1. Dr. Jagram Meena Under the guidance of Dr Richa Jain Su-VII
Obstructed Inguinal Hernia With Undescended Testis
Dr. Jagram Meena
Under the guidance of
Dr Richa Jain
Su-VII

2. Patient particulars Mr Devakinandan, 50 years old Married, Hindu, Male
Hailing from Heerpura , Niwai (Tonk)
Farmer

3. History of presenting illness
Apparently well 5 yrs back.
Noticed a small swelling in Rt inguinal region
insidious onset, gradually increased in size
Decreases on lying down and becomes prominent on standing, walking & straining
Swelling became irreducible-2 days
Sudden pain abdomen, obstipation a/w nasuea/vomiting

4. Contd….
On enquiry pt revealed that he is not having Rt testis since childhood
No history of trauma
No history of fever
No history of abdominal lump
No history of blood in urine/stool

5. PAST HISTORY No h/s/o TB/HTN/IHD/COPD/Asthma
No h/o surgeries in the past
No h/o similar ailment in the past

6. Personal history Takes mixed diet
Chronic smoker but denied other addictions & high risk behavior
Married for 23 years, having 3 children

7. Examination
GENERAL
Pt conscious, oriented, co-op to time, place & person.
Avg built, moderately nourished
No pallor, icterus, clubbing, cyanosis, lymphadenopathy
Afebrile
PR-112/min, regular, normal rhythm & character
BP-112/74 mm of Hg ,Rt upper arm, supine position
RR-20/min regular abdomino-thoracic

8. Local Examination STANDING POSITION INSPECTION-
Rt inguinal swelling measuring approx 12 x 7 cm, confined to inguinal region, overlying skin was normal
Rt scrotum underdeveloped compared to Lt
No expansile impulse on cough seen

9. Contd….. PALPATION- No local rise of temp.
12X7 cm soft, irreducible swelling, confined to the Rt inguinal region, no cough impulse, dilated veins
No testis in Rt scrotum.
Lt inguino-scrotal region was normal with normal testis & sensations.

10. SYSTEMIC EXAMINATION Resp system Cardio vascular system
NAD
Resp system
Cardio vascular system
Central nervous system
P/A
Mild distension,Soft , no scar /dilated veins
No e/o free fluid/ mass in the abdomen
Bowel sounds exagerated
PR-NAD

11. PROVISIONAL DIAGNOSIS
Right sided obstructed inguinal hernia with Rt undescended testis

12. MANAGEMENT INVESTIGATIONS CBC-Hb-14.1 g/dl Rbs-88 mg/dl
TLC-12000/cmm
PLT-2.24 lakh
Rbs-88 mg/dl
S.Urea-20 mg/dl
S.Creat-0.9 mg/dl
S.Bil-0.9 mg/dl
SGOT-34 U/L
SGPT-29 U/L

13. CONTd….. X-Ray FPA-Dilated bowel loops HIV/HBsAG-Negative CXR-WNL
ECG-WNL

14. USG ABDOMEN/SCROTUM Dilated bowel loops in abdomen
Aperistaltic bowel loop in Rt inguinal region with minimal free fluid
Rt scrotum was empty
Lt Testis-normal in size shape & echo texture (34.0 x 23.8 x 13.6)

15. DIAGNOSIS
Right sided obstructed inguinal hernia with Rt undescended testis
PLAN
Emergency exploration through a right inguinal incision.

16. Per op findings
There was an hernial sac of 10x8 cm with gut loops as contents.
Rt Testis was atrophied and present at superficial inguinal ring, and was obstructing the gut .
As soon as the superficial inguinal ring was opened , sac reduced on it`s own .
Gut was explored , proximally and distally of the obstruction site and was found to be normal.

24. Procedure
Reduction of hernial sac , Right bassini`s herniorraphy with right sided orchidectomy
Post op period was uneventfull and pt was discharged on day-3 after getting normal usg abdomen
The biopsy report is as follows…..

26. Discussion

27. Definition
An undescended testis is one which has failed to descend to the scrotum & is retained at any point along the normal path of descend
Right side: 50%
Left side: 30%
Bilateral: 20%
cryptorchidism

28. Types of undescended testis
UDT
Palpable
Along Line of Normal descent
Ectopic
Non-palpable
Abdominal
Vanishing or Atrophied

29. Epidemiology
Undescended testis is present in about 1-4.5% of newborns.
Higher incidence in preterms (30-45%).
The testes may descend into the scrotum in 75% of full-term neonates and in 90% of premature newborn boys in infancy.

