ISSN: 2455-2283
Archives of Clinical Gastroenterology
Research Article       Open Access      Peer-Reviewed

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
*Corresponding author: Kevin Emeka Chukwubuike, Department of Surgery, Enugu State University Teaching Hospital, Enugu, Nigeria, E-mail: chukwubuikeonline@yahoo.com
Received: 24 March, 2021 | Accepted: 21 April, 2021 | Published: 22 April, 2021

Cite this as

Chukwubuike KE (2021) Incidence of appendices of the testis and epididymis in children who underwent groin/scrotal surgeries in a tertiary hospital in Enugu, Nigeria. Arch Clin Gastroenterol 7(1): 018-020. DOI: 10.17352/2455-2283.000092

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.

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 fluid in the space of the tunica vaginalis [3,6]. 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. The testes were examined during the surgery for the presence or absence of appendices of the testes and epididymis. Confirmation of the presence of appendices of the testes and epididymis was done intra-operatively, not by imaging investigation. Patients who have had groin/scrotal surgeries at a peripheral hospital before referral to ESUTH for reoperation were excluded from this study. ESUTH is a tertiary hospital located in Enugu, South East Nigeria. The hospital serves the whole of Enugu State, which according to the 2016 estimates of the National Population Commission and Nigerian National Bureau of Statistics, has a population of about 4 million people and a population density of 616.0/km2. The hospital also receives referrals from its neighboring states. Information about the patients was extracted from the case notes, operation notes, operation register and admission-discharge records. The information extracted included the age, presenting symptoms, clinical diagnosis, intra-operative finding (presence/absence of testicular appendage), definitive operative procedure performed, complications and outcome of treatment. Ethical approval was obtained from the ethics and research committee of ESUTH and informed consent was obtained from the patients’ caregivers. Statistical Package for Social Science (SPSS) version 21 (manufactured by IBM Corporation Chicago Illinois) was used for data entry and analysis. Data were expressed as percentages, median, mean, and range.

Research Article

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.

Presenting symptoms/clinical diagnosis

The presenting symptoms depended on the pathology the patient presented with. For instance, children with inguinal hernia/hydrocele presented with groin/scrotal swelling. Patient with testicular torsion had testicular pain. Two hundred and ninety patients (76.7%) underwent inguinal surgeries for inguinal hernia/hydrocele while 88 (23.3%) patients had scrotal explorations for testicular torsion.

Definitive operative procedure performed

Patients (76.7%) who had inguinal hernia/hydrocele received herniotomy. Those with testicular torsion were treated by orchidopexy (23.3%).

Complications of treatment

Three hundred and forty (89.9%) patients had no complications. Twenty (5.3%) patients had surgical site infection, 18 (4.8%) had stitch sinus and 2 (0.5%) had hypertrophied scar.

Outcome of treatment

All the patients achieved good recovery and were discharged home. There was no mortality.

Discussion

In 1761, Morgagni described a hydatid at the globus major of the epididymis and a small fimbria at the upper end of the testis. Following the translation of Morgagni’s work to English by Alexander in 1769, the 2 appendages were called “hydatids of Morgagni”. Generally speaking, four testicular appendages have been identified: the appendix testis (a remnant of the paramesonephric duct), the appendix epididymis (a remnant of the mesonephric duct), the paradidymis (organ of Giraldes) and the vas aberrans (organ of Haller). Morgagni made no distinction between epididymal appendix and a testicular appendix. He considered the appendix testis a ruptured hydatid [1].

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 finding 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 findings of Taqvi, et al. [10]. However, it is important to note that inguinal and scrotal surgeries may be performed at any age depending on the surgical indication and time of presentation. Herniotomy and scrotal explorations in children are performed as day case surgeries. However, in a background of associated comorbidities such as hemoglobinopathies, patients are admitted and observed closely in the hospital.

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.

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 fluid within the tunica vaginalis.

