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ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 1  |  Page : 205-211

Sonographicevaluation of testicular hemodynamics after inguinal hernia repair


1 Department of General and Pediatric Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Departmentof General and Pediatric Surgery, Al Amria Hospital, Al Amria, Egypt

Date of Submission01-Jan-2017
Date of Acceptance19-Mar-2017
Date of Web Publication14-Jun-2018

Correspondence Address:
Mohamed F Ahmed Gafar
Alexandria, Elagamy
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_5_17

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  Abstract 


Objective
The aim of this work was color Doppler ultrasound assessment of the effect of inguinal hernia repair on testicular blood flow using open approaches.
Background
Anatomically, a close relation exists between the spermatic cord and inguinal hernias. Inguinal hernias can carry the risk of ischemia of the testis by intermittent mechanical compression (pressure) on the testicular vessels. The spermatic cord structures may be exposed to invasive surgical intervention during inguinal hernia reconstruction. Surgical dissection, division, or mechanical trauma to the spermatic artery and veins accounts for serious trophic changes in the testis.
Patients and methods
This study was conducted on 20patients, suffering from inguinal hernia, admitted to General Surgery Department in Faculty of Medicine, Menoufiya University and the Department of Surgery, Elamria Hospital in Alexandria. All patients were subjected to preoperative evaluation such as history taking, clinical examination, and laboratory investigations.
Results
This study was designed on 20patients with primary inguinal hernia(direct and indirect). The age range was between 20 and 50years. All patients included had primary inguinal hernia. Eight patients had right-sided hernia, whereas 12patients had left-sided hernia. All the patients were assessed by Doppler ultrasound preoperatively and 3months postoperatively. Postoperative testicular scan showed no ischemic changes in any patient in our study, and postoperative complications recorded included seroma and mild hematoma.
Conclusion
Testes are richly supplied by different blood vessels. In the Lichtenstein's hernia repair, there is no significant effect on testicular blood flow.

Keywords: inguinal hernia repair, sonographic evaluation, testicular hemodynamics


How to cite this article:
Lolah MA, Sultan TA, Ahmed Gafar MF. Sonographicevaluation of testicular hemodynamics after inguinal hernia repair. Menoufia Med J 2018;31:205-11

How to cite this URL:
Lolah MA, Sultan TA, Ahmed Gafar MF. Sonographicevaluation of testicular hemodynamics after inguinal hernia repair. Menoufia Med J [serial online] 2018 [cited 2019 Aug 19];31:205-11. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/205/234216




  Introduction Top


The spermatic cord anatomy has been well studied because of its important role in testicular physiology and surgery. The spermatic cord is composed of the vas deferens, testicular vessels, including the testicular artery and veins, autonomous nerves, spermatic muscle, and fascia. Each of these structures can have various effects on testicular perfusion [1].

Anatomically, a close relation exists between the spermatic cord and inguinal hernias. Inguinal hernias can carry the risk of ischemia of the testis by intermittent mechanical compression(pressure) on the testicular vessels [1],[2].

Lichtenstein hernia repair is one of the most comfortable effective methods of inguinal hernia repair, and it has similarities with totally extraperitoneal preperitoneal because of the prosthetic mesh use [1],[2].

The preoperative and postoperative use of color Doppler ultrasound(CDUS) to evaluate the spermatic cord structure and scrotal structure has been well documented in testicular pathologies and hernias. CDUS is extremely helpful in all cases to investigate extratesticular vascularization and testicular perfusion, with parameters optimized to display low-flow velocities, including peak systolic velocity and end diastolic velocity(EDV).

The color Doppler examination of the scrotum should include measurement of intratesticular resistive index (RI), as an elevated RI can be suggestive of ischemia [3].

Testicular dysfunction(atrophy) is one of the most dreaded sequelae of inguinal hernioplasty [2],[4].

All inguinal hernia repair techniques aim to close the internal ring with a suture or a biomaterial such as polypropylene mesh. Concern has been raised about whether the spermatic cord structures are compromised with these techniques [5].

