Laparoscopic Repair of Extraperitoneal Ureteral Inguinal Hernia With Mesh Placement

Abstract

Ureteral inguinal hernias are a well-described entity, within the spectrum of sliding hernias, with over 140 cases described since 1880. Though herniation of the ureter is relatively rare and complete ureteric obstruction is infrequent, a massive herniation may cause complete obstruction, leading to hydronephrosis. Management of these hernias is challenging and poses a significant danger of inadvertent injury and entrapment of a tortuous ureter. When faced with this type of hernia, extreme care should be taken to perform the appropriate preoperative workup and thoroughly plan the surgical approach. The present case describes a patient with a known ureteral inguinal hernia, who underwent a laparoscopic repair of the hernia with mesh placement.

Management of an obstructing calculus in an anticoagulated patient with a ureteral hernia

“… 3 , 4 , 5 They are more commonly involved with indirect hernias than with direct hernias and the right side is more often involved that the left postulated to be due to the Fascia of Toldt, stationed at the root of the sigmoid colon mesentery, anchoring the left ureter in the retroperitoneum. 1 , 3 , 6 , 7 , 8 , 9 …”

“…An entangled ureter within an inguinal hernia might be suspected preoperatively, if the patient presents with signs and symptoms of urinary obstruction or renal failure. 1 , 6 , 7 , 10 , 11 , 12 , 13 , 14 However, many are discovered incidentally and intraoperatively; lack of awareness of ureteral involvement prior to hernia repair poses a risk of inadvertent damage, which may lead to long-term renal consequences. 15 Identifying ureteral involvement in an inguinal hernia prior to herniorrhaphy is difficult.…”

“…It is estimated that half of patient with ureteral hernias present with obstructive urinary tract symptoms such as weak urinary stream and dysuria while other symptoms described in the literature include dysuria, flank pain, urinary incontinence, or unexplained UTI. 1 , 6 , 10 , 14 Laboratory studies, including a serum creatinine increased from baseline, and imaging showing hydronephrosis or hydroureter in a patient with an inguinal hernia may also raise suspicion for ureteral involvement. 6 , 8 , 9 , 10 , 12 Previous studies suggest in those patients receiving an abdominal-pelvic CT scan prior to herniorrhaphy, noticeable displacement of the ureter at the position of the L4 vertebrae anterior to the psoas muscle by at least 1 cm may be indicative of ureteral entrapment in the hernia 15 .…”

“… 1 , 6 , 10 , 14 Laboratory studies, including a serum creatinine increased from baseline, and imaging showing hydronephrosis or hydroureter in a patient with an inguinal hernia may also raise suspicion for ureteral involvement. 6 , 8 , 9 , 10 , 12 Previous studies suggest in those patients receiving an abdominal-pelvic CT scan prior to herniorrhaphy, noticeable displacement of the ureter at the position of the L4 vertebrae anterior to the psoas muscle by at least 1 cm may be indicative of ureteral entrapment in the hernia 15 . Additionally, presence of a particularly large right sided inguinoscrotal hernia may warrant suspicion given the relation of the left ureter and the Fascia of Toldt.…”

“…In cases when the ureter is identified preoperatively to be involved, a ureteric stent can be placed to aid in identification and preservation during the hernia repair. 5 , 6 , 9 , 10 However, often ureteral involvement goes undiagnosed until surgery is performed to herniorrhaphy, which increases the intraoperative risk of ureteral damage. Current literature reports some commonalities which may clue a surgeon into the presence of a ureter in the inguinal hernia.…”