Giant inguinal hernia: Report of a case and reviews of surgical techniques

Giant inguinal hernia with mal-rotation in a resource-limited area: Case report

INTRODUCTION

Giant inguinoscrotal hernias (GIH), defined as hernias extending below the inner thigh midpoint in a standing position, are rare and often seen in resource-limited settings due to delayed medical care. These hernias pose surgical challenges, particularly in low- and middle-income countries (LMICs), where standardized management protocols are lacking, and risks such as cardiorespiratory compromise are significant.

CASE PRESENTATION

A 55-year-old male presented with a large, irreducible right inguinoscrotal hernia of 1.5 years duration. Elective surgery involved sac separation and laparotomy, revealing herniation of bowel segments, including the terminal ileum and sigmoid colon, with concurrent intestinal malrotation. Ladd's procedure, appendectomy, and hernia repair were performed without complications. Postoperative recovery was uneventful, with the patient remaining asymptomatic during follow-up.

DISCUSSION

GIH management depends on hernia classification. While Type I hernias require simpler repairs, Types II and III often necessitate advanced techniques, such as Preoperative Progressive Pneumoperitoneum or bowel resection, to prevent abdominal compartment syndrome (ACS). Anatomical anomalies, such as malrotation, complicate surgical planning. Successful outcomes rely on individualized, resource-appropriate strategies and meticulous care, especially in LMICs.

CONCLUSION

GIH presents unique challenges, particularly in resource-constrained settings. Tailored approaches, informed by classification and patient-specific factors, are essential. This case underscores the importance of innovative strategies, careful planning, and standardized protocols to improve outcomes for GIH patients globally.

Management strategy of giant inguinoscrotal hernia-a case series of 24 consecutive patients surgically treated over 17 years period

PURPOSE

Management of giant inguinoscrotal hernia (GIH) is still a challenging procedure associated with a higher risk of intraabdominal hypertension and abdominal compartment syndrome as a life-threatening condition. The aim of the study was to present our management strategy for GIH.

METHODS

This is a retrospective review of a case series including 24 consecutive patients with 25 GIH who underwent reconstructive surgery from January 2006 to June 2023, at the University Clinic for Digestive Surgery and Hernia Center Zuvela. A combined surgical strategy was applied: the modified Rives repair for groin hernias alone, Rives combined with organ resection to reduce hernia contents, and Rives combined with procedures for abdominal cavity enlargement. A surgical approach was defined based on the patient's general health, the volume of the hernia sac, and perioperative parameters.

RESULTS

All patients were male aged between 43 and 82 years. Rives was the only procedure in 12 patients. In addition to Rives, omentectomy was performed in four patients and intestinal resection in one. Abdominal cavity enlargement was performed following Rives hernioplasty in 9 patients. The median operative time was 215 min (range, 70-720). Surgical complications occurred in seven patients. In-hospital mortality was 12.5%. There was no groin hernia recurrence.

CONCLUSION

Our strategy is a single-stage treatment including modified Rives repair with or without additional procedures for abdominal cavity enlargement or hernia volume reduction, tailored to the individual patient characteristics. The procedure is associated with a higher risk of major morbidity requiring a well-trained intensive care unit team.

Lichtenstein repair for giant inguinoscrotal hernia: a retrospective case-control study

PURPOSE

Giant inguinoscrotal hernia (GISH) is a rare condition in high-income regions, and the management presents a significant challenge for surgeons. A retrospective analysis was conducted of a single center's experience in treating GISH by Lichtenstein approach. The objective was to gain insight into the characteristics of GISH and assess the clinical efficacy of the Lichtenstein approach, as well as the degree of improvement in patient quality of life (QoL).

METHODS

Data from consecutive GISH patients who had undergone Lichtenstein repair at our institution from December 2018 to December 2023 were prospectively collected. The control group for the 1:2 matched case-control study was selected from pure inguinal hernia patients who underwent Lichtenstein repair during the same period. The demographics and surgical characteristics were analyzed. QoL and surgical satisfaction were respectively evaluated using the Carolina Comfort Scale and Numerical Rating Scale.