The spermatic cord structures may be exposed to invasive surgical intervention during inguinal hernia reconstruction. Surgical dissection, division, or mechanical trauma to the spermatic artery and veins accounts for serious trophic changes in the testis [2],[6].

It is well known that thrombosis, ligation, and/or cutting of the spermatic vessels may lead to ischemia, ischemic orchitis, and testicular atrophy [2].


  Patients and Methods Top


This prospective randomized study included 20patients, suffering from inguinal hernia, admitted to General Surgery Department in Faculty of Medicine, Menoufiya University and the Department of Surgery, Elamria Hospital in Alexandria, from September 2014 to September 2016. Cases suffering from recurrent inguinal hernia were excluded. In addition, patients with a past history of inguinoscrotal surgery were excluded.

Ethical considerations were covered by standard preoperative consent following proper instructions/guidelines from the Ministry of Health (clinical/surgical methods, biological samples/laboratory tests).

All patients were subjected to the following.

Inclusion criteria

Patients with primary unilateral inguinal hernia(direct and indirect), those aged 20–50years old, and who were generally fit were included in thisstudy.

Exclusion criteria

Exclusion criteria were age above 50 or below 20years, recurrent hernia, complicated hernia, any scrotal or testicular disease, hepatic diseases, and complications such as ascites, severe urinary symptoms(benign prostatic hyperplasia), and laboratory abnormalities.

Laboratory investigations

Liverfunctions(serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase, albumin, bilirubin, alkaline phosphatase), kidney functions (urea, creatinine), complete blood picture, random blood glucose, and prothrombin time and concentration(any patient with disturbed coagulation profile was excluded) were assessed for all patients.

Patienthistory was recorded, including age, occupation, marital status, residency, special habits of medical importance (smoking, drinking, sports); history of previous or chronic illness and current medications; full sexual history regarding frequency of sexual intercourse, presence of immature ejaculation, orgasms, sexual satisfaction; history of urinary symptoms(burning micturition, symptoms of prostatic enlargement); and history of chest symptoms(chronic cough, bronchial asthma, tuberculosis).

General examination

Generalexamination was done for all patients, including vital signs(pulse, blood pressure, temperature, respiratory rate); head and neck examination to exclude general diseases such as jaundice and toxic goiter; chest examination; abdominal examination to exclude organomegaly, ascites, and abdominal wall hernias; and paradoxical reaction was done to exclude enlargement(for patients above 40years).

The 20patients found to be suitable for the study were selected and specific investigations were done for them, including 'preoperative and postoperative testicular perfusion scan'.

Operative procedure

A total of 20patients underwent a Lichtenstein's hernia repair.

Anesthesia

The operations were performed under spinal anesthesia with the patient in supine position. An indwelling catheter was placed to establish bladderdecompression.

Incision

A 5 to 6cm skin incision, which started from the pubic tubercle and extended laterally within the Langer's lines, gave an excellent exposure of the pubic tubercle and the internal ring. After skin incision, the external oblique aponeurosis was opened and its lower leaf was freed from the spermatic cord. The upper leaf of the external oblique was then freed from the underlying internal oblique muscle until the internal oblique aponeurosis was exposed[Figure1].
Figure 1: Skin incision.

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Dissection

The anatomic cleavage between these two layers was avascular and the dissection was done rapidly and nontraumatically. High separation of these layers has a dual benefit because it visualized the iliohypogastric nerve and internal oblique aponeurosis and created ample space for insertion of a sufficiently wide sheet of mesh that could overlap the internal oblique well above the upper margin of the inguinal floor. The cord with its cremaster covering was separated from the floor of the inguinal canal and the pubic bone for a distance of∼2cm beyond the pubic tubercle.

