Spermatic cord (with the genital
branch of the genitofemoral nerve)
Ilioinguinal nerve (passes through the
superficial ring but does not
completely run through the entire
Genital branch of the genitofemoral
16. INGUINAL HERNIA
An inguinal hernia is an abnormal protrusion of intra-
abdominal contents either through the deep inguinal
ring (indirect inguinal hernia; lateral to the inferior epigastric
artery) or through the weakened posterior wall of the inguinal
canal (direct inguinal hernia; medial to the epigastric artery)
17. INGUINAL HERNIA
International incidence in paediatrics is 1 – 5%
Inguinal hernia common in males than in females, ratio of 4 –
8 : 1
Premature infants are at an increased risk of inguinal hernia,
with incidence of 7 – 30 %
18. INGUINAL HERNIA
Prematurity and low birth weight
(Incidence approaches 50%.)
Exstrophy of the bladder
Patent processus vaginalis, which may be
present because of increased abdominal
pressure due to ventriculoperitoneal
shunts, peritoneal dialysis, or ascites
Abdominal wall defects
Connective tissue disease
Congenital dislocation of the
Liver disease with ascites
19. INGUINAL HERNIA
DI REC T I NGUI NAL HERNI A
Medial to the inferior epigastric blood vessels
(within Hesselbach's triangle)
Hernial sac protrudes directly through the posterior wall
of the inguinal canal (without involvement of
the spermatic cord or round ligament of the uterus)
Only herniates through the superficial (external) ring
Only surrounded by the external spermatic fascia
I NDI REC T I NGUI NAL HERNI A
Lateral to the inferior epigastric blood vessels
(outside Hesselbach's triangle)
Runs from the deep (internal) inguinal ring through
the inguinal canal to the superficial (external) inguinal
ring (in men, along with the spermatic cord)
Surrounded by the external spermatic fascia, cremasteric
muscle fibers, and internal spermatic fascia
20. INGUINAL HERNIA
Visible, palpable groin protrusion or bulge
The bulge commonly occurs after crying or straining and
often resolves during the night while the baby is sleeping.
Indirect hernias are more common on the right side
because of delayed descent of the right testicle. Hernias are
present on the right side in 60% of patients, on the left in
30%, and bilaterally in 10% of patients.
INGUINAL PAIN (COMPLICATION)
22. INGUINAL HERNIA
Incarcerated hernia: inability to reduce
the hernia back into abdominal cavity; fixation of
contents in the hernial sac
Surgical emergency in case of concurrent bowel
Strangulated hernia: tight constriction of hernial
contents leading to constriction of blood vessels
and bowel ischemia
Patients must undergo surgery within 4–6 hours to avoid
possible bowel loss.
Symptoms of bowel obstruction
Symptoms of intestinal necrosis: pain and erythema in
the lower abdomen and scrotum
Possible intestinal perforation and/orperitonitis
Possible systemic inflammatory response
The child may be fussy, unwilling to feed, and
inconsolably crying. The skin overlying the bulge
may be edematous, erythematous, and discolored.
23. INGUINAL HERNIA
Inguinal hernia diagnosis is typically established based on
medical history and physical exam findings!
Imaging test of choice
Visualization of the hernial orifice and hernial contents may
CT/MRT: to distinguish from differential diagnoses in
25. INGUINAL HERNIA
Inguinal hernias do not spontaneously heal and must be
surgically repaired because of the ever-present risk of
Generally, a surgical consultation should be made at the time
of diagnosis, and repair (on an elective basis) should be
performed very soon after the diagnosis is confirmed.
26. INGUINAL HERNIA
Herniotomy is all that is required with ligation and excision of
the patent processus vaginalis.
Paediatric surgeons will repair soon after diagnosis,
regardless of age or weight, in healthy full-term infant boys with
asymptomatic reducible inguinal hernias.
