Histopathologyreport confirmed the presence of Leydig cells seminiferoustubule and Sertoli cells without TGCT The treatment ofcryptorchidism reduces the risks of infertility and gonadalneoplasia Surgical repair for cryptorchidism will result inearlier detection of an eventual tumor

It is difficult to understand the surgical anatomy ofinguinal hernias but once the surgical exploration is per-formed surgical repair is simple It is controversial whethera contralateral orchidopexy is needed or not Furthermorethe incidence of testicular cancer does not decrease with fixedtestes [9 10] In our case the contralateral orchidopexy wasnot performed

Case Reports in Surgery 3

Figure 5 Hernioplasty

Figure 6 Histopathological study of atrophied testis

6 Conclusion

This case is particularly notable because of the unusualpresentation of cryptorchid testis as an obstructed inguinalhernia at the age of 40 years The patient remained asymp-tomatic for 40 years To our knowledge the present caserepresents one of the very few cases of cryptorchid testisrevealed at the age of 40 years with an inguinal hernia

ldquoThe surgeon must always be alert to the possibility ofcryptorchid testis during a surgical exploration of an inguinalherniardquo

Competing Interests

The authors declare that there are no competing interestsregarding the publication of this paper

Authorsrsquo Contributions

All authors contributed to the paper

Acknowledgments

The authors are grateful to all the staff members of Depart-ment of Surgery who were involved in one way or another inthemanagement of our patients Special thanks to our patientfor participation in this study

References

[1] C A Longui ldquoCryptorchidism diagnosis and treatmentrdquoArquivos Brasileiros de Endocrinologia eMetabologia vol 49 no1 pp 165ndash171 2005

[2] M S Jensen G Toft A MThulstrup J P Bonde and J OlsenldquoCryptorchidism according to maternal gestational smokingrdquoEpidemiology vol 18 no 2 pp 220ndash225 2007

[3] E M Kaftanovskaya Z Huang A M Barbara et al ldquoCryp-torchidism in mice with an androgen receptor ablation ingubernaculum testisrdquo Molecular Endocrinology vol 26 no 4pp 598ndash607 2012

[4] R Kassir E Tarantino R Lacheze A Brek A Di Bartolomeoand O Tiffet ldquoManagement of Spigelian hernia caused bynecrobiotic fibroma of the uterus in a pregnant womanrdquoInternational Journal of Surgery Case Reports vol 4 no 12 pp1176ndash1178 2013

[5] G E Tasian H L Copp and L S Baskin ldquoDiagnostic imagingin cryptorchidism utility indications and effectivenessrdquo Jour-nal of Pediatric Surgery vol 46 no 12 pp 2406ndash2413 2011

[6] VMehendale S Shenoy R Shah N Chaudhari andAMehen-dale ldquoLaparoscopic management of impalpable undescendedtestes 20 years1015840 experiencerdquo Journal of Minimal Access Surgeryvol 9 no 4 pp 149ndash153 2013

[7] R Kassir ldquoManagement of the Aymandrsquos hernia in laparoscopyrdquoJournal of Current Surgery vol 3 no 2 pp 92ndash94 2013

[8] A Pettersson L Richiardi A Nordenskjold M Kaijser andO Akre ldquoAge at surgery for undescended testis and risk oftesticular cancerrdquo The New England Journal of Medicine vol356 no 18 pp 1835ndash1841 2007

[9] T J Walsh M A DallrsquoEra M S Croughan P R Carroll andP J Turek ldquoPrepubertal orchiopexy for cryptorchidism may beassociated with lower risk of testicular cancerrdquo The Journal ofUrology vol 178 no 4 pp 1440ndash1446 2007

[10] S Kjaeligr and K J Mikines ldquoHCG in the treatment of cryp-torchidism the effect of age and position of the testisrdquoUgeskriftfor Laeger vol 168 no 14 pp 1448ndash1451 2006

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Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom

2 Case Reports in Surgery

Figure 1 Preoperative picture

Figure 2 Hernia with sac

10 of the cases The causes of cryptorchidism are prema-turity spina bifida hormonal disorders testicular absenceor retractile testes Smoking more than 10 cigarettes a dayduring pregnancy increased the risk of cryptorchidism [2] Itis concluded that the second inguinoscrotal stage of testiculardescent is clearly androgen-dependent [3] The diagnosisof cryptorchidism is made by physical examination Thediagnosis of cryptorchidism should be considered whennonpalpable testis and inguinal hernia are present Howevereach patient may experience symptoms differently Nonethe-less for inguinal hernia the clinical presentation variesdepending on the contents of the hernial sac and the degreeof herniation Because of its varied presentation clinicalexamination is often inconclusive [4] The correct diagnosisof inguinal hernia is usually made during an inguinal herniarepair although ultrasonography and computerized tomog-raphy have been used to identify an inguinal hernia [5]

The complications of unrepaired cryptorchidism aremainly testicular torsion infertility inguinal hernia andtesticular cancer The testicles begin to lose the process ofspermatogenesis if they are not in the scrotum because thescrotum is a ldquocooler locationrdquo This process explains the linkbetween cryptorchidism and infertility In our case inspiteof old age histopathology report confirmed the absence of

Figure 3 Pregangrenous bowel with atrophic testis as contents ofindirect sac

Figure 4 After sac ligation and excision

tumor Because the incidence of testicular cancer generallyincreases in cryptorchid testes careful follow-ups are essen-tial [6 7]

Usually cryptorchidism resolves without any interven-tion before the age of 6 months Surgical repair for cryp-torchidism will be carried out if the testicles have notdescended Studies have shown that individuals who hadcorrective surgery after the age of 13 years had an incidencerate of 54 whereas those who were treated before 13years had an incidence rate of 223 [8] Histopathologyreport confirmed the presence of Leydig cells seminiferoustubule and Sertoli cells without TGCT The treatment ofcryptorchidism reduces the risks of infertility and gonadalneoplasia Surgical repair for cryptorchidism will result inearlier detection of an eventual tumor

It is difficult to understand the surgical anatomy ofinguinal hernias but once the surgical exploration is per-formed surgical repair is simple It is controversial whethera contralateral orchidopexy is needed or not Furthermorethe incidence of testicular cancer does not decrease with fixedtestes [9 10] In our case the contralateral orchidopexy wasnot performed




6 Conclusion



Competing Interests




Acknowledgments


References
















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



















6 Conclusion



Competing Interests




Acknowledgments


References
















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















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