RESULTS

A total of 51 patients with GISH who underwent Lichtenstein repair were identified, and 102 patients with a pure inguinal hernia who underwent Lichtenstein repair were included in the control group. Patients in the GISH group exhibited a higher BMI than those in the control group; they also had a significantly longer hernia duration and a higher incidence of irreducible bulge. Additionally, the GISH patients had significantly higher ASA scores. All the Lichtenstein procedures were uneventful. There were more additional surgical procedures in GISH group, including hernia sac resection in 50 patients (98%) and adhesion release in 23 patients (45.1%). Five patients with GISH underwent omentectomy and one patient underwent testicular resection due to severe adhesions. The GISH group exhibited a higher incidence of postoperative complications. Five patients experienced urinary retention, and one intestinal obstruction. Two patients underwent surgical drainage under local anesthesia at one month postoperatively and made a full recovery. At six months postoperatively, the mean CCS score for the patients was 0.5 ± 0.8, with 21 patients (20.6%) scoring ≥ 2 out of the 23 categories. The results of the surgical satisfaction survey indicated that 130 patients (85.0%) gave a score of 5, reflecting high levels of satisfaction after Lichtenstein hernioplasty.

CONCLUSION

Patients with GISH typically have a long medical history, a high proportion of irreducible masses, and severe comorbidities, making surgery challenging. However, Lichtenstein repair remains a feasible and safe with high patient satisfaction and improved postoperative quality of life.

Giant (complex) inguinal hernia in female patient left untreated for 40 years: a case report

A giant inguinal hernia is a rare clinical presentation in patients refusing hernia repair for different reasons during a long period. The appearance is remarkable, and the preoperative preparation and the surgery itself might be challenging. They can present in an emergency (hernia incarceration) or elective setting. Most of the patients are male, but exclusions exist. This is a rare case of a female patient with a giant inguinal hernia left untreated for 40 years.

Giant Inguino-Scrotal Hernia With Loss of Domain: Surgical Report and Literature Review

The surgical repair of giant inguinal hernias with loss of domain, defined as the relocation of the majority of the intestine into the hernia sac, poses a significant challenge. In the majority of cases, a combination of different surgical techniques with the placement of multiple meshes is necessary to achieve reduction of such complex hernias. The reduction of chronic giant hernias can increase the risk of abdominal compartment syndrome or cardiopulmonary complications. This case study presents a rare and complex case of a patient with a chronic giant inguinal hernia, in which almost the entire intestine was herniated, involving the scrotum and reaching mid thigh. The reduction of the hernia was achieved by a combined open transabdominal and inguinal approach, utilizing the abdominal component separation technique and multiple preperitoneal mesh placements. This multimodal approach resulted in optimal outcomes in terms of cosmesis, functionality, and abdominal wall integrity.

A Unique Case of Perforated Appendicitis in a Giant Incarcerated Right-Sided Inguinal Hernia: Challenges and Surgical Management

BACKGROUND Amyand hernia is a rare condition described as the presence of the appendix within an inguinal hernia. The clinical presentation of can be atypical, depending on the length of the defect's history and the size of the hernia. As inguinal hernia repair is considered a routine surgical procedure, giant hernias are mostly encountered in countries with limited medical care or with patient rejection of surgical management. CASE REPORT We report a case of a 56-year-old patient with a history of a chronic giant inguinal-scrotal hernia for more than 10 years who presented himself to the Emergency Department with acute pain in the scrotum and fever. Computed tomography revealed a perforated appendicitis located in the inferior part of the scrotum. The patient underwent a surgical procedure with an inguinal and middle laparotomy approach, revealing a full incarceration of the right and traverse colon, terminal ileal loop, and omentum, along with evidence of a perforated appendicitis. Standard appendectomy and direct hernia repair were successfully performed. CONCLUSIONS To the best of our knowledge, this is the first case of a perforated appendicitis within a right giant inguinal hernia described in the modern English-language literature. Rare in our daily practice, giant hernias are a real challenge regarding their surgical management during and after surgery, making this case with a perforated appendicitis even more arduous.