There is no significant difference in operative time for unilateral
hernias but laparoscopy is faster than open surgery for bilateral
There is no difference in recurrence rate but wound infection is higher
with open surgery than with laparoscopy.
27. INGUINAL HERNIA
• Inguinal hernias in premature infants are usually repaired prior to discharge
from the neonatal intensive care unit (NICU).
• Since infants are now being discharged home at much lower weights there
has been a trend towards postponing surgery for 1-2 months to allow
• However one study advocated early surgery in order to avoid perioperative
morbidity and to reduce the risk of incarceration, subsequent testicular
ischemia and hernia recurrence.
28. INGUINAL HERNIA
RISK OF SURGERY
Vas deferens injury
Spermatic vessels injury, dissection, or constriction, which may lead
to testicular necrosis
Injury to femoral nerve, artery, or vein
Chronic inguinal pain
Recurrence: 1.0% - most happening within five years of operation.
Recurrence rate increases:
In children aged younger than 1 year.
In those with ongoing increased intra-abdominal pressure.
Where there is growth failure.
30. UNDESCENDED TESTIS
Incomplete descent of the testis occurs when the testis is
arrested in some part of the normal path to the scrotum
About 4% of boys are born with one or both testes incompletely
About 2/3 of these reach the scrotum during the 1st three months of life,
but full descent after that is uncommon.
The incidence of testicular maldescent at the age of one year is around 1%.
The condition is sometimes missed in the neonatal period and only
discovered later in life.
In a few cases, the presence of a hernia, testicular pain or acute torsion
directs attention to the abnormality.
In 10% of cases, there is a family history.
31. UNDESCENDED TESTIS
More common on the right and is bilateral in 20% of cases.
In adults, secondary sexual characterictics are typically normal.
The testis may be:
Intra- abdominal; usually lying extraperitoneally just inside the internal
Intra- canalicular; it may or may not be palpable
Extra- canalicular usually at the scrotal neck;
Ectopic; the most common site is within the superficial inguinal pouch
which lies just inferior and medial to the superficial inguinal ring. Other
rarer ectopic sites include the femoral triangle, the root of the penis and
33. UNDESCENDED TESTIS
In some boys, any stimulation of the skin of the scrotum or thigh causes
the testis to ascend and to temporarily disappear into inguinal canal. This is
called a retractile testis.
In comparison to a true undescended testis, the scrotum of a boy with a
retractile testis is normal as opposed to underdeveloped.
When the cremaster relaxes, the testis reappears only to vanish when the
scrotal skin is touched again.
A retractile testis can be gently milked from its position in the inguinal
region to the bottom of the scrotum.
Retractile testes require no treatment
34. UNDESCENDED TESTIS
Performed before the boy reaches 12 months of age in an attempt to
prevent the consequences described earlier.
Testis and spermatic cord are mobilized and the testis is repositioned in
The operation is performed through a short incision over the deep inguinal
The inguinal canal is exposed by division of the external oblique
aponeurosis in the direction of its fibers.
FA ILURE TO B RI NG T HE TESTI S DOWN
Sometimes for a high undescended testis a two- stage surgical procedure is
Orchidectomy should be considered if the incompletely descended testis is
atrophic, particularly in the post- pubertal boy if the other testis is normal.
Presence of abnormal collection of serous fluid within
the tunica Vaginalis
Incidence : 3.5 to 5.0% in full term infants and 44 to
55% in premature and low birth weight babies
Babies who are born prematurely have a higher risk of
having a hydrocele
processus vaginalis and the
cavity of the tunica vaginalis
of the testis.
The processus vaginalis
normally obliterates till the
fourth month of life.
Congenital hydroceles occur
mostly through lack of
closure of the processus
(NON COMMUNICATING TOO)
Usually, there is a balance
between fluid production and
outflow in the cavity of the
The following diseases
disturb this balance:
testicular trauma, torsion of
the testis or testicular
lymphatic drainage (after
surgery for varicoceles or
INCREASED PRODUCTION OF FLUID
Inflammation of the testis (orchitis) or epididymis (epididymitis)
Testicular torsion (rotation of the testis) may cause a reactive
hydrocele in 20% of cases.