The anatomic plane between the cremasteric muscle and attachment of rectus sheath to the pubic bone is avascular, so there was no risk of damaging the testicular blood flow. When lifting the cord, great care was taken to include the ilioinguinal nerve, the easily visible blue external spermatic vein(the blue line), and the genital nerve with the cord. This assured that the genital nerve, which is always in juxtaposition to the external spermatic vessels, was preserved.

To explore the internal ring, for indirect hernia sacs, the cremasteric sheath was incised longitudinally at the level of the deep ring. This prevents the testicle from hanging low and also prevents dysfunction of the cremasteric muscle, which may lead to dysejaculation. Complete stripping and resection of the cremasteric fibers was avoided, as it could result in direct exposure of the genital nerve, vas deferens, and paravasal nerves to the mesh, resulting in chronic groin and testicular pain [7][Figure2].
Figure 2: The cord before dissecting the sac.

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Management of hernial sac

Indirect hernial sacs were freed from the cord to a point beyond the neck of the sac and were excised after transfixation. To minimize the risk of postoperative ischemic orchitis, complete nonsliding scrotal hernia sacs were transacted at the midpoint of the canal, leaving the distal section in place. However, the anterior wall of the distal sac was incised to prevent postoperative hydrocele formation [8][Figure3].
Figure 3: Spermatic cord and the sac.

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Placement of prosthesis

A sheet of 6×11cm of monofilament polypropylene mesh was used. The mesh was tailored to its standard shape, which resembles the tracing of a footprint, with a lower sharper angle to fit into the angle between the inguinal ligament and the rectus sheath and an upper wider angle to spread over the rectus sheath. With the cord retracted upward, the sharper corner was sutured with a nonabsorbable monofilament suture material to the insertion of the rectus sheath to the pubic bone and overlapping the bone by 1–2cm [9].

This was a crucial step in the repair because failure to cover this bone with the mesh is said to result in recurrence of the hernia. The periosteum of the bone was avoided. This suture was continued(as a continuous or interrupted suture with up to four passages) to attach the lower edge of the patch to the inguinal ligament up to a point just lateral to the internal ring. Aslit was made at the lateral end of the mesh, creating two tails, a wide one(two-thirds) above and a narrower one(one-third) below. The wider upper tail was grasped with forceps and passed toward the head of the patient from underneath the spermatic cord; this positions the cord between the two tails of the mesh. The wider upper tail was crossed and placed over the narrower one and held with a hemostat. With the cord retracted downward and the upper leaf of the external oblique aponeurosis retracted upward, the upper edge of the patch was sutured in place with interrupted absorbable sutures, one to the rectus sheath and the others to the internal oblique aponeurosis.

Using a single nonabsorbable monofilament suture, the lower edges of each of the two tails are fixed to the inguinal ligament just lateral to the completion knot of the lower running suture. This creates a new internal ring made of mesh. The excess patch on the lateral side is trimmed, leaving at least 5cm of mesh beyond the internal ring. This is tucked underneath the external oblique aponeurosis, which was then closed over the cord with an absorbable suture[Figure4]. Fixation of the tails of the mesh to the internal oblique muscle, lateral to the internal ring, was avoided as it could result in entrapment of the ilioinguinal nerve with the fixation suture.
Figure 4: Mesh application.

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Closure of the wound

The external oblique aponeurosis was approximated using continuous 2/0 prolene suture without a drain. The skin was then closed[Figure5].
Figure 5: Skin closure.

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Postoperative data

Patients were discharged when clinically free after the operation. Instructions on discharge included avoidance of any of the predisposing factors of hernia postoperatively. Allpatients were advised to visit the outpatient clinic after 3months during the follow-up period to undergo CDUS on the inguinal region and scrotum. The duration of operation, postoperative pain, length of hospital stay, duration of incapacity for work, postoperative complications(infection, wound dehiscence), and postoperative recurrence were recorded for the studied group. Then, the groups were compared. Data were fed to the computerusingIBM SPSS software package version20.0 (SPSS Inc., Chicago, Illinois, USA). Qualitative data were described using number and percentage.