  1. Sahni D, Jit I, Joshi K, Sanjeev (1996) Incidence and structure of the appendices of the testis and epididymis. J Anat 189: 341-348. Link: https://bit.ly/3dA49HR
  2. Kernohan NM, Coutts AG, Best PV (1990) Cystadenocarcinoma of appendix testis. Histopathology 17: 147-154. Link: https://bit.ly/2Qop9IR
  3. Jacob M, Barteczko K (2005) Contribution to the origin and development of the appendices of the testis and epididymis in humans. Anat Embryo (Berl) 209: 287-302. Link: https://bit.ly/3ekJfMb
  4. Skoglund RW, McRoberts JW, Ragde H (1970) Torsion of the testicular appendages: presentation of 43 new cases and a collective review. J Urol 104: 598-600. Link: https://bit.ly/3sDRnwg
  5. Pomajzi AJ, Leslie SW (2021) Appendix Testis Torsion. In: StatPearls, Treasure Island (FL): StatPearls Publishing. Link: https://bit.ly/2QK6GWY
  6. Ivens U (1972) Morphology and function of the appendix testis. Andrologie 42: 245-258. Link: https://bit.ly/32BsRRU
  7. Miliaras D, Koutsoumis G, Vlahakis-Miliaras E (1995) Appendix testis and appendix epididymis-Incidental findings in inguinal hernia and cryptorchidism operations. Paediatric Surgery International 10: 241-242. Link: https://bit.ly/3n3RNLq
  8. Favorito LA, Cavalcante GL, Babinski MA (2004) Study on the incidence of testicular and epididymal appendages in patients with crytorchisism. Int braz J Urol 30: 49-52. Link: https://bit.ly/3v5AKLI
  9. Graf JL, Caty MG, Martin DJ, Glick PL (2002) Pediatric hernias. Semin Ultrasound CT MR 23: 197-200. Link: https://bit.ly/3ed80tu
  10. Taqvi SR, Akhtar J, Batool T, Tabassum R, Mirza F (2006) Complications of inguinal hernia surgery in children. J Coll Physicians Surg Pak 16: 532-535. Link: https://bit.ly/3v54QPu
  11. Marino MJ, Kimble RM (2018) Paediatric torsion of the paradidymis. J Paediatr Surg Case Rep 32: 82-84. Link: https://bit.ly/3enKPga
  12. Tostes GD, Costa SF, Carvalho JP, Costa WS, Sampaio FJ, et al. (2013) Structural analysis of testicular appendices in patients with cryptorchidism. Int Braz J Urol 39: 240-247. Link: https://bit.ly/3v6XStd
  13. Nazem M, Dastgerdi MM, Sirousfard M (2015) Outcomes of pediatric inguinal hernia repair with or without opening the external oblique muscle fascia. J Res Med Sci 20: 1172-1176. Link: https://bit.ly/3dDhAqQ
  14. Rakha E, Puls F, Saidul I, Furness P (2006) Torsion of the testicular appendix. Importance of associated acute inflammation. J Clin Pathol 59: 831-834. Link: https://bit.ly/3sEdC5t
  15. Gupta DK, Rohatgi M (1993) Inguinal hernia in children: an Indian experience. Pediatr Surg Int 8: 466-468. Link: https://bit.ly/3tFegAO
  16. Ibrahim M, Ladan MA, Abdussalam US, Getso KI, Mohammad MA, et al. (2016) Open inguinal herniotomy: Analysis of variations. Afr J Paediatr Surg 12: 131-136. Link: https://bit.ly/32vKVNk
  17. Vaze D, Samujh R, Narasimha Rao KL (2014) Risk of surgical site infection in paediatric herniotomies without any prophylactic antibiotics: A preliminary experience. Afr J Paediatr Surg 11: 158-161. Link: https://bit.ly/3v55sVi
  18. Dreuning K, Matt S, Twisk J, van Heum E, Derikx J (2019) Laparoscopic versus open pediatric inguinal hernia repair: state-of-the-art comparison and future perspectives from a meta-anaysis. Surg Endosc 33: 3177-3191. Link: https://bit.ly/2QKo8Lf
  19. Aihole JS (2020) The demographic profile and management of infantile inguinal hernia: a 3-year’s review. Afr J Urol 26: 28. Link: https://bit.ly/3gsSQmP
  20. Nilsson H, Stylianidis G, Haapamaki M, Nilsson E, Nordin P (2007) Mortality after groin hernia surgery. Ann Surg 245: 656-660. Link: https://bit.ly/32B6MCZ
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