Tumors of the testis, especially germ cell tumors or tumors of the
testicular adnexa may cause hydrocele.
DECREASED RESORPTION OF FLUID
Surgery in the inguinal region or a renal transplantation can affect the
lymphatics or venous system causing decreased absorption.
Radiation therapy is associated with cases of hydrocele.
Peritoneal dialysis and ventriculoperitoneal shunts.
Primary hydrocele: when there is no definitive cause / idiopathic.
Secondary hydrocele: when there is a prior diseases of testis:
1. TB of epididymis
2. Syphilitic orchitis
3. Testicular tumours: teratoma—1st and 2nd decades of life
4. Orchitis arising by virus
7. Testicular cancer
IN SPEC TION
1. Usually Unilateral
2. Cough impulse - Negative
3. Site – Scrotal area below Inguinal ligament
4. Size – may be very large
5. Shape – Globular
6. Skin – normal with prominent vein on scrotal skin
1. Able to get above the swelling
2. Relation to testis – inseparable from testis (impossible to
3. Surface – smooth
4. Consistency – soft unless calcified, mixed with blood
5. Trans illumination test – Positive unless secondary infection,
mixed with blood/pus or calcified
Generally not essential
Leukocytosis with a higher
percentage of neutrophils
suggests an infectiousand/or
inflammatory process (eg,
not require radiographic
USG can help evaluate for an
underlying process, such as a
tumour or torsion
In Children, a non-communicating hydrocele aka simple hydrocele usually
resolves spontaneously by the time the child reaches the age of 1 year.
Thus, watch and wait – If the hydrocele is small.
Aspiration under ultrasound guidance – To relieve symptoms but tend to re-
accumulate again. Not recommended for suspected testicular tumor to
prevent needle tract implantation
INDICATIONS FOR SURGERY
Continued Scrotal discomfort or pain
Cosmetic - disfigurement due to the sheer size of the hydrocele.
Failure to resolve by age 2 years
Enlargement or waxing and waning in volume
Secondary infection (very rare)
LIGATION & DIVISION OF PATENT PROCESSUS VAGINALIS THROUGH
SMALL INGUINAL INCISION
Done if hydrocele persists beyond one year of age
LORD’S PLICATION (when the sac is reasonably thin-walled)
Small incision through the scrotum to lift up the testis. Sac is
plicate with a series of interrupted suture to the junction of
epididymis. It is used for small to medium
with thin sac. Benefits - reduced risk of
Some articles suggest a slight incidence of
recurrence of the hydrocele following this procedure.
JABOULAY’S OPERATION (larger)
Longitudinal incision and the sac is everted. Excess sac is
excised and remainder replace behind the cord or sutured
behind the testis. It is associated with a reduced risk of
recurrence but may have an increased risk of hematoma
SUBTOTAL EXCISION or HYDROCELECTOMY
In cases of large sac, where there is risk of a large redundant swelling post
operatively, excision of the sac with 1 cm margin around the testis &
Congenital hydrocele (communicating type) treated by herniotomy if they
do not resolve spontaneously, hydrocele that persists longer than 12 to 18
SHARMA & JHAWERS TECHNIQUE
ASPIRATION WITH/WITHOUT INJECTION OF SCLEROSINGAGENT
Haematocele due to spontaneous bleeding into the sac or as
result of trauma
Herniation of the hydrocele sac through the dartos muscle
Atrophy of the testis in long standing cases
Calcification Of Sac (D/D For Testicular Tumour)
Herniation of hydrocele sac (Rare)
Due to dilated pampiniform plexus of spermatic cord
(veins draining testis) and the internal spermatic vein
Occurs in approximately 15- 20% of all males
Onset usually after puberty , if it occurs in adults,
sought for other pathologies, renal carcinoma.
