Rare things do exist. Rare things can cause problems to those who do not know them. Surgeons must study continuously so that rare things do not stop them. Keep in mind that what scares the most a human being is the unknown.
Sliding hernia can pose a difficult time to the surgeon. In a sliding hernia the content itself (colon or bladder for instance) is many times part of the hernia wall. In that setting, those surgeons who do not understand the sliding hernia will do several injuries trying to dissect. Sometimes the Laroque Approach is the only way to bring back the herniated contents into the abdomen.
One hernia that can cause important damage to the patient is the inguinal hernia of the ureter. This is an extremely rare sliding hernia, but surgeons must know it. Obesity and renal transplant are risk factors. It is even rarer in patients with native kidneys. Inguinal hernia of the ureter is usually large, and incarceration is a rarity. Unexplained renal failure, urinary symptoms and unilateral hydronephrosis are common. Many cases published in worldwide literature are described as a “groin lump and renal failure”. However, some patients can be asymptomatic. Is this a problem? How can we preoperatively overcome this underrated diagnosis?
In 2018, Dr Sidiqi et al. from the General Surgery Department of the Geraldton Regional Hospital, Australia, published an interesting case of an inguinal hernia of the ureter diagnosed intraoperatively. The authors describe a sliding hernia with a great amount of retroperitoneal fat, initially thought to be a huge lipoma of the cord, with a tubular structure with peristalsis within, the ureter. They managed to push all the retroperitoneal fat and the ureter back into the abdomen and performed a Lichtenstein repair. Is this entity worth to talk about just because of its rarity? There are some other ideas I would like to highlight. First of all, the patient presented by Dr Sidiqi et al. was asymptomatic at diagnosis. As many surgeons tell, inguinal hernia is a clinical diagnosis. Meaning, there is no need for preoperative image. Following the legis artis, the patient was immediately schedule for the operation room. Would a preoperatively image diagnose the herniated ureter? Would that make any difference? I believe it would. It is always good to have the entire clinical picture before surgery so that surgical team can be prepared. Having the greatest amount of intel before surgery can help us reduce complications. This brings us to the second highlight point. Inguinal hernia commonly has a lipoma which is ligated and removed without fear. It is just a lipoma! The authors also thought it was just a lipoma. Imagine if they had blindly cut it. Would they have a different attitude if a herniated ureter had been preoperatively diagnosed? Yes, at least they would be more aware of the risk. It is important to avoid blind ligations of the fat with risk of damage to the ureter. Remember this in your future hernia repairs.
Some would say it is not cost-effective nor possible to justify a preoperative image for all patients with an inguinal hernia. Others would say it is not statistically significant. However, some patients will be in the dark side of the statistics. Cutting a ureter is a severe complication. If one pre-operative ultrasound can help us avoid one of such complication, I say do it. However, CT scan seems to be the best option. So, at least select patients for preoperative CT (urinary symptoms, unilateral hydronephrosis, unexplained renal impairment). Ultrasound for all patients? Think about it.
Inguinal hernia of the ureter is frequently indirect and on the right side. Men are more affected than women and under the age of 40. Two types of inguinal hernia of the ureter can be found. In the paraperitoneal type (80%) the ureter goes with the peritoneal sac forming part of the hernia wall. In the extraperitoneal type (20%) there is no sac and the retroperitoneal fat slides down and pulls the ureter. Surgeons must know about this possibility because there is a risk to damage the ureter during dissection.
I would like to raise one topic. Laparoscopic approach might have advantages treating a sliding hernia, including hernia with the ureter. Laparoscopy will eventually help us identifying a sliding hernia and probably will help us reduce the contents in the difficult cases where a Laroque Approach would be necessary. TEP or TAPP? I do not know.
Be aware of the possible herniated ureter and avoid blindly ligations of fat during inguinal hernia repair. Think about preoperative image (US?) of all inguinal hernia patients. I will always remember a statement from Sidiqi et al.: “This case suggests no inguinal hernia repair is routine.”
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Dr. Carlos Eduardo Costa Almeida
General Surgeon
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