30. Ectopic testis The testis fails to descend into the scrotum
& is deviated from its normal path of descent
Position
Superficial inguinal pouch
Pubopenile ectopia
Perineal ectopia
Crural or femoral ectopia

31. A, Ectopic testes. Perineal ectopia not shown.
B, Undescended testes. Percentages of testes arrested at different stages of normal descent

32. Undescended & Ectopic testis
Undescended testis
The testis is arrested in its normal path of descent
Usually undeveloped
Undeveloped & empty scrotum on the affected side
Shorter length of spermatic cord
Poor spermatogenesis after 6 yrs
Usually associated with indirect inguinal hernia
Treatment: surgery & HT
Associated with a number of complications
Ectopic testis
The testis deviates from its normal path of descent
Fully developed testis
Empty but usually fully developed scrotum
Longer length of spermatic cord
Spermatogenesis is perfect
Never associated with indirect inguinal hernia
Treatment: basically surgical
Complications: liability to injury
HT: hormone therapy

33. DESCENT OF TESTIS – 2 PHASES
Intra-abdominal phase-(10-15th week) the gubernaculum enlarges to anchor the testis near the inguinal region as the embryo enlarges
Inguinal phase (28-35th week): the gubernaculum migrates out of the inguinal canal across the pubic region and into the scrotum

34. Embryology A-5th week Testis begins its primary descent.
B-8th-9th weeks, Kidney reaches adult position.
C-7th month, Testis at internal inguinal ring; gubernaculum (in inguinal fold) thickens and shortens.
D-Postnatal life.

39. Factors affecting testicular descent
Normal testicular descent is dependent on an intact hypothalamo–pituitary–testicular axis. Although the exact etiology is still unknown, it is postulated that genetic, hormonal (hypothalamic-pituitary-gonadal axis dysfunction, congenital hypogonadotropic hypogonadism, testicular dysgenesis), and anatomical (short vas deferens and spermatic vessels) factors are involved

40. Contd…
The risk is 10.1 fold higher in male twins if present in one of them and 2.3 fold higher in males with a father with the condition.
A birth weight <2.5 kg
Prematurity and Low maternal estrogen levels
Placental insufficiency with decreased HCG secretion
Maternal smoking, and maternal diabetes mellitus.

41. Diagnosis and Clinical exam`n
In an anxiety-free medium with warm hands, since cold or anxiety can cause the cremasteric reflex to retract the testes .
In supine position with legs abducted initially.
The examination should begin with exploration of testes at the anterior superior iliac spine then groin from lateral to medial with the non-dominant hand.

42. Contd…
Once the testis is palpated, it should be grasped with the dominant hand & continue to sweep the testis toward the scrotum with the other hand.
Testicular mobility, size, consistency, and spermatic cord tension should be assessed.
The position of the testis in the scrotum should be maintained for a minute, so that the cremaster muscle is fatigued.

43. Contd…
The key to distinguishing a retractile from an undescended testis is success of delivery and stability of the testis within the scrotum.
The retractile testis will remain intrascrotal after overstretching of the cremaster muscle, whereas a low undescended testis will return to its undescended position after being released
In all patients, the size, location, and texture of the contralateral descended testes should also be checked

44. Exam of Hernia in Kids Standing the patient upright may help at times.
Ask the older child to jump or bounce up and down, which may allow the mass to appear in the inguinal region.
Ask the older child (>6 years of age) to cough or blow up a balloon. This will make the bulge appear.

45. Imaging and Laboratory Tests
Nearly 20% of undescended testes are impalpable.
Usg, CT and MRI
Diagnostic Laparoscopy.
Endocrinological and chromosomal investigations
Testicular biopsy during orchiopexy

46. Need for Treatment Risk for Infertility
10% of infertile males have a history of undescended testes.
The infertility risk is six fold higher in patients with bilateral undescended testes compared to patients with unilateral undescended testis or with a healthy population .