Feel of a ‘bag of worms’ during palpation of the cord
Grade I: Small varicocele which is palpable only when patient
performs Valsalva maneuver (expiration against a closed glottis)
Grade II: Moderate sized. Easily palpable varicocele without
Grade III: Large varicocele visible through the scrotal skin
Grade IV : Very much dilated and tortuous veins
Due to incompetency of valves. 98% occur on the left side
Pelvic or abdominal mass.
Lt renal cell carcinoma with tumor thrombus in left renal vein.
Nutcracker syndrome- SMA compressing left renal vein.
Other conditions- Retroperitoneal fibrosis or adhesions
98 % OF VAR ICOC ELE AR E LEFT SID ED
Left spermatic vein is more vertical
where it connects to left renal vein.
Left renal vein can be compressed by
Left testicular vein is longer than the
Lacks of terminal valve
Nephroblastoma in childhood
Left testicular artery is arching over left
Left renal vein is compressed b/w the
Aorta and SMA
It is usually more prominent when standing up.
Single/multiple : usually unilateral
Cough impulse : may be positive
Site : scrotal area below inguinal ligament, usually left sided & testis
hang lower than other side
Skin : dilated tortuous vein
PA L PAT I ON
Not Able to get above the mass(In severe)
Relation to testis : testis can be palpated separately
Surface : ‘Bag of worms’
Consistency : soft
Transilluminable : Negative
Aim to seal the affected veins
scrotal support and reassurance
treatment is required, only
Non surgical - Radiologically-guided embolization of testicular
veins using sclerosants or spring coil.
Surgical ligation – Palamo operation (high retroperitoneal
approach and ligation of internal spermatic vein above internal
Steel coil or silicone balloon catheter is introduced into a vein
below the groin through a nick in the skin.
Passed under X-ray guidance.
Tiny metal coils or other embolizing agents introduced through
No stitches needed.
Patient can go back in 24hrs.
Lower rates of complications. Less effective, higher
recurrence(5-11%), danger that the coil could migrate to the
heart and cause death Coil Embolization
Symptomatic varicocele—Excision of the pampiniform plexus in
the inguinal canal after ligating them. Testis still has venous
drainage via the cremasteric veins
VARICOCELECTOMY- The most common approaches are inguinal
(groin) -easier and safer.
Suprainguinal extraperitonial( Palomo’s operation) Open &
Scrotal approach- For Gr 4
70. TESTICULAR TORSION
A condition whereby the testicle twists in such a way that its blood supply
If left untreated – ceases of blood flow to testicle and the testicle dies
71. TESTICULAR TORSION
It is uncommon because the normal testis is anchored and cannot rotate
For torsion to occur, one of the several abnormalities must be present:
i. Inversion of testis
ii. High investment of tunica vaginalis causes the testis to hang within
the tunica like a clapper in a bell
Separation of epididymis from the body of testis permits torsion of
testis on the pedicle that connects the testis with the epididymis
72. TESTICULAR TORSION
TYPES OF TESTICULAR TORSION
INTR AVAGINAL TORS ION
In 17% of males and 40%
In a mature attachment, tunica
vaginalis is attached securely to
the posterior lateral aspect of
But if the attachment of tunica
vaginalis is inappropriately high,
spermatic cord can rotate within it
Common at adolescents
Associated with bell clapper
73. TESTICULAR TORSION
TYPES OF TESTICULAR TORSION
EXTR AVAGINAL TORS ION
Most often occurs in newborns without the ‘bell clapper’ deformity
It is thought to result from a poor or absent attachment of the testis to
scrotal wall, allowing a rotation of testis, epididymis, and tunica vaginalis
as a unit of the cord at the level of external ring
74. TESTICULAR TORSION
Most common age – between 10 and 25 years old, although a
few cases occur in infancy
Typically, there is a sudden agonizing pain in the groin and the