Giant inguinal hernia repair using standard transverse inguinal incision with mesh. A retrospective case control study

BACKGROUND

Giant inguinal hernia (GIH) is a rare condition in the developed world, and the literature is scarce. Case reports describe different techniques in an attempt to prevent abdominal compartment syndrome (ACS). We aimed to review our experience with GIH repair.

METHOD

A retrospective review of the medical records of all consecutive patients who underwent a tension-free mesh GIH repair using a transverse inguinal incision between 2014 and 2021 at a tertiary university referral center. In brief, the technique included head-down positioning, maximal pre-incision reduction of hernia contents, and repair with mesh. Follow-up was conducted in outpatient clinic. We compared the results to a time-based open standard inguinal hernia repair group (control group).

RESULTS

During the study period, 58 patients underwent an open GIH repair with mesh without abdominal preparation. 232 patients were included in the control group. The mean surgery duration was 125.5 min in the GIH group and 84 min in the control group (p < 0.001). Bowel resection was not necessary in any case. In-hospital complication rates were 13.8% vs. 5.6% in the GIH and control groups, respectively (p = 0.045). Early complication rates (up to 30 days post-operatively) were 62.1% vs. 14.7% in the GIH and control groups, respectively (p < 0.001). Late complications rate was similar (p = 0.476). ACS and mortality were not reported. No recurrence event was reported in the GIH group.

CONCLUSION

Tension-free mesh repair for GIH using a standard transverse inguinal incision is feasible and safe and there is no need for abdominal cavity preparation. Early complications are more common than in the control group, but there were no higher rate of late or severe complications and no recurrence event.

Systematic Review and Guidelines for Management of Scrotal Inguinal Hernias

Introduction: Of the more than 20 million patients undergoing groin hernia repair annually worldwide, 6% are scrotal hernias in high resource countries rising to 67% in low resource countries which represents a heavy disease burden on relatively young men during their most productive period of life. There are many open questions concerning management of scrotal hernia. These guidelines aim to improve the care for scrotal hernia patients by reducing recurrence rates, chronic pain and infection. Methods: After developing 19 key questions a systematic literature review was performed till 31 March 2021 for all relevant publications with search terms related to Scrotal Hernia. The articles were scored by all co-authors according to Oxford, SIGN and Grade methodologies. Statements and recommendations were formulated. Online Consensus meetings with 25 HerniaSurge members were organised with voting and grading Recommendations as "strong" (recommendations) or "weak" (suggestions) and by consensus, in some cases upgraded. Results: Only 23 articles (two level 2 registry and 21 level 3-5) were selected. It is proposed to define scrotal hernia as an inguinal hernia which has descended into and causes any scrotal distortion. A new classification for scrotal hernias was proposed based on hernia size, SI for upper third thigh, SII for middle thigh and SIII for lower third thigh or below. Irreducibility is denoted with IR. Despite weak evidence antibiotic prophylaxis is recommended. Urinary catheterization is recommended (upgraded) in complex cases (S2-3) due to prolonged operative time. Scrotal hernia repairs have higher associated morbidity and mortality compared to non-complex groin hernia repairs irrespective of surgical experience. Open anterior (mesh) approach is commonest technique and suture techniques in low resource countries. For minimally invasive approaches, TAPP resulted in less conversion to open approach compared to TEP. Conclusion: Although the evidence is scarce and often low quality scrotal hernia management guidelines aim to lead to better surgical outcomes irrespective of where patients live. This necessarily means a more tailored approach based on available resources and appropriate skills. The guidelines provide an impetus for future research where adoption of proposed classification will enable more meaningful comparison of different techniques for different hernia sizes.

