PMC5587904_01
Large right-sided scrotal enlargement secondary to indirect inguinal herniation of retroperitoneal fat, kidney, and ureter.
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Our patient is a 70-year-old, morbidly obese (body mass index 37) male with no prior abdominal/inguinal surgery or urinary complaint, who was begrudgingly referred to general surgery by his primary care physician after evaluation for a 15-year history of a bothersome, nonpainful, enlarging, right-sided scrotal swelling ~25 cm in diameter (Fig. 1).
CT imaging demonstrating right nephroptosis (yellow arrow) and right ureter within the scrotum (red arrow). Note large amount of retroperitoneal fat within the scrotum.
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Imaging identified right nephroptosis with a posteriorly rotated renal pelvis and a large right inguinal hernia with scrotal contents, including a long-looping, dilated right ureter (Fig. 2).
(A) Retrograde pyelogram demonstrating long-looping ureter with distal end within the inferior aspect of the scrotum. (B) Retrograde pyelogram demonstrating nephroptosis with renal pelvis adjacent to urinary bladder.
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Retrograde pyelogram redemonstrated a long-looping ureter with the inferior margin located at the base of the scrotum (Fig. 3A) and the renal pelvis adjacent to the bladder (Fig. 3B).
(A) Intracorporeal survey demonstrating no herniation of intraperitoneal structures. (B) Internal retraction of peritoneal flaps employing Hem-o-Lok clips. (C) Mesh placed over internal ring defect and retroperitonealized by closing peritoneal flap to reduce retroperitoneal fat.
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Visual inspection of the peritoneal cavity confirmed no intraperitoneal contents within the hernia confirming an extraperitoneal-type hernia (Fig. 4A). The peritoneal flaps were isolated from the surgical field by internal retraction accomplished with Hem-o-Lok clips (Fig. 4B). A ProGrip  self-fixating laparoscopic mesh (Medtronic, Minneapolis, MN) was trimmed to size and placed over the fascial defect (Fig. 4C).