١ ﺮﻴﺨﺑ ﻢﺘﻧاو مﺎﻋ ﻞآ ﺮﻴﺨﺑ ﻢﺘﻧاو مﺎﻋ ﻞآ Happy New Year Inguino scrotal Swellings in Children Essam Elhalaby, M.D. Prof. of Pediatric Surgery Director of Quality Assurance Unit Faculty of Medicine, Tanta University قﺎﺜﻴﻣ قﺎﺜﻴﻣ ةﺮﺿﺎﺤﻤﻟا ﻩﺬه ةﺮﺿﺎﺤﻤﻟا ﻩﺬه ﻻ􀂄􀂄 ﻻ لﻮﻤﺤﻤﻠﻟ لﻮﻤﺤﻤﻠﻟ 􀂄􀂄 مؤﺎﺸﺘﻠﻟ ﻻ مؤﺎﺸﺘﻠﻟ ﻻ 􀂄􀂄 بؤﺎﺜﺘﻠﻟ ﻻ بؤﺎﺜﺘﻠﻟ ﻻ 􀂄􀂄 ﺔﻴﺒﻧﺎﺠﻟا تﺎﺛدﺎﺤﻤﻠﻟ ﻻ ﺔﻴﺒﻧﺎﺠﻟا تﺎﺛدﺎﺤﻤﻠﻟ ﻻ ﻢﻌﻧ ﻢﻌﻧ􀂄􀂄 ﻚﻟؤﺎﻔﺘﻟ ﻚﻟؤﺎﻔﺘﻟ 􀂄􀂄 ﻚﺘﻣﺎﺴﺘﺑﻻ ﻚﺘﻣﺎﺴﺘﺑﻻ 􀂄􀂄 ﺔﻴﺑﺎﺠﻳﻻا ﻚﺘآرﺎﺸﻤﻟ ﺔﻴﺑﺎﺠﻳﻻا ﻚﺘآرﺎﺸﻤﻟ 􀂄􀂄 ﺔﻤﻈﻨﻤﻟا ﺔﻠﺌﺳﻸﻟ ﺔﻤﻈﻨﻤﻟا ﺔﻠﺌﺳﻸﻟ 􀂄􀂄 تﺎﺣاﺮﺘﻗﻼﻟ تﺎﺣاﺮﺘﻗﻼﻟ ةءﺎﻨﺒﻟا ةءﺎﻨﺒﻟا Inguino Inguino-scrotal Swellings in Children scrotal Swellings in Children 􀂄􀂄 Congenital inguinal hernia Congenital inguinal hernia 􀂄􀂄 Hydrocele Hydrocele 􀂄􀂄 Testicular torsion Testicular torsion 􀂄􀂄 Acute scrotum Acute scrotum 􀂄􀂄 Varicocele Varicocele 􀂄􀂄 Others Others Inguino Inguino-scrotal Swellings in Children scrotal Swellings in Children 􀂄􀂄 Congenital inguinal hernia Congenital inguinal hernia 􀂄􀂄 Hydrocele 􀂄􀂄 Testicular torsion 􀂄􀂄 Acute scrotum 􀂄􀂄 Varicocele 􀂄􀂄 Others ٢ Congenital Inguinal Hernia Congenital Inguinal Hernia 􀂄􀂄 Incidence Incidence 􀂄􀂄 Pathophysiology Pathophysiology 􀂄􀂄 Clinical presentation Clinical presentation 􀂄􀂄 Diagnosis Diagnosis 􀂄􀂄 Investigation Investigation 􀂄􀂄 Treatment Treatment 􀂄􀂄 Complications Complications Incidence of Inguinal Hernia Incidence of Inguinal Hernia 􀂄􀂄 3% 3%-5% of full term 5% of full term 􀂄􀂄 9% 9%-11% of preterm 11% of preterm Incidence of Inguinal Hernia Incidence of Inguinal Hernia 􀂄􀂄 Right side 60% Right side 60% 􀂄􀂄 Left side 25% Left side 25% 􀂄􀂄 Bilateral 15% Bilateral 15% 􀂄􀂄 Bilaterality Bilaterality is more common in girls is more common in girls Pathophysiology Pathophysiology 􀂄􀂄 The The processus processus vaginalis vaginalis (PV) develops during the (PV) develops during the third month of gestation as an out third month of gestation as an out-pouching of the pouching of the peritoneal cavity through the internal ring. peritoneal cavity through the internal ring. 􀂄􀂄 It obliterates spontaneously from the internal ring to It obliterates spontaneously from the internal ring to the testis after completion of the testicular descent. the testis after completion of the testicular descent. 􀂄􀂄 The PPV is a potential hernia The PPV is a potential hernia Embryonic Development Embryonic Development Testis Formation of P V Gubernaculum Descent of Testes Descent of Testes Descent begins at ~3 months Adult Configuration Fused Processus Vaginalis٣ Anomalies of the Anomalies of the Processus Processus Vaginalis Vaginalis Normal Partially Patent Completely Patent Anomalies of the Anomalies of the Processus Processus Vaginalis Vaginalis Normal Deep and Superficial Rings in Infancy Herniation Completely Patent Partially Patent Types of Inguinal Hernia in children ? Types of Inguinal Hernia in children ? 􀂄􀂄 Indirect Indirect 􀂄􀂄 Direct ( very rare) Direct ( very rare) Risk Factors for developing a Risk Factors for developing a Congenital hernia? Congenital hernia? 