Metastatic colon adenocarcinoma presenting as a giant inguinal hernia: A case report

INTRODUCTION AND IMPORTANCE

Giant inguinoscrotal hernias (GIH) are a rare form of inguinal hernia. There have been few reported cases of GIH containing colon adenocarcinoma.

CASE PRESENTATION

This case describes a 72-year-old male with a right GIH containing the right colon, terminal ileum, and associated mesentery with a large heterogenous, irregular mass with necrosis involving the cecum and ascending colon measuring 14 × 8 × 9 cm. The patient initially presented with pain and evidence of partial large bowel obstruction. Due to suspected extensive local invasion of tumor, the patient was scheduled for evaluation for possible neoadjuvant chemotherapy. Unfortunately, the patient re-presented with a large bowel obstruction and was subsequently taken for an exploratory laparotomy with trans-scrotal incision for en bloc resection of cecal adenocarcinoma and involved hernia contents.

CLINICAL DISCUSSION

Due to the rarity of this pathology, there is not a standard approach to management or optimal surgical technique described. In this case, a trans-scrotal incision paired with an exploratory laparotomy allowed for superior access to the adhered cancer containing bowel as well as skin excision, following standard oncologic principle of high ileocolic mesenteric excision.

CONCLUSION

The complexity of management of GIH containing colon cancer has been documented, however a standard oncologic approach has not been described. This case report presents exploratory laparotomy with trans-scrotal incision as an approach.

Orchiectomy due to delayed severe scrotal hematocele after laparoscopic transabdominal preperitoneal repair for a giant inguinoscrotal hernia: a case report

BACKGROUND

A giant inguinoscrotal hernia is a rare inguinal hernia that extends below the midpoint of the inner thigh while standing. Although reports of laparoscopic surgery for giant inguinoscrotal hernias have increased, the risk of delayed hematocele has not yet been clarified.

CASE PRESENTATION

A 68-year-old man was evaluated for a left giant inguinoscrotal hernia, and laparoscopic transabdominal preperitoneal repair (TAPP) was performed. In the procedure, the distal hernia sac was not resected. The postoperative course was uneventful for 3 months postsurgery, after which he complained of giant scrotal swelling, which gradually grew to 13 cm. It did not improve with several punctures and caused dysuria because of increased pressure on the urethra. Thus, reoperation was performed 9 months after surgery. The hematocele consisted of a thickened hernia sac, which was tightly adhered to the spermatic cord and testicle. The hernia sac including the hematocele was removed from the scrotum through an anterior approach, preserving the spermatic cord and testicle. On the third postoperative day, an orchiectomy was performed due to poor testicular perfusion caused by spermatic cord injury. There was no hematocele or hernia at the 3-year follow-up. The remnant sac after laparoscopic TAPP for a giant inguinoscrotal hernia possibly caused refractory hematocele. Additionally, the removal of the hernia sac, including hematocele, from the spermatic cord and testicle has a risk of inducing injury, leading to orchiectomy.

CONCLUSION

Surgeons should be aware of the possibility of delayed refractory hematoceles after laparoscopic TAPP for giant inguinoscrotal hernias when the hernia sac is not resected.

Retrospective analysis of open preperitoneal mesh repair of complex inguinal hernias

PURPOSE

The open posterior approach in the form of either a Stoppa or Wantz operation may be a good alternative technique particularly in the repair of complex inguinal hernias. The term "complex inguinal hernia" designates hernias with a combination of arduous features including large hernia defects, large to giant hernia sacs, multiple recurrences, and bilaterality. In this retrospective analysis, we investigated our results of open posterior repair in view of its feasibility in patients with complex inguinoscrotal hernias.

METHODS

From a series of 845 inguinal hernia patients, we retrospectively reviewed the records of 60 patients with complex inguinal hernias whom were directed to open preperitoneal repair by either a Stoppa or Wantz procedure.

