Incidence of appendices of the testis and epididymis in children who underwent groin/scrotal surgeries in a tertiary hospital in Enugu, Nigeria

Background: Appendices of the testis and epididymis are small congenital structures attached to the testis and epididymis respectively. The aim of this study was to assess the incidence of appendices of the testes and epididymis in children who had inguinal and scrotal surgeries. Materials and methods: This was a retrospective study of children aged 15 years and younger who underwent groin/scrotal surgeries between January 2015 and December 2019 at the pediatric surgery unit of Enugu State University Teaching Hospital Enugu (ESUTH), Nigeria. During the surgery, the presence or absence of appendices of testis and epididymis were assessed. Results: A total of 521 inguinal/scrotal surgeries were performed during the study period but only 378 patients had appendices of the testis and epididymis: This gives an incidence of 72.6%. Infants were mostly affected and the right testis had more appendices. There were more inguinal hernia/hydrocele and herniotomy was the most performed surgical procedure. Surgical site infection was the most common post-operative complication but there was no mortality. Conclusion: Appendices of the testes and epididymis although may be small and vestigial in children, it is quite common in children. Research Article Incidence of appendices of the testis and epididymis in children who underwent groin/scrotal surgeries in a tertiary hospital in Enugu, Nigeria Kevin Emeka Chukwubuike* Pediatric Surgery Unit, Department of Surgery, Enugu State University Teaching Hospital, Enugu, Nigeria Received: 24 March, 2021 Accepted: 21 April, 2021 Published: 22 April, 2021 *Corresponding author: Kevin Emeka Chukwubuike, Department of Surgery, Enugu State University Teaching Hospital, Enugu, Nigeria, E-mail: https://www.peertechzpublications.com


Introduction
In the past, little attention was paid to the appendices of the testes and epididymis due to their small and vestigial nature. However, in recent years, pediatric surgeons and urologists have shown considerable interest in appendices of the testes and epididymis due to their involvement in torsion (acute scrotum) [1]. Cystadenocarcinoma of the testicular appendage has also been reported [2]. The appendix of the testis is a small pedunculated/sessile globular structure located at the upper pole of the testes just below the head of the epididymis and is considered to be remnant of the cephalic end of the paramesonephric duct. The epididymal appendix is located on the head of the epididymis and represents the cranial blind end of the mesonephric duct [3]. The appendix testis is particularly susceptible to torsion because it is often pedunculated. The appendix testis accounts for 95% of cases of torsion of appendices of the testes and epididymis [4]. Although uncommon, multiple testicular and epididymal appendices can occur; this could be bilateral or unilateral. There is a report of a 14-year old male who had 2 torsions from 2 pedunculated testicular appendices [5]. Histologically, the normal appendix testis is made of loose gelatinous vascular connective tissue stroma covered by mullerian-type cuboidal to columnar epithelium. The testicular appendage may be responsible for controlling testicular descent and the amount of serous fl uid

Patients' demographics
A total of 521 inguinal/scrotal surgeries were performed during the study period but only 378 patients had appendices of the testis and epididymis: This gives an incidence of 72.6%.
Details are depicted in Table 1.

Appendices of the testis and epididymis (Side and types)
Two hundred and twenty-six (59.8%) appendices were found on the right side while 152 (40.2%) appendices were found on the left side. Three hundred and forty four (91%) patients had appendix testis and 34 (9%) patients had appendix epididymis. None of the appendices was multiple in a single patient.

Outcome of treatment
All the patients achieved good recovery and were discharged home. There was no mortality. In the present study, the incidence of appendices of the testes and epididymis is comparable to the result of Sahni, et al. [1]. However, this fi nding is at variance to the reports of Miliaras, et al. [7]. The occurrence of testicular and epididymal appendages is quite variable and may depend on the setting of assessment [8]. Most of the patients in the current study were infants. The high number of infants may be due to higher incidence of hernias/hydroceles in infants [9]. The age range of our patients is similar to the fi ndings of Taqvi, et al. [10].  There were more right sided appendices of the testis and epididymis in the index study. This is consistent with the report of other authors [11,12]. Howbeit, Rakha, et al. reported more appendices on the left side [13]. The exact reason for the right or left predominance is not known.

Discussion
Hernias, hydroceles and testicular torsions were the indications for inguinal and scrotal surgeries in the current study. Inguinal hernia is one of the most common conditions in children and is a frequent reason for surgical intervention [14].
Scrotal exploration for testicular torsion offered opportunity for examination of the testes for the presence of the appendices of the testes and epididymis.
Herniotomy was the predominantly performed surgical procedure in the current series. It is one of the most frequent operations performed in pediatric surgery practice [15]. The testes were assessed for appendices of the testis and epididymis during the herniotomy. Ibrahim, et al. also documented herniotomy as the most common surgical procedure [16].
Surgical site infection was the most common post-operative complication in our patients. Other studies also found surgical site infection as a common complication of inguinal hernia repair in children [16,17]. Dreuning, et al. reported stitch sinus and abnormal scar following inguinal hernia repair in children [18]. Other series also did not record any mortality [16,19]. However, Nilsson et al reported a seven fold increase in mortality risk in emergency groin hernia surgery [20].

Conclusion
Appendices of the testes and epididymis although may be small and vestigial in children, it is quite common in children.
They may play a role in testicular descent and in determining the quantity of serous fl uid within the tunica vaginalis.