􀂄􀂄 A parent or sibling who had a hernia as an infant A parent or sibling who had a hernia as an infant 􀂄􀂄 Cystic fibrosis Cystic fibrosis 􀂄􀂄 Developmental Developmental dysplasia dysplasia of the hip of the hip 􀂄􀂄 Undescended Undescended testes testes 􀂄􀂄 Abnormalities of the urethra Abnormalities of the urethra Inguinal versus Femoral Inguinal versus Femoral٤ Femoral hernia: 􀂃 Opening in fascia covering femoral canal 􀂃 May allow small bowel to slide through, causing obstruction Inguinal versus Femoral Inguinal versus Femoral Clinical Diagnosis Clinical Diagnosis 􀂄􀂄 Usually Usually easy easy 􀂄􀂄 But is But is not always not always possible possible 􀂄􀂄 A transient inguinal swelling that could not A transient inguinal swelling that could not be detected clinically at the time of be detected clinically at the time of examination examination Clinical Diagnosis Clinical Diagnosis 􀂄􀂄 Usually Usually easy easy 􀂄􀂄 History History 􀂄􀂄 Clinical findings Clinical findings Clinical Diagnosis Clinical Diagnosis 􀂄􀂄 Investigation Investigation 1. 1. Diagnostic Diagnostic Pneumopritonium Pneumopritonium (Goldstein (Goldstein’s Test) s Test) 2. 2. Preoperative Preoperative Herniography Herniography 3. 3. Intra operative laparoscopy Intra operative laparoscopy 4. 4. Ultrasonography Ultrasonography٥ 1. Diagnostic 1. Diagnostic Pneumopritonium Pneumopritonium (Goldstein (Goldstein’s Test) s Test) 􀂄􀂄 Clinical interpretation of the Clinical interpretation of the contralateral contralateral crepitus crepitus or or swelling swelling 􀂄􀂄 Has a sensitivity of 92% Has a sensitivity of 92% 􀂄􀂄 Its false negative result is 1.8% Its false negative result is 1.8% 􀂄􀂄 Simple Simple 􀂄􀂄 Safe Safe 􀂄􀂄 Rapid Rapid 2. Preoperative 2. Preoperative Herniography Herniography 􀂄􀂄 It can delineate an inguinal hernia with 90% It can delineate an inguinal hernia with 90% accuracy accuracy 􀂄􀂄 Intramural Intramural haematoma haematoma 􀂄􀂄 Intestinal perforation Intestinal perforation 􀂄􀂄 Invasive Invasive 􀂄􀂄 Not cost effective Not cost effective 3. Intra operative laparoscopy 3. Intra operative laparoscopy 􀂄􀂄 sensitivity 73% sensitivity 73% 􀂄􀂄 specificity 92% specificity 92% 􀂄􀂄 invasive modality invasive modality 􀂄􀂄 It might not fit the delicate narrow hernia sac It might not fit the delicate narrow hernia sac 􀂄􀂄 It is time consuming It is time consuming 􀂄􀂄 Risk of iatrogenic complications. Risk of iatrogenic complications. 4. 4. Ultrasonography Ultrasonography 􀂄􀂄 Type I: Presence of intestine in the inguinal canal Type I: Presence of intestine in the inguinal canal 􀂄􀂄 Type II: Cystic pattern in the internal inguinal canal Type II: Cystic pattern in the internal inguinal canal 􀂄􀂄 Type III: PPV enlarges with increasing abdominal Type III: PPV enlarges with increasing abdominal pressure pressure 􀂄􀂄 Type IV: Moving material in PPV without enlargement Type IV: Moving material in PPV without enlargement Ultrasonography Ultrasonography٦ Ultrasonography Ultrasonography Surgery Surgery Identification and Identification and ligation ligation of a PPV of a PPV To explore or NOT to explore the contralateral side of congenital inguinal hernia Contra lateral Exposure Contra lateral Exposure 􀂄􀂄 The risk of developing contralateral The risk of developing contralateral hernia is 24% especially when the initial hernia is 24% especially when the initial hernia was on the left side hernia was on the left side Why Exploration of the Contralateral Side Why Exploration of the Contralateral Side overlooking other side hernia is overlooking other side hernia is 􀂄􀂄 A big burden to the baby A big burden to the baby 􀂄􀂄 A big burden family A big burden family 􀂄􀂄 A big burden resources A big burden resources٧ Why not to Explore the Contralateral Side Why not to Explore the Contralateral Side 􀂄􀂄 High incidence of negative exploration High incidence of negative exploration 􀂄􀂄 Unnecessary lengthening of the operative