  Results Top


A total of 20patients were randomly selected. Participants were divided according to Age into 6 groups (A, B, C, D, E, F) each is formed of 5years.

According to types of hernia, there were two cases of direct type and 18 had oblique type. Intraoperatively, six of the oblique types were bubonocele, five funicular, and seven complete inguinoscrotal type[Table1].
Table 1: Clinical type of hernia

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Inour study, there is Doppler ultrasound(US) comparison according to [Table2].
Table 2: Preoperative and postoperative Doppler ultrasound of the scrotum

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  • Type and side of hernia
  • Size and echogenicity of the testicle
  • Arterial and venous testicular blood supply
  • Postoperative complications.


Postoperativecomplications

Refer to [Table3] for postoperativecomplications.
Table 3: Postoperative complications

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Seroma: as no drains were used in any of the patients, five patients had mild seroma postoperatively, which disappeared on medical treament within 1–2weeks (reparil three times a day).

Hematoma: mild scrotal hematoma was detected in one patient who had complete inguinoscrotal hernia. Hematomadisappeared on medical treatment and scrotal elevation.

Infection: no cases of wound infection were detected among the cases included.

Retention: there was no complaint of dysuria or urine retention postoperatively.

Sinus formation: none of the patients had developed stitchsinusduring the period of follow-up.

Recurrence: no cases had developed recurrence of the hernia during the period of follow-up.

Postoperative pain: four patients complained of longer period of pain, and all of them improved on oral analgesics within 48–72h postoperatively.

Regarding the statistical analysis, all patients underwent a Doppler study of their testicular blood flow both preoperatively and postoperatively. It has been shown that there was no significant statistical difference between the preoperative and postoperativevalues(P>0.05).

End diastolic velocity

In our group(Lichtenstein's approach): this is a statistical comparison between the preoperative and postoperative EDV. The preoperative EDV has a mean of 3.26 and a SD of 2.31, whereas the postoperative EDV has a mean of 3.16 and a SD of 2.19. The P value was 0.91[Table4].
Table 4: Preoperative and postoperative Doppler parameters of the testes (the end diastolic velocity)

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Resistance index parameters

In our group(Lichtenstein's approach): [Table5] analyzes astatistical comparison between the preoperative and postoperative RI parameters. The preoperative RI parameters have a mean of 0.64 and a SD of 0.06, whereas the postoperative RI parameters have a mean of 0.64 and a SD of 0.07. The P value was 0.485 [Table5].
Table 5: Preoperative and postoperative Doppler parameters of the testes (resistance index)

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  Discussion Top


The study was designed on 20patients with primary inguinal hernia(direct and indirect). The age range was between 20 and 50years.

All the patients were assessed by Doppler US preoperatively and 3months postoperatively.

All patients included in the study had primary inguinal hernia. Most authors prefer to study the effect of the mesh on repair of primary inguinal hernia. One of the exclusion criteria in the study by Zieren etal. [10] was recurrent hernia. In addition, Taylor etal. [11] chose all his patients to have primary hernia. Any complicated hernia or any associated testicular pathology must be excluded from the trial. The aim of this criteria is to protect against any other variant that may affect the testes and give false positive results.

In addition, it was intended to choose only unilateral cases so that any effect on the testes can be easily detected by comparing it with the other normal side. The same idea was approved by most authors.

Uzzo etal. [12] studied the same idea but using canine models(12male beagle dogs). They created unilateral inguinal hernial defect, which was repaired either by Marlex mesh(50%) or by using classic shouldice technique. They followed them up after 3 and 6months. They found that half of the testicles had gross abnormalities after mesh repair versus none in the control or shouldice groups.

The difference in results of Uzzo etal. [12] and our results can be explained by the difference in anatomy between canines and humans. The course of the spermatic cord is angled in canines andhumans. The angled course of the spermatic cord in canines makes it more liable to be affected by fibrosis than human spermatic cord. Therefore, it is thought that results of the study on canine models cannot be applied on humans.

