|Year : 2018 | Volume
| Issue : 1 | Page : 205-211
Sonographic evaluation of testicular hemodynamics after inguinal hernia repair
Magdi A Lolah1, Tamer A Sultan1, Mohamed F Ahmed Gafar2
1 Department of General and Pediatric Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General and Pediatric Surgery, Al Amria Hospital, Al Amria, Egypt
|Date of Submission||01-Jan-2017|
|Date of Acceptance||19-Mar-2017|
|Date of Web Publication||14-Jun-2018|
Mohamed F Ahmed Gafar
Source of Support: None, Conflict of Interest: None
The aim of this work was color Doppler ultrasound assessment of the effect of inguinal hernia repair on testicular blood flow using open approaches.
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 20 patients, 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.
This study was designed on 20 patients with primary inguinal hernia (direct and indirect). The age range was between 20 and 50 years. All patients included had primary inguinal hernia. Eight patients had right-sided hernia, whereas 12 patients had left-sided hernia. All the patients were assessed by Doppler ultrasound preoperatively and 3 months postoperatively. Postoperative testicular scan showed no ischemic changes in any patient in our study, and postoperative complications recorded included seroma and mild hematoma.
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. Sonographic evaluation 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. Sonographic evaluation of testicular hemodynamics after inguinal hernia repair. Menoufia Med J [serial online] 2018 [cited 2019 Jun 20];31:205-11. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/205/234216
| Introduction|| |
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 .
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 ,.
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 ,.
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 .
Testicular dysfunction (atrophy) is one of the most dreaded sequelae of inguinal hernioplasty ,.
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 .
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 ,.
It is well known that thrombosis, ligation, and/or cutting of the spermatic vessels may lead to ischemia, ischemic orchitis, and testicular atrophy .
| Patients and Methods|| |
This prospective randomized study included 20 patients, 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.
Patients with primary unilateral inguinal hernia (direct and indirect), those aged 20–50 years old, and who were generally fit were included in this study.
Exclusion criteria were age above 50 or below 20 years, 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.
Liver functions (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.
Patient history 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 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 40 years).
The 20 patients found to be suitable for the study were selected and specific investigations were done for them, including 'preoperative and postoperative testicular perfusion scan'.
A total of 20 patients underwent a Lichtenstein's hernia repair.
The operations were performed under spinal anesthesia with the patient in supine position. An indwelling catheter was placed to establish bladder decompression.
A 5 to 6 cm 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 [Figure 1].
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 ∼2 cm 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  [Figure 2].
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  [Figure 3].
Placement of prosthesis
A sheet of 6 × 11 cm 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 1–2 cm .
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. A slit 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 5 cm 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 [Figure 4]. 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.
Closure of the wound
The external oblique aponeurosis was approximated using continuous 2/0 prolene suture without a drain. The skin was then closed [Figure 5].
Patients were discharged when clinically free after the operation. Instructions on discharge included avoidance of any of the predisposing factors of hernia postoperatively. All patients were advised to visit the outpatient clinic after 3 months 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 computer using IBM SPSS software package version 20.0 (SPSS Inc., Chicago, Illinois, USA). Qualitative data were described using number and percentage.
| Results|| |
A total of 20 patients were randomly selected. Participants were divided according to Age into 6 groups (A, B, C, D, E, F) each is formed of 5 years.
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 [Table 1].
In our study, there is Doppler ultrasound (US) comparison according to [Table 2].
|Table 2: Preoperative and postoperative Doppler ultrasound of the scrotum|
Click here to view
- Type and side of hernia
- Size and echogenicity of the testicle
- Arterial and venous testicular blood supply
- Postoperative complications.
Refer to [Table 3] for postoperative complications.
Seroma: as no drains were used in any of the patients, five patients had mild seroma postoperatively, which disappeared on medical treament within 1–2 weeks (reparil three times a day).
Hematoma: mild scrotal hematoma was detected in one patient who had complete inguinoscrotal hernia. Hematoma disappeared 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 stitch sinus during 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 48–72 h 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 postoperative values (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 [Table 4].
|Table 4: Preoperative and postoperative Doppler parameters of the testes (the end diastolic velocity)|
Click here to view
Resistance index parameters
In our group (Lichtenstein's approach): [Table 5] analyzes a statistical 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 [Table 5].
|Table 5: Preoperative and postoperative Doppler parameters of the testes (resistance index)|
Click here to view
| Discussion|| |
The study was designed on 20 patients with primary inguinal hernia (direct and indirect). The age range was between 20 and 50 years.