Nausea and may vomit
Torsion of a fully descended testis is usually easily recognized
The testis seems high and the tender twisted cord can be
palpated above it
Lost cremasteric reflex is lost
High riding testes
Bell clapper deformity
Pain relief with detorsion
Negative Phren’s sign
76. TESTICULAR TORSION
Management of the case should be determined primarily on
If there is doubt as to the diagnosis, then urgent scrotal
exploration is indicated
While Doppler ultrasound scanning can confirm the absence
of blood supply to affected testis, false positive result can be
seen, so it is not routinely recommended
Exploration of testis should be performed through a scrotal
Infection reaches the epididymis via the vas from a primary
infection of the urethra, prostate or seminal vesicles
A general rule is that epididymitis arises in sexually active
young men from a genital infection, while in older men it
more usually arises from a urinary infection or may be
secondary to an indwelling urethral catheter
Epididymitis must be differentiated from a testicular torsion
SIGNS AND SYMPTOMS
Gradual onset of scrotal pain and swelling, usually unilateral
Dysuria, frequency or urgency
Fever and chills (up to 71% in children case)
Usually no nausea and vomiting (contract with testicular
Urethral discharge preceding the onset of acute epididymitis
AS SOC IATE D WITH CHRON IC EPIDIDYM ITIS
Long standing (>6 weeks) history of pain
Scrotum that is not usually swollen but may be indurated in
long standing cases
Tenderness and induration occurring first in the epididymal tail
and then spreading
Normal cremasteric reflex
Erythema and mild scrotal cellulitis
Reactive hydrocele (advanced epididymo-orchitis)
Bacterial prostatitis or seminal vesiculitis
In children, an underlying congenital anomaly of the
Complete Blood Count
Gram stain of urethral discharge – if present
Non pharmacological treatment:
Reduction in physical activity
Scrotal support and elevation
Avoidance of urethral instrumentation
Infrequently performed in patients with acute
Typically reserved for refractory cases
Indicated only for patients with unrelenting
Skeletonization of the spermatic cord via subinguinal
Performed in rare cases of refractory pain due to
chronic epididymitis and orchialgia
84. TESTICULAR TORSION VS EPIDIDYMO-
AGE 8 – 12 years old 18 – 25 years old
PAIN Sudden acute, more severe Acute, less severe
FEVER Usually negative Positive
UT SYMPTOM Usually negative Dysuria, frequency and urgency
URT INFECTION Usually negative Mumps
Negative May be positive
TESTIS High locate
PREHN’S TEST No relieve Relieve
CREMASTERIC REFLUX Absent Present
U/S DOPPER Vascularity decrease High vascularity
TREATMENT Emergency, surgery within 6 hours Antibiotic
86. EPIDIDYMAL CYSTS
Filled with crystal- clear fluid.
Very common, usually multiple and vary in size at presentation.
Represent as cystic degeneration of the epididymis.
Usually found in middle- age and often bilateral.
The clusters of tense cysts feel like tiny bunches of grapes that
lie posteriorly to and quite separate from the testis.
Should transilluminate briliantly.
Diagnosis confirmed by ultrasound.
88. EPIDIDYMAL CYSTS
Aspiration is useless because the cysts are usually multi-
Excised when it is a single large cysts and causes discomfort
Partial or total epididymectomy when it is recurrent or
presence of multilocular cysts.
Excision should be expected to interfere with the
transportation of sperm from the testis on that side and
young men should be counselled regarding this.
Bailey and Love’s Short Practice of Surgery 26th Edition
Dr Laurence Knott, Feb 2016. Inguinal Hernia.The
Information Standard [https://patient.info/doctor/inguinal-
Ramsook C, Endom EE. Overview of inguinal hernia in
children. In: Post TW, ed. UpToDate. Waltham, MA:
of-inguinal-hernia-in-children]. Last updated October 6,
2016. Accessed December 12, 2016.