Unnecessary lengthening of the operative time time 􀂄􀂄 Possible increasing morbidity in those Possible increasing morbidity in those patients patients 􀂄􀂄٨ Inguino Inguino scrotal Swellings in Children scrotal Swellings in Children 􀂄􀂄 Congenital inguinal hernia Congenital inguinal hernia 􀂄􀂄 Hydrocele Hydrocele 􀂄􀂄 Testicular torsion Testicular torsion 􀂄􀂄 Acute scrotum Acute scrotum 􀂄􀂄 Varicocele Varicocele 􀂄􀂄 Others Others Hydrocele Hydrocele 􀂄􀂄 Diagnosis Diagnosis 􀂄􀂄 Indication for surgery Indication for surgery 􀂄􀂄 Timing for surgery Timing for surgery 􀂄􀂄 Complications Complications Inguino Inguino scrotal Swellings in Children scrotal Swellings in Children 􀂄􀂄 Congenital inguinal hernia Congenital inguinal hernia 􀂄􀂄 Hydrocele Hydrocele 􀂄􀂄 Testicular torsion Testicular torsion 􀂄􀂄 Acute scrotum Acute scrotum 􀂄􀂄 Varicocele Varicocele 􀂄􀂄 Others Others٩ Normal vs. Abnormal Scrotum Normal vs. Abnormal Scrotum 􀂄􀂄 Normal Testis Normal Testis 􀂄􀂄 Testicular torsion Testicular torsion Testicular torsion Testicular torsion 􀂄􀂄 Diagnosis Diagnosis 􀂄􀂄 Timing for surgery Timing for surgery 􀂄􀂄 Contralateral Contralateral orchidopexy orchidopexy 􀂄􀂄 Complications Complications Acute scrotum Acute scrotum 􀂄􀂄 Testicular torsion Testicular torsion 􀂄􀂄 Strangulated Strangulated inguinoscrotal inguinoscrotal hernia hernia 􀂄􀂄 Orchitis Orchitis/epididmo epididmo-orchitis orchitis 􀂄􀂄 Testicular trauma Testicular trauma Acute scrotum Acute scrotum 􀂄􀂄 Diagnostic workup Diagnostic workup 􀂄􀂄 Differential Diagnosis Differential Diagnosis 􀂄􀂄 Indication of for surgery Indication of for surgery 􀂄􀂄 Complications Complications Inguino Inguino scrotal Swellings in Children scrotal Swellings in Children 􀂄􀂄 Congenital inguinal hernia Congenital inguinal hernia 􀂄􀂄 Hydrocele Hydrocele 􀂄􀂄 Testicular torsion Testicular torsion 􀂄􀂄 Acute scrotum Acute scrotum 􀂄􀂄 Varicocele Varicocele 􀂄􀂄 Others Others • Expansion of pampiniform plexus • Usually seen on left (why??) • Can be palpated • a. feels like a “bag of worms” Varicocoele Varicocoele١٠ Varicocele Varicocele 􀂄􀂄 Diagnosis Diagnosis 􀂄􀂄 Indication for surgery Indication for surgery 􀂄􀂄 Timing for surgery Timing for surgery 􀂄􀂄 Complications Complications Inguino Inguino scrotal Swellings in Children scrotal Swellings in Children 􀂄􀂄 Congenital inguinal hernia Congenital inguinal hernia 􀂄􀂄 Hydrocele Hydrocele 􀂄􀂄 Testicular torsion Testicular torsion 􀂄􀂄 Acute scrotum Acute scrotum 􀂄􀂄 Varicocele Varicocele 􀂄􀂄 Others Others 􀂃􀂃 Generally have unknown etiology Generally have unknown etiology 􀂃􀂃 Most arise from primordial germ cells Most arise from primordial germ cells 􀂃􀂃 Usual symptom: scrotal mass of Usual symptom: scrotal mass of increasing size increasing size 􀂃􀂃 May be associated with pain May be associated with pain 􀂃􀂃 Any firm mass or cystic mass in Any firm mass or cystic mass in scrotum should be checked scrotum should be checked Testicular tumor Testicular tumor Testicular Tumor: Doppler U/S Testicular Tumor: Doppler U/S Biopsy is primary diagnostic tool a. Chest x-ray, IVP b. To check for direct/indirect metastasis Treatment a. Surgical excision if tumor is benign b. Castration with chemotherapy & radiation if malignant Testicular tumor Testicular tumor Endodermal Endodermal Sinus and Yolk Sac Tumor Sinus and Yolk Sac Tumor Doppler U/S Tumor of Testis١١ Conclusions Conclusions ? Only in EGYPT ﺮﺼﻣ ﻲﻓ ﺪﻴآأ ﺪﻴآأ ﺖﻧأ ﻲﻘﺒﺗ Only in TANTA١٢ Thank You Essam Elhalaby. M.D.