8. Surgery 2 Flashcards
Why is only half the scrotum red?
What is the common cause of red, swollen painful hemiscrotum in a prepubertal boy?
Pathology is limited by tunica vaginalis (peritoneal extension containing ipsilateral testes).
The most common cause of red, swollen painful hemiscrotum in a prepubertal boy is torsion of hydatid morgagni.
golden rule: surgical causes of acute scrotum (torsion of testes/hydatid of morgagni) are limited to hemiscrotum, as scrotum contains two separate peritoneal cavities.
Why is the inflammation spreading beyond the hemiscrotum here? What is the cause?
Cause here - usually uritcaria or cellulitis - is outside the tunica vaginalis (in/on skin) and therefore not limited by the peritoneal membrane.
REd, swolen and painfull scrotum in adolescent - how does it present and what is the likely diagnosis?
Testicular torsion -and it can present with only pain in the iliac fossa, so you always need to check scrotum in boys with iliac fossa pain
Why does the testes twist and why is tosion common in early adolescence?
What is the role of surgery in torsion?
The testes is intraperitoneal (inside the tunica vaginalis) on a mesentry/mesorchium which has a minor anatomical variation in that is can be too long - known as ‘bell-clapper testes’.
Increased mesorchium length predisposes to torsion.
Torsion is common in early adolescence because the testis has recently enlarged with testosterone and increased size predisposes to torsion.
Can only be saved by immediate scrotal exploration - best test and treatment. (no time for US) Also surgery - fixation of other testes to prevent torsion (bell clapper anomaly is present in 80-90% bilaterally.
in the case of a necrotic, haemorrhagic testis caused by intravaginal torsion ,why should incision by midline?
To fix the opposite testes.
Red, painful hemiscrotum with blue pea - what is the diagnosis and when is it common?
Torsion of hydatid of morgagni (testicular appendage)
common in 10-12 y.o boys as low oestrogen levels in early puberty stimulate normal remnants fo the mullerian duct
What is the hydatid of morgagni? How do you know that the blue pea isn’t the testis?
hydatid = normal remnant of the cranial end of the Mullerian duct (which would form fimbria of fallopian tube) which is present in >80%
The testis is much bigger- before puberty is the same size as the glans
What’s going on here and what is the treatment?
Surgical midline excision - no torsion of the testes but inflammation of right head of epididymus and torsion of the hydatid (engorgement and haemorrhage).
The right head of epididymus is inflamed secondary to adjacent hydatid infarction.
Treatment= simple excision - but torsion of hydatid is self limiting ,surgery is elective.
In a baby - What is this? is it painful?
Likely dx: perinatal testicular torsion, could also be tumour. Only painful if occurs after birth but often starts before birth.
Why does testis twist before or just after birth?
Testes migrates to scrotum inside processus vaginalis (peritoneal diverticulum) which grows insdide the gubernaculum, which is not attached to the inside of scrotum until after descent is complete.
(extra vaginal torsion- twist is outside the tunica)
Painless scrotal mass at birth needs US to separate prenatal torsion o r tumour of testis.
What’s going on here?
The scrotum is asymmetrical - the right testis is undescended or missing
Where is an undescended testis usually found?
In the groin, outside the inguinal canal, as the second phase of testicular descent (canal to scrotum) is the common abnormality
Is a testis inside the inguinal canal palpable?
What is the recommended age for orchidopexy? (surgery to move undescended testes into scrotum)
Not palpable in inguinal canal.
6-12 months for congenital undescended testis> orchidopexy
Why do many boys present with asymmetrical scrotum at 4-10 years?
What causes this?
Many develop ‘acquired’ UDT after infancy due to failure of spermatic cord to increase in length as teh boy grows (as the pelvis grows)/
Most common reason for this is failure of complete obliteration and resorption of processus vaginalis, leaves a fibrous remnant, prevents elongation of vas and vessels.
In CP may be abnormal tone in cremaster muscle.
Which testis is abnormal? What might this be due to?
The right testis is about the same size as the glans, so it is normal. the left testis is no big- if there is no hydrocele then the left testis must have a tumour
What is going on here?
Empty right hemiscrotum with lump just lateral to it- ectopic, undescended testis
What is going on here and waht are the signs?
Cause of asymmetry here is bilateral hydroceles with patency of processus vaginalis on each side allowing intraperitoneal fluid to trickle down into the scrotum.
Signs:
- brilliantly transilluminate swellings
- can get ‘above’ swelling
- spermatic cords about swellings are not enlarged with bowel
- when you squeeze mass cannot empty it quickly (onlysmall connection to intraperitoneal cavity, not a hernia)
What’s going on here? Does it need to be fixed? Why?
Left ing hernia.
Urgent to fix in babies - high risk of incarceration and strangulation.
Much more dangerous in babies as bowel gets stuck at external inguinal ring which is v shaped rather than round.
Where is the lump? How common is this? What might be in it?
Tx?
Just outside external inguinal ring. 10% as common in girls as boys.
could contain bowel, ovary, fallop tube.
Herniotomy
What’s the cause of this and what might be the injuries?
Trauma after straddle injury fall
Testes are rarely injured because they are mobile, but the bulb of urethra may be torn (hence bleeding from eretile tissue), and there is a risk of urinary extravasation
