Undescended testis and swelling in spigelian belt: Not always a spigelian hernia.

Sir,

Ectopic testis (ET) is a type of undescended testis (UDT) where the testis deviates from its normal path of descent and migrates to some other site.[1] There are certain sites where an ET has classically been described. These include femoral, pubopenile, perineal, and transverse ectopic testis.[1] However, an ectopic testis in the abdominal wall is reported only once.[2] It may be associated with inguinal hernia. In an extremely rare situation, an inguinal hernia, associated with an ectopic testis in the abdominal wall, may masquerade spigelian hernia (SH).

A 5-month-old male child was referred to us with complaint of a right inguinal swelling and left flank swelling for last four months. We also noticed left UDT, which the parents failed to notice [Figure 1a]. The left flank swelling appeared like a spigelian hernia. On examination, both the swellings were reducible. However, on reducing the left swelling, the origin appeared to be at the deep inguinal ring. We were also able to feel testis like structure inside the flank swelling.

Figure 1

(a) It shows a right inguinal hernia and left flank bulge, suggestive of a spigelian hernia. There is left undescended testis (b) It shows the sac present in the subcutaneous space. The incision is in the lower inguinal crease (c) The testis is present inside the sac (d) Testis after full mobilization. The peritoneal sac is closed at the deep inguinal ring

After right herniotomy, we made an incision in left lower inguinal crease. After dividing the subcutaneous tissue, we noticed a sac like structure coming out through the deep ring and going towards anterior abdominal wall in the subcutaneous plane [Figure 1b]. After retrieving the sac, we mobilized it toward its origin at the deep ring. There was no other muscular defect anywhere.

When we opened the sac, the testis was present inside it. The testis was mobilized and separated carefully from the sac [Figure 1c]. The hernia sac was repaired carefully [Figure 1d], and the left orchiopexy was performed. Post-operative period was uneventful, and the patient was discharged in satisfactory condition.

The first look of the swelling is easily mistaken for a SH. Most of SHs occur in the lower abdomen where the posterior sheath is deficient.[3] SH is very rare in children, and only 59 pediatric cases have been reported up until 2012.[4]

SH has been found to be associated with UDT.[4] It has been suggested that SH is the primary defect and the undescended testis takes the path of least resistance to descend and lie in the hernial sac accounting for this association.[4] Besides this, absence of gubernaculum or UDT being the primary anomaly and secondarily causing the development of SH has also been suggested.[45]

In a SH, the fascial defect is in the muscle layer, which was not present in this patient. In SH, the sac lies in between the muscle layers and not the subcutaneous plane. The incision is made over the swelling. In our patient, the sac was in the subcutaneous space, and we made a lower inguinal crease incision to repair it. Besides the defect at the deep ring, there was no other muscular defect in our patient.

This abnormal presentation needs careful clinical evaluation and proper surgical management for good outcome. This can rightly be regarded as a new location of the ectopic testis.