47. Contd…
In unilateral undescended testis, although one testis descends in early term, the number of germ cells is lower in these patients compared to the healthy population due to intrinsic pathology (testicular dysgenesis).
Several histological changes in the contralateral testis, which is in its normal scrotal location, have been observed in patients with unilateral undescended testis (shared intrinsic pathology)

48. Contd…
Risk for Cancer
The risk for cancer is 35 to 48 times higher in patients with undescended testes compared to the overall population .
A total of 10% of testis malignancies are associated with undescended testes .
Some authors reported that the risk for malignancy cannot be reduced by early orchiopexy ,it has also been reported that the risk for malignancy is increased six fold in patients who do not undergo orchidopexy in the pre-pubertal period or in patients with delayed surgery.

49. Contd…
Malignancy risk is 32 times higher in patients undergoing orchiopexy later than age 11 years.
The age range during which testis tumors most frequently develop in these cases is years .
The most common types of testicular cancer encountered are seminoma and embryonal carcinoma.

50. Contd… Risk for Torsion
The risk for torsion is higher in adult patients with undescended testes compared to overall population.
The risk for torsion was associated with the duration of the undescended testes

51. Contd… Risk of Inguinal Hernia and it`s Complication
It has been studied that UDT is associated with inguinal hernia in 70-90% (>90% in some studies).present in early age group.
23.8% of infants with hernia may present with incarceration(CMAJ. 2008 November 4; 179)
6% of these pts may have Testicular ischemia due to incarceration.(Pediatr Radiol. 2012 Feb;42(2): )

52. Treatment Options
Several treatment protocols have been proposed for treatment of undescended testes.
Medical or surgical treatment should be initiated after the age of 6 months.
The success rates of these modalities depend on the treatment options (dose and duration), age of the patient, position of testes, and unilateral or bilateral nature of the disease.

53. Contd…
Proper identification of the anatomy, position, and viability of the undescended testis   
•    Identification of any potential coexisting syndromic abnormalities  
•   Placement of the testis within the scrotum in timely fashion to prevent further testicular impairment in either fertility potential or endocrinologic function.
•   Attainment of permanent fixation of the testis with a normal scrotal position that allows for easy palpation   
•    No further testicular damage resulting from the treatment
Definitive treatment of an undescended testis should take place between 6 and 12 months of age

54. Hormone therapy Not used routinely Indications:
When the surgeon is not sure whether the case is one of retractile testis or not
Bilateral incomplete descended testis associated with hypogenitalism & obesity
The hormone mostly used is human chorionic gonadotrophin

55. Medical Treatment Exogenous HCG and Exogenous GnRH or LHRH.
Increases serum testosterone production by stimulation at different levels of the hypothalamic-pituitary-gonadal cascade
Successful results are more commonly reported in older groups of children and in testes that were retractile or below the external inguinal ring. E.g. the lower the pretreatment position, the better the success rate

56. Contd…
The overall efficacy of hormonal treatment is less than 20% for cryptorchid testes and is significantly dependent on pretreatment testicular location.
Therefore, Surgery remains the gold standard for the management of undescended testes.

57. Surgical Treatment
It is recommended that undescended testes should be surgically descended to the scrotum at 6-12 months.
The success of surgery is defined as presence of testes in the scrotum without testicular atrophy and/or any recurrence for ≥1 year.
The success rate of surgery is 90%, whereas the reported success rate of hCG treatment by randomized studies is 19-25%

58. Surgical options for palpable UDT
Inguinal Orchidopexy ( Standard)
Transscrotal Orchidopexy- A primary scrotal approach can be considered when the testis is palpable , although some surgeons reserve this approach for testes that are close to or can be drawn into the scrotum

59. Standard Orchidopexy. The key steps in this procedure are ---
complete mobilization of the testis and spermatic cord,
(2) repair of the patent processus vaginalis by high ligation of the hernia sac,
(3) skeletonization of the spermatic cord without sacrificing vascular integrity to achieve tension-free placement of the testis within the dependent position of the scrotum, and
(4) creation of a superficial pouch within the hemiscrotum to receive the testis.

