A case of giant inguinal hernia with intestinal malrotation

Abstract

INTRODUCTION

Giant inguinal hernia is uncommon nowadays.

PRESENTATION OF CASE

A 75-year-old man with schizophrenia presented with complaints of episodic abdomen pain and constipation accompanied by a huge right scrotal mass. Physical examination revealed a large, irreducible, non-tender right inguinoscrotal hernia. The hernial mass was about 30 cm and extended to the midpoint of the inner thigh. At laparotomy, the intestine from the proximal transverse colon to the terminal ileum with mesentery was found to have herniated through the right inguinal tract without evidence of ischemia or strangulation. The ascending colon showed no adherence to the retroperitoneum and the third and fourth parts of the duodenum descended vertically without Treitz's ligament. The inguinal defect was closed without complications. Ladd's procedure and appendectomy were performed simultaneously.

DISCUSSION

Several techniques such as distending the abdominal wall progressively or debulking the abdominal contents have been reported. However, no consensus has been reached on a standard surgical procedure for the management of giant inguinoscrotal hernias.

CONCLUSION

This was the first reported case of giant inguinal hernia containing malrotated intestine.

Giant inguinal hernias are defined to extend below the midpoint of the inner thigh in the standing position¹ and are uncommonly encountered in modern surgical practice. However, they may still occasionally present after years of neglect. We present a case of giant inguinal hernia extending to the midpoint of the inner thigh containing malrotated bowel in the hernial sac.

1. Case report

A 75-year-old man with schizophrenia visited our emergency room complaining of episodic abdomen pain and constipation accompanied by huge right scrotal mass. His son reported that he had noticed the large scrotal mass 1 year previously and that it has been increasing in size since then. In fact, because during the previous 1 year he had been neglected by his family and had become socially isolated, this was the first time to visit hospital due to this problem. This development severely compromised his quality of life, prompting him to finally agree to visit hospital. Physical examination revealed a huge, irreducible, non-tender right inguinoscrotal hernia. The hernia mass was about 30 cm and extended to the midpoint of the inner thigh. There were no signs of cellulitis or ulceration of the scrotal skin. Computed tomography showed dislocation of the small bowel and ascending colon into the hernial sac (Fig. 1). At operation, because it was not possible to return the hernia contents back to the abdomen, the hernia was approached through a midline incision. Intestine from the proximal transverse colon to the terminal ileum with mesentery were delivered into the abdomen. There was no evidence of ischemia or strangulation of the intestine. Furthermore, the ascending colon showed no adherence to the retroperitoneum and the third and fourth parts of the duodenum descended vertically without Treitz's ligament. The inguinal defect was closed without complication. Ladd's procedure including appendectomy was performed simultaneously. It was possible to close the midline defect without undue tension and no resection of the bowel or any reconstructive procedure of the abdominal wall such as mesh was attempted. The patient's postoperative course was uneventful. He was extubated during the immediate postoperative period and did not require any post-operative mechanical ventilator support. He did not show the signs of scrotal hydrocele or seroma postoperatively. He was discharged on the third postoperative day without any complication. At a follow-up visit on the 10th postoperative day, the patient only complained of early satiety. At subsequent follow up 2 month later, the surgical wound had healed satisfactorily and the patient was otherwise well.

Fig. 1.

Preoperative computed tomography scan. This scan showed a 28 cm – sized right inguinal hernia with dislocation of the small bowel and ascending colon into the hernia sac.

2. Discussion

Giant inguinal hernias present are uncommon in developed countries. Generally, they are of a recurrent nature, and in addition to the classical complications of inguinal hernias, they pose problems that dramatically impair quality of life. The massive size of these hernias can interfere with walking and routine work.² In addition, the penis can be buried inside the scrotum causing urine to dribble over scrotal skin, already congested by lymphatic and venous edema, causing excoriation, ulceration, and secondary infection.³ These problems have considerable psychological impact and often lead to social isolation, which happened to our patient. In general, the problems associated with the management of giant inguinal hernias are threefold. First, the loss of domain within the abdominal cavity makes reduction of the contents difficult. Diaphragmatic splinting decreases tidal volume and vital capacity and can cause respiratory compromise, and postoperative increases in abdominal tension heighten the risk of abdominal dehiscence. Second, when a hernia is large, the risk of recurrence is high, and third, the large amount of residual scrotal skin might need excision for cosmetic reasons. For successful surgery and to overcome these problems, several techniques such as distending the abdominal wall progressively⁴ or debulking the abdominal contents³ have been reported. However, the success of these techniques has only been reported in single case reports or small case series and no consensus has been reached on a standard surgical procedure for the management of giant inguinoscrotal hernias. After herniated bowel reduction and closure of the inguinal defect, fortunately, my patient did not experience postoperative morbidity including respiratory distress. Thus, the management of giant inguinal hernia poses unique challenges and proper surgical management should be chosen after carefully considering the patient's condition.

Intestinal malrotation is a congenital anomaly that concerns either a lack of or incomplete rotation of the fetal intestines around the axis of the superior mesenteric artery during fetal development. Intestinal malrotation is a diagnosis usually made early in life.⁵ However, because most patients remain asymptomatic, the condition is never diagnosed.⁶ A survey⁷ of the English and German language literature from 1923 to 1992 revealed only 40 adults with symptomatic intestinal malrotation and no report of inguinal hernia with malrotation. One case report was found of incomplete fixation of the colon ascendens and an unusually located peritoneal fold together with a direct inguinal hernia.⁸ Although I did not identify abnormal peritoneal folds in my case, the unusually located peritoneal fold was interpreted as the result of fixation anomaly and a predisposing factor for the accompanying direct inguinal hernia.⁸ The peritoneal fold would be thought to contributing to the herniation of the intestine due to the medial inguinal fossa mechanically. Further study is needed to confirm the relationship between fixation anomaly and inguinal hernia.

This was the first reported case of giant inguinal hernia containing malrotated intestine.

Conflict of interest statement

None.

Funding

This research was supported by the Chung-Ang University Research Grants in 2010.

Ethical approval

I obtained written and signed consent to publish the case report from the patient.

Author contributions

As a 1st author and corresponding author, Seung Eun Lee contributed to all the parts of this article.