All the patients were assessed by Doppler US preoperatively and 3 months 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 et al.  was recurrent hernia. In addition, Taylor et al.  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 et al.  studied the same idea but using canine models (12 male 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 6 months. 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 et al.  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 and humans. 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 et al.  preferred to use scrotal US and color duplex of spermatic artery to asess the vascularity of the testes. Taylor et al.  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 et al.  used plug-and-patch technique. Taylor et al.  used single-layer prolene mesh; in 10 patients the hernia was repaired by open technique and in 10 patients by laparoscopic technique. Wantz  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 . On the other hand, Kux et al.  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 et al.  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 et al.  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  included unilateral or bilateral testicular atrophy among the rare complication recorder in his study on 86 patients who underwent inguinal hernia repair. Complications were more prevalent between 50 and 70 years. He concluded that the majority of complications can be avoided by use of better surgical technique.
Dieudonne  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 1 year and a maximum of 10 years.
Fortelny et al.  used simple hernia repair for inguinal hernia repair of 105 patients. They found a rate of 1.8% of testicular atrophy with a follow-up period of 13 months average.
Amid et al.  recorded a single case of testicular atrophy among 4000 cases who underwent inguinal hernia repair with different types of repair.
Kingsley et al.  recorded two cases of unilateral testicular atrophy among 27 patients who underwent inguinal hernia repair with anterior inguinal herniorrhaphy.
Gianetta et al.  recorded one case (0.7%) among 144 patients of recurrent inguinal hernia.
Huang  recorded three cases of testicular atrophy among 87 patients with first-time recurrent inguinal hernia repaired by modified shouldice technique.
| Conclusion|| |
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dilek ON. Hernioplasty and testicular perfusion. Springerplus 2014; 3
Dilek ON. Are there adverse effects of herniorrhaphy techniques on testicular perfusion?. In: Schumpelick V, Fitzgibbons RJ, editors. Hernia repair sequelae
. New York: Springer; 2010. pp. 3–13.
Blaivas M, Brannam L. Testicular ultrasound. Emerg Med Clin North Am 2004; 22
Štula I, Družijanić N, Sršen D, Čapkun V, Perko Z, Sapunar A. Influence of inguinal hernia mesh repair on testicular flow and sperm autoimmunity. Hernia 2012; 16
Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL, Campanelli G, Conze J. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2009; 13
Lee SL, DuBois JJ, Rishi M. Testicular damage after surgical groin exploration for elective herniorrhaphy. J Pediatr Surg 2000; 35
Amid PK, Friis E, Horeyseck G, Kux M. Tension-free onlay mesh hernioplasty. Oper Tech Gen Surg 1999; 1
Collaboration EH. Mesh compared with non-mesh methods of open groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000; 87
Covidien Co. European Product Catalogue 2013: hernia care
. Covidien, Boulder, CO, USA; 2013. p. 11.
Zieren J, Beyersdorff D, Beier KM, Muller JM. Sexual function and testicular perfusion after inguinal hernia repair with mesh. Am J Surg 2001; 18
Taylor SG, Hair A, Baxter GM, O'Dwyer PJ. Does contraction of mesh following tension free hernioplasty effect testicular or femoral vessel blood flow? Hernia 2001; 5
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. J Urol 1999; 161
Wantz GE. Testicular atrophy as a sequela of inguinal hernioplasty. Int Surg 1986; 71
Ibingira CB. Long-term complications of inguinal hernia repair. East Afr Med J 1999; 76
Kux M, Fuchsjager N, Feichter A. Lichtenstein-patch versus shouldice technique in primary inguinal hernia at high risk of recurrence (German). Chirurg 1994; 65
Dieudonne G. Plug repair of groin hernias: a 10-year experience. Hernia 2001; 5
Fortelny R, Sporn S, Gero A. PHS – A double-leaved mesh in the open surgery of inguinal hernias. Zentralbl Chir 2002; 127
Kingsley D, Vogt DM, Nelson MT, Curet MJ, Pitcher DE. Laparoscopic intraperitoneal onlay inguinal herniorrhaphy. Am J Surg 1998; 176
Gianetta E, Cuneo S, Vitale B, Camerini G, Marini P, Stella M. Anterior tension-free repair of recurrent inguinal hernia under local anesthesia: a 7-year experience in a teaching hospital. Ann Surg 2000; 231
Huang CS. Surgical treatment of recurrent groin hernia. J Formos Med Assoc 1999; 98
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]