Abstract
Objective
We present a case of small intestinal perforation within an inguinal hernia following low-energy indirect trauma.
Patient
A 55-year-old man with a known right inguinal hernia which had no prior indication for surgery developed acute right groin pain after sudden braking caused his scooter handlebar to strike his right thigh.
Results
Physical examination and computed tomography (CT) scan of the abdomen and pelvis revealed multiple pockets of extraluminal air within the hernia sac, as well as gas bubbles in the surrounding intestinal contents. Based on these findings, we made a diagnosis of small intestinal perforation within the inguinal hernia.
Conclusion
Small intestinal perforation within an inguinal hernia is an uncommon but potentially life-threatening complication requiring emergent surgical intervention. Delays in diagnosis and management can lead to peritonitis, abscess formation, sepsis, and prolonged hospitalization. Therefore, clinicians should maintain a high index of suspicion for intestinal perforation in patients with inguinal hernias, even in the absence of direct trauma or subsequent low-energy injuries.
Keywords: inguinal hernia, intestinal perforation, trauma, life-threatening complication
Introduction
Approximately 25–27% of men will develop an inguinal hernia during their lifetimes, with a higher prevalence observed in those over 45 years of age1). An estimated 1.6 million inguinal hernias are diagnosed annually, with approximately 700,000 surgically repaired cases1). Watchful waiting is considered an appropriate strategy when hernia-related pain or discomfort does not interfere with daily activities, and the hernia is easily reducible1). The most common complications of unrepaired hernias are intestinal incarceration and strangulation. Although rare, indirect blunt trauma to an unrepaired hernia sac can result in serious complications, often necessitating emergent surgical intervention. We report a case of small bowel perforation within an inguinal hernia secondary to low-energy indirect blunt trauma.
Patient and Method
A 55-year-old man with a known right indirect inguinal hernia previously managed conservatively without an absolute surgical indication presented with acute-onset right groin pain. The hernia had been minimally symptomatic and was observed for over five years. The pain began immediately after the patient’s scooter handlebar struck his right thigh after sudden braking while travelling at approximately 40 km/h (20 mph). Following the injury, the patient experienced progressively worsening pain and presented to our urgent care clinic 30 minutes later.
On presentation, the patient’s vital signs were as follows: a temperature of 36.9°C (98.4°F), blood pressure of 119/69 mmHg, heart rate of 75 beats per minute in normal sinus rhythm, and an oxygen saturation of 96% on room air. Physical examination revealed a dark red discoloration, warmth, and severe tenderness over the right inguinal hernia bulge. Abdominal and pelvic computed tomography (CT) scans revealed free extraluminal air adjacent to the small intestine within the right inguinal hernia sac. Furthermore, the surrounding intestinal contents and free air extended into the scrotum. These findings were consistent with a tear in the small bowel wall (Figure 1a–1d).
Figure 1.
Axial (a) and sagittal (b) non-contrast computed tomography (CT) images at the level of the hip joint show multiple pockets of extraluminal air within the hernia sac. Axial non-contrast CT images of the scrotum in panels (c) and (d) demonstrate multiple extraluminal air collections and surrounding intestinal contents with gas bubbles within the lumen of the small intestine located in the scrotum.
A diagnosis of traumatic small bowel perforation within an inguinal hernia was made. The patient was transferred for emergent surgical repair. A groin incision was made and the injured segment of the small intestine was resected with primary end-to-end anastomosis. The abdominal cavity and groin were thoroughly irrigated. A scrotal incision was also made and a drainage tube was placed from the scrotum to the inguinal region. Hernia repair was performed using the McVay procedure. The surgery was uneventful, with no complications or significant bleeding. Due to peritoneal cavity contamination secondary to intestinal perforation, systemic antibiotics were initiated for presumed peritonitis. A CT-guided drainage procedure was subsequently performed for a pelvic floor abscess, followed by daily irrigation via a scrotal incision. Following the surgery, the patient developed paralytic ileus with associated nausea. Oral intake was temporarily restricted to water. However, as his symptoms gradually resolved, oral intake was reintroduced after a few days. The patient recovered without sequelae and was discharged 31 days after admission.
Discussion
Small bowel perforation within an inguinal hernia has been reported as an uncommon but serious complication of blunt trauma to the hernia2). This phenomenon was first described in 1814 by the Italian anatomist Antonio Scarpa, who reported a case of small bowel rupture within an inguinal hernia after a minor blunt abdominal trauma2). Bowel perforation within an inguinal hernia sac is reported to occur more frequently in patients older than 40 years of age, particularly in those with right-sided inguinal hernias2), as observed in our case. Only a few cases of small bowel perforation resulting from low-impact trauma to an inguinal hernia have been documented. These include injuries caused by a fall while walking a dog and the impact of a soccer ball colliding with the right groin3, 4).
These limited data suggest two possible mechanisms for small bowel perforation within an inguinal hernia. First, increased intra-abdominal pressure may lead to a concomitant increase in intraluminal pressure, potentially resulting in a blowout rupture. Traumatic events can cause an abrupt elevation of intra-abdominal pressure within the hernia sac, which is subjected to a higher pressure gradient due to its confined space2). In such scenarios, pressures have been estimated to exceed the 150–260 mmHg threshold required to perforate the small intestine in experimental models2). Second, shearing forces may develop between the bowel within the hernia and its mesenteric attachment, leading to the stretching and subsequent tearing of the bowel wall2). In cases of an incarcerated hernia, pathological changes such as inflammation and edema of the herniated intestine can weaken the bowel wall. This makes it susceptible to rupture from minor trauma or even nontraumatic events5). Our case featured no direct trauma to the inguinal hernia. Instead, the patient’s sudden braking and emergency stop likely induced generalized muscle tension and increased the intra-abdominal pressure, which was potentially exacerbated by the impact of the scooter handlebar against his right thigh. This sequence of events may have resulted in an acute increase in the intraluminal pressure within the hernia sac, ultimately leading to small bowel perforation.
Emergent surgical intervention is typically indicated for small bowel perforation within an inguinal hernia. The clinical course is often characterized by peritonitis, abscess formation, and sepsis, leading to prolonged hospitalization. Due to contamination of the abdominal cavity with intestinal contents, thorough local irrigation and systemic antibiotic therapy are generally required2).
Conclusion
Although uncommon, perforation of intestinal structures within an inguinal hernia should remain a diagnostic consideration. Small bowel perforation has been reported after direct high-energy trauma as well as relatively indirect low-impact injuries. Importantly, clinicians should recognize that ruptures can occur without direct trauma to the hernia sac. Early detection through imaging is crucial because this rare complication can lead to serious outcomes and often necessitates prolonged hospitalization.
Conflict of interest
None declared.
Funding information
None declared.
Ethics approval and consent to participate
We obtained consent from the patient for the publication of this report, including the images.
Consent for publication
All the authors read the manuscript and gave their final approval before submission.
Author contributions
Yuki Ohnishi and Jun Ebiko acquired the clinical data and imaging and were responsible for patient care. Yuki Ohnishi drafted the manuscript. Hiroyuki Otsuka was responsible for editing the manuscript. Yasuhiro Suyama served as the scientific advisor.
Acknowledgments
The authors would like to express our gratitude to the surgeons for the management of the patient.
References
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