Giant inguinoscrotal hernia presenting with acute renal failure: a case report and review of literature

Abstract

We present a case of a giant inguinoscrotal hernia. The patient presented with acute renal failure secondary to obstructive uropathy caused by a large inguinoscrotal hernia. It was treated by reduction of its contents through a right transverse abdominal incision below the arcuate line. The hernial sac contained loops of small bowel along with its mesentery, appendix, caecum and ascending colon. The defect was repaired using Marlex mesh.

Giant inguinoscrotal hernias are uncommon in the Western world because of the availability of early elective repair.¹ They are defined as ‘hernias that extend below the mid-point of the inner thigh in the standing position’.² As well as the usual complications of inguinoscrotal hernia, patients will encounter difficulty in walking, sitting or lying down, with restricted mobility. Patients will also often develop cutaneous complications such as eczema, candidiasis, and gangrene or ulcers. If the ureter or bladder are contained in the hernia’s sac, acute renal failure, acute urinary retention, recurrent urinary tract infections may also occur.^3,12

Caution in treatment has been advised because of anticipated complications following alterations in intra-abdominal and, therefore, intrathoracic pressures consequent to reduction of the hernia content.⁸

Case history

A 50-year-old man presented to the emergency department with acute renal failure secondary to obstructive uropathy. He was known to have a giant inguinoscrotal hernia for the past 4 years. He had problems with initiating micturition and passing small amounts of urine frequently in the previous 2 weeks. His swelling had already reached up to his knees. He had problem in walking but his bowel habits were normal. There was no history of emphysema, constipation or prostatism and he was generally in good health.

On examination, he had a large right-sided irreducible inguinoscrotal hernia (Fig. 1). Penis was buried within this hernia and his left testis was palpable but the right was not. A few dilated veins were present on the scrotum but the skin was not ulcerated.

Figure 1.

Large right-sided irreducible inguinoscrotal hernia.

On admission, his serum creatinine was 2127 μmol/l, urea was 56.6 mmol/l and potassium was 8.3 mmol/l. His blood pressure was recorded as 200/110 mmHg.

He was catheterised which drained a residual volume of urine of 3200 ml.

He was transferred to the intensive care unit for further management of his renal failure.

He was given 10 ml of 10% calcium gluconate, followed by 10 units of insulin in 50 ml of 50% dextrose over 20 min and 5 mg of salbutamol nebulising for treatment of his hyperkalaemia. His fluid balance was strictly managed as part of his renal failure treatment. He developed a postobstructive diuresis of 7 l in the first 24 h. He did not require dialysis while in ITU.

While in ITU, he developed fast atrial fibrillation and was started on Bisoprolol 10 mg orally, Digoxin 250 μg and aspirin 75 mg initially and subsequently cardioverted. His pre-operative renal function was normal with a urea of 6.1 mmol/l and creatinine of 108 μmol/l.

A computed tomography (CT) scan, which was performed during the admission without contrast due to poor renal function, revealed an extremely large right inguinal hernia which contained most of the small bowel loops, caecum and proximal ascending colon with the right testicle in the lower portion of the hernia (Fig. 2).

Figure 2.

Computed tomography scan showing an extremely large right inguinal hernia which contained most of the small bowel loops, caecum and proximal ascending colon with the right testicle in the lower portion of the hernia.

He was discharged after 9 days in hospital with a long-term catheter with a date to fix his hernia electively.

Management

Patient was operated in 6 weeks allowing time for his atrial fibrillation to settle. A right iliac fossa transverse incision below the arcuate line was made (Fig. 3). After developing the extraperitoneal plane, the peritoneum was opened and the hernial contents which consisted of small bowel, caecum and ascending colon reduced into abdomen (Fig. 4). A large (15 × x 15cm) Marlex mesh was cut to size and placed in pelvis to cover the wide defect (Fig. 5). Postoperatively, the patient developed a short spell of ileus followed by atrial fibrillation and was briefly kept under observation in ITU. He was discharged after 5 days in hospital.

Figure 3.

Operational approach – right iliac fossa transverse incision below the arcuate line.

Figure 4.

Operational approach – peritoneum opened and the hernial contents reduced into abdomen.

Figure 5.

Operational approach – Marlex mesh placed in pelvis to cover the wide defect.

Arrangements were made to have a future scrotoplasty to reduce the size of his stretched scrotum.

Discussion

Management of giant inguinal hernia has inherent challenges and meticulous planning in pre-operative preparation and postoperative monitoring is essential for its successful repair without respiratory compromise and recurrence.¹⁰

Giant groin hernia repair is basically re-introduction of herniated bowel into the abdominal cavity. The problems associated with this are 3-fold. First, the loss of domain within the abdominal cavity leads to difficulty in reduction of the contents. Diaphragmatic splinting decreases tidal volume and vital capacity and can cause respiratory compromise. Increased abdominal tension can lead to abdominal compartment syndrome and increases the risk of abdominal dehiscence. A colonic resection is sometimes required to allow closure of the abdominal wall. However, a stretched mesentery may lead to vascular deficit and impairing colonic vitality and anastomotic integrity.¹¹ Second, with a large hernial defect, the risk of recurrence is high. Lastly, the large residual scrotal skin might need excision for cosmetic reasons.

The methods described in the literature for the management of giant inguinoscrotal hernia are as follows. El Saadi et al.¹ described a two-stage operation with intestinal and omental resection, followed by Lichtenstein’s hernioplasty with scrotal reconstruction. This is appropriate in the emergency setting and in presence of infected scrotal skin ulcers. The other is pre-operative pneumoperitoneum described by Moreno in 1940.³ Staged pneumoperitoneum is obtained through a percutaneous catheter with 500–1500 ml air insufflated every 1–3 days for 2–3 weeks. The pre-operative induction of pneumoperitoneum allows adequate time for the patient to compensate for it and diminish intra-operative difficulty and postoperative morbidity.^4–6 This allows the abdominal wall to be stretched and create a larger cavity to accommodate the hernial contents. Mesenteric and omental swelling caused by chronic hernia are reduced. Stretching of the hernia sac causes elongation of adhesions, making dissection easier. Pre-operative respiratory and circulatory adjustment to the elevated position of the diaphragm occurs.

Component separation in the repair of a giant inguinoscrotal hernia is explained in a case of giant inguinal hernia by creating a mid-line anterior abdominal wall defect, covering both the hernial and the mid-line defect by Marlex mesh and then strengthening the mid-line mesh by a rotation flap of the inguinoscrotal skin, as described by Merret et al.⁷ Mehendale et al.⁸ have managed a giant inguinal hernia by debulking of contents by performing right hemicolectomy and small bowel resection and reconstruction of the abdominal wall using Marlex mesh and a tensor fascia lata flap. Preperitoneal mesh hernioplasty for such giant hernias has also been described.⁹

We performed a one-stage surgical procedure with anterior inguinal pre-peritoneal non-absorbable mesh repair.