Zieren etal. [10] preferred to use scrotal US and color duplex of spermatic artery to asess the vascularity of the testes. Taylor etal. [11] also perferred to use the same investigation.

In the current study, testicular perfusion scan was used to assess testicular vascularity as it is more accurate to give an image of the vascularity of the testes itself both arterial and venouus, it can show areas of infarction, ischemia or congestion wich may not appear in US or CDUS.

Regarding the method of inguinal hernia repair, Zieren etal. [10] used plug-and-patch technique. Taylor etal. [11] used single-layer prolene mesh; in 10patients the hernia was repaired by open technique and in 10patients by laparoscopictechnique. Wantz [13] preferred to use prolene mesh in open technique of inguinal hernia repair. Majority of these complications could be avoided by first investigating for the aetiology of the hernia in elective cases, use of better surgical techniques and expertise. Good follow up is essential to avert distressing complications like testicular atrophy, faecal and urine fistulae [14]. On the other hand, Kux etal. [15] studied the complications of both Bassini and Shouldice methods of inguinal hernia repair including testicular atrophy.

On reviewing the literature regarding the rate of testicular atrophy as a complication of inguinal hernia repair, we found the following:

Zieren etal. [10] found no patients with permanent testiclar changes postoperatively, and they concluded that the mesh-and-plug technique has no significant effect on testicular perfusion.

Taylor etal. [11] found that there is no effect of inguinal hernia repair with mesh, either open(single-layer prolene mesh) or laparoscopically, on testicular or femoral blood flow and they concluded that mesh contraction following inguinal hernia repair does not adversly affect the testicular or femoral vessels and can be used safely for both anterior and preperitoneal approaches.

Ibingira [14] included unilateral or bilateral testicular atrophy among the rare complication recorder in his study on 86patients who underwent inguinal hernia repair. Complications were more prevalent between 50 and 70years. He concluded that the majority of complications can be avoided by use of better surgical technique.

Dieudonne [16] found a rate of 0.8% of testicular atrophy among 4024 hernia operations and implanted 3332 plugs in groin hernia(from April 1990 to July 2000) in a follow-up period of a minimum of 1year and a maximum of 10years.

Fortelny etal. [17] used simple hernia repair for inguinal hernia repair of 105patients. They found a rate of 1.8% of testicular atrophy with a follow-up period of 13months average.

Amid etal. [7] recorded a single case of testicular atrophy among 4000cases who underwent inguinal hernia repair with different types of repair.

Kingsley etal. [18] recorded two cases of unilateral testicular atrophy among 27patients who underwent inguinal hernia repair with anterior inguinalherniorrhaphy.

Gianetta etal. [19] recorded one case(0.7%) among 144patients of recurrent inguinalhernia.

Huang [20] recorded three cases of testicular atrophy among 87patients with first-time recurrent inguinal hernia repaired by modified shouldice technique.


  Conclusion Top


Testes are richly supplied by different blood vessels.

In the Lichtenstein's hernia repair, there is no significant effect on testicular blood flow.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
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Uzzo RG, Lemack GE, Morrissey KP, Goldstein M. The effects of mesh bioprosthesis on the spermatic cord structures: a preliminary report in a canine model. JUrol 1999; 161:1344–1349.  Back to cited text no. 12
    
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Wantz GE. Testicular atrophy as a sequela of inguinal hernioplasty. Int Surg 1986; 71:159–163.  Back to cited text no. 13
    
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Ibingira CB. Long-term complications of inguinal hernia repair. East Afr Med J 1999; 76:396–399.  Back to cited text no. 14
    
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Kux M, Fuchsjager N, Feichter A. Lichtenstein-patch versus shouldice technique in primary inguinal hernia at high risk of recurrence(German). Chirurg 1994; 65:59–62.  Back to cited text no. 15
    
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    Figures

  [Figure1], [Figure2], [Figure3], [Figure4], [Figure5]
 
 
    Tables

  [Table1], [Table2], [Table3], [Table4], [Table5]



 

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