Archives of International Surgery

CASE REPORT
Year
: 2019  |  Volume : 9  |  Issue : 1  |  Page : 13--15

Undescended testis with Spigelian hernia: A rare association treated laparoscopically


Amit Kumar, Rashi, Amit K Sinha, Bindey Kumar, Sambedna 
 Department of Pediatric Surgery, AIIMS, Patna, Bihar, India

Correspondence Address:
Dr. Rashi
Department of Pediatric Surgery, AIIMS, Patna - 801 507, Bihar
India

Abstract

Spigelian hernia (SH) is rarely seen in the pediatric population and it is usually associated with undescended testis on the ipsilateral side. The condition has remained a question as to whether this is a cause, effect, or a new syndrome. Herein, we report the case of a 2-year-old child with right iliac region swelling that bulges out when he cries and the swelling disappears when he is sleeping. There was no vomiting or constipation. The parents also noticed the absence of the right testicle since birth. Examination revealed a reducible swelling in the right iliac region. The right hemiscrotum was hypoplastic and the testicle was not palpable. A diagnosis of right-sided Spigelian hernia with ipsilateral cryptorchidism was made. Contrast-enhanced computed tomography scan (CECT) did not reveal a hernia defect and the testicle was not localized. The hernia was repaired laparoscopically. The testes were found in the hernia sac and orchidopexy effected. The cryptorchid testis was a content of hernia sac which is a rare occurrence. Swelling in the iliac region in combination with ipsilateral undescended testes should be carefully evaluated. When the diagnosis of SH is established, it can be successfully repaired laparoscopically.



How to cite this article:
Kumar A, Rashi, Sinha AK, Kumar B, Sambedna. Undescended testis with Spigelian hernia: A rare association treated laparoscopically.Arch Int Surg 2019;9:13-15


How to cite this URL:
Kumar A, Rashi, Sinha AK, Kumar B, Sambedna. Undescended testis with Spigelian hernia: A rare association treated laparoscopically. Arch Int Surg [serial online] 2019 [cited 2020 May 29 ];9:13-15
Available from: http://www.archintsurg.org/text.asp?2019/9/1/13/282578


Full Text



 Introduction



A Spigelian hernia (SH) is defined as herniation through the Spigelian aponeurosis, which is part of the aponeurosis of the transverse abdominal and internal oblique muscle between the semilunar line and the lateral margin of the rectus abdominis muscle.[1] Adult SHs are generally acquired because of trauma or increased intra-abdominal pressure but pediatric cases are suspected to be congenital.[2] Around 75% of male infants with SHs, have associated ipsilateral cryptorchidism.[3] Raveenthiran in 2005 proposed that SH is a syndrome due to defect in the Spigelian fascia combined with ipsilateral cryptorchidism.[4]

 Case Report



An 18-month-old male child was brought by the parents to the outpatient department with complaints of absent right testis since birth and swelling over right lower abdomen noticed 2 months prior to presentation. The swelling increased in size while crying and disappeared when the child sleeps. The swelling was not associated with abdominal pain, irreducibility, or vomiting. His bowel and bladder habits were regular. There were no respiratory or urinary symptoms.

On clinical examination, the general condition of the child was fair. On inspection, there was a 5 × 5 cm bulge in the right iliac fossa region while the child cried and it disappeared when the child was calm. The defect was neither palpable clinically nor was it appreciated on any radiological investigations. Right hemiscrotal sac was empty and hypoplastic. Right testis was impalpable in the right inguinal region. The left testis was normally palpable in left hemiscrotum. Routine blood investigations were within normal limit. Ultrasonography confirmed absent right testis in right hemiscrotum without any parietal wall defect in right iliac fossa region. In view of the right-sided undescended testis and parietal wall swelling differential diagnosis of parietal wall swelling was made as Spigelian hernia and a contrast-enhanced computed tomography scan was done to more accurately define the swelling but there was no anterior abdominal wall defect seen. Right testis was not visualized in the right hemiscrotum or elsewhere in the abdomen. Few enlarged bilateral inguinal lymph nodes were present. The child was planned for laparoscopic repair of the Spigelian hernia and orchidopexy. Intra-operatively, illumination of the parietal wall defect was observed after pneumoperitoneum [Figure 1]. The left deep inguinal ring was closed and the right deep inguinal ring waswide open with vas and vessels entering the ring.. The right deep ring was further extending superolateral with vas and vessels and inferomedial part was closed shortly [Figure 2]. The testis along with the peritoneal sac was pulled inside [Figure 3] and the sac was excised. Right testis was laparoscopically fixed into the subdartos pouch of right hemiscrotum. Hernial defect was closed with interrupted intracorporeal sutures. Postoperative period was uneventful. The child was discharged on postoperative day 3.{Figure 1}{Figure 2}{Figure 3}

 Discussion



There have been significant explanations and controversies regarding the probable mechanism of cryptorchidism in Spigelian hernia. As per the general consensus, in Spigelian hernia the basic pathology is the cryptorchid testis takes the path of least resistance to descend into the hernial sac. During the due course of testicular descent, the testis deviates from its normal course into the inguinal canal and down to the scrotal sac. Instead of descending down it moves to the parietal wall defect (Spigelian hernia) as it becomes easier, shorter, and less pressure zone for descending testis. Raveenthiran opined that ectopic location of the testis is the basic pathology, and it leads to the formation of Spigelian hernia by dragging a peritoneal sac along with it.[4] Rushfeldt et al. speculated that ectopic location of testis in Spigelian hernia is due to absence of gubernaculum[5],[6] and the testis remains in their intra-abdominal position in the Spigelian hernial sac. We diagnosed an 18-month-old child with SH and undescended testis and successfully did a laparoscopic orchidopexy with Spigelian hernia repair. This is the third pediatric case being reported in the literature which was managed laparoscopically. The previous cases were reported by Desmukh et al. and Khan et al., respectively.[7],[8]

In the index case when the abdomen was inspected through the umbilical port the deep ring was found obliterated in its distal course supporting Rushfeldt hypothesis of absent gubernaculum and absent inguinal canal.

The management of this case included repair of the Spigelian hernia and orchidopexy. As the expected inguinal canal was not properly formed, we performed an orchidopexy through a new internal ring created through the abdominal wall medial to the inferior epigastric vessels and just lateral to the pubic tubercle as explained by Inan.[9]

 Conclusion



Possibility of Spigelian hernia should be kept in mind when dealing with parietal wall swelling with cryptorchid testis and vice versa. One should also look for undescended testis in the hernial sac. Laparoscopy is a good alternative as it gives better delineation of internal anatomy and better cosmesis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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