60. COMPLICATIONS OF ORCHIOPEXY
The most important surgical complication of orchiopexy is testicular atrophy, which may result from four causes:  
1.   Injury to the spermatic vessels during standard orchiopexy  2.   Tension on the spermatic vessels with subsequent ischemia  3.   Inadvertent torsion of the spermatic vessels when passing the testis into the scrotum  4.   Intentional ligation of the vessels as part of a Fowler- Stephens orchiopexy

61. Contd…
Any of the complications of inguinal hernia repair can also occur during orchiopexy.
Testicular retraction may result from short testicular vessels, inadequate mobilization of the testicular vascular pedicle, incomplete division of the cremasteric muscle fibers to the testis, or improper scrotal fixation of the testis.

62. Contd… Hematoma formation, Ilioinguinal nerve injury,
Postoperative torsion (either iatrogenic or spontaneous),
Damage to the vas deferens

63. Special Conditions encountered during treatment of Undescended testis

64. Anomalies of the Epididymis, Processus Vaginalis, and Gubernaculum
Failure of closure of the processus vaginalis and attachment of the gubernacular remnant are common.
Anomalies of the tunica and processus vaginalis in cryptorchidism predispose to development of testicular torsion or clinical hernia.
Anomalies of fusion between the caput and/or cauda epididymis, elongation and/or looping, and atresia

65. Anomalies of the Epididymis, Processus Vaginalis, and Gubernaculum
Failure of closure of the processus vaginalis and attachment of the gubernacular remnant are common.
Anomalies of the tunica and processus vaginalis in cryptorchidism predispose to development of testicular torsion or clinical hernia.
Anomalies of fusion between the caput and/or cauda epididymis, elongation and/or looping, and atresia

66. Polyorchidism
It is the presence of a supernumerary testis that is more commonly unilateral and on the left side, with rare cases of bilateral duplication or triplication.
Affected individuals are frequently asymptomatic, and the polyorchidism is identified at the time of orchidopexy or hernia repair, although a scrotal or inguinal mass and pain with or without torsion may occur.

67. Transverse testicular ectopia
It may occur as an isolated anomaly in otherwise normal males with cryptorchidism or vanishing testes.
The classic presentation is inguinal hernia with contralateral nonpalpable testis, although both testes may be palpable in the same hemiscrotum.
The etiology may be related to mechanical hindrance to descent by fusion of wolffian duct derivatives

68. Contd…
TTE should be considered when an inguinal hernia and contralateral nonpalpable testis are present. A modified Ombrédanne operation is useful for TTE because it can avoid the injury of the spermatic vessels and vas deferens.(Indian J Urol. 2011 Jul-Sep; 27(3): 397–398). A single case of TTE with incarcerated hernia is also reported(Duygu, Kemal Cases Journal 2008, 1:200  )

69. Persistent Mullerian duct syndrome
It is a rare form of male pseudo-hermaphroditism characterized by the presence of Mullerian duct structures in an otherwise phenotypically, as well as genotypically, normal man; only a few cases have been reported in the worldwide literature.
 Obstructed inguinal hernia containing a uterus and fallopian tube (that is, hernia uteri inguinalis; type I male form of persistent Mullerian duct syndrome) coincidentally detected during an operation for an obstructed left inguinal hernia have also been reported (Nishikant N, Ravikumar K Journal of Medical Case Reports 2011, 5:586)

70. Contd…
Cases of unilateral or bilateral cryptorchidism associated with inguinal hernia, the possibility of persistent Mullerian duct syndrome should be kept in mind in order to prevent further complications such as infertility and malignant change.
Hernia uteri inguinalis is characterized by one descended testis and herniation of the ipsilateral corner of the uterus and fallopian tube into the inguinal canal.

71. Surgery for Non-palpable testis
Open Transabdominal Orchidopexy(Jones Procedure)- Extensive dissection of the vas and vessels is facilitated by a longitudinal opening of the internal oblique and peritoneum through an extended inguinal incision or via a higher incision medial to the pubic tubercle and a preperitoneal approach.

72. Contd…
Laparoscopic Orchidopexy and Fowler-Stephens Orchidopexy- The feasibility of primary versus Fowler-Stephens orchidopexy
depends on the length of the vas and vessels, presence or absence of looping ductal structures, and age of the patient. Although laparoscopy allows the surgeon to assess some of these features before choosing a specific surgical procedure, the choice may be difficult . Observed testicular position alone may correlate poorly with the ultimate length of the cord after
mobilization.

73. Non-palpable testis

74. Thank You