RESULTS

More than 80% of cases were males with large to giant inguinoscrotal hernias. One half of patients had bilateral hernias, and one fourth had recurrent hernias. Early postoperative complications occurred in almost half of patients; however, most of them were minor. The most important early complication in this series was the full recurrences we encountered in the very next morning in two patients. Eighty-three percent of patients left hospital in the first 2 days averaging 1.8 days of hospital stay. The mesh:defect area ratio is < 7 in recurrent hernias while it is > 9 in nonrecurrent cases.

CONCLUSION

The open posterior approach to complex inguinal hernias facilitated both handling and repair of difficult hernias. It was very well tolerated by the patients, and yielded favorable postoperative results. We think the open posterior repair may be a method of choice in the repair of complex inguinal hernias.

Giant lumbar incisional hernia with loss of domain

Giant lumbar hernia, with loss of domain, is a complex scenario to treat. Abdominal compartment syndrome is a dreaded post-operative complication. This can gravely impair the patient's respiratory function and also cause insufficient perfusion of the viscera. Pre-operative progressive pneumoperitoneum can facilitate bowel repositioning and can reduce impairment of the post-surgery lung function, essential for a favourable post-operative outcome. Here, we describe the treatment of a case of giant lumbar incisional hernia by the creation of progressive pneumoperitoneum and hybrid repair of incisional hernia with left posterior component separation and placement of giant prosthetic reinforcement of the defect.

Bilateral giant inguinoscrotal hernia: A case report

Introduction

Bilateral giant inguinoscrotal hernia (GIH) is rare and creates significant challenge in surgical management. The main concern of hernia reduction to abdominal cavity is development of abdominal compartment syndrome (ACS). Different approaches for prevention of ACS after surgery have been suggested.

Case presentation

We report a case of 68-year-old male with bilateral inguinoscrotal hernia for 20 years reaching just below midpoint of thigh. He presented with difficulty in micturition and mobility. Preoperative investigations were normal. He underwent bilateral mesh repair without any preoperative or intraoperative adjunct measures. No significant complication occurred in postoperative period.

Case discussion

Bilateral GIH is rare and the patients usually present late. GIH has been classified into three types on the basis of extension. Type I GIH can be managed with simple hernioplasty, in both unilateral and bilateral cases. Measures like resection of hernia contents and measures to enlarge intraabdominal space are warranted in type II and III GIH. Abdominal volume can be increased by utilising techniques like Pre-operative Progressive Pneumoperitoneum (PPP), injection of Botulinum toxin A (BTA) in the anterior abdominal wall, and rotation of viable tissue. The measures can be used either alone or in combination.

Conclusion

Type I GIH can be treated with simple hernioplasty with safety with monitoring for features of ACS and respiratory complications postoperatively. However, additional measures like resection of hernia contents or procedures to enlarge intra-abdominal space are warranted for type II and III GIH.

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Surgical management of bilateral giant inguinoscrotal hernia is challenging as reduction of hernia contents to abdominal cavity may lead to development of abdominal compartment syndrome (ACS) and cardiorespiratory complications.

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We report a case of bilateral GIH managed with bilateral mesh repair with postoperative monitoring for features of ACS and cardiorespiratory complications.

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There was no significant complication in the postoperative period and no recurrence in six month follow-up period.

Giant sliding inguinal hernia requiring intraoperative aspiration of fluid: a case report and literature review

Giant inguinal hernias are defined as inguinal hernias that extend below the midpoint of the inner thigh when the patient is in the standing position or an anteroposterior diameter of at least 30 cm or a laterolateral diameter of ~50 cm with non-reducibility for >10 years. This article presents a 39-year-old male with a five-year history of a giant left inguinal hernia that was treated with left inguinal hernia repair with mesh, orchiectomy, complicated scrotoplasty, intraoperative ultrasound and aspiration of 3.9 L of fluid from the hernia sac. Surgical repair of giant inguinal hernias can be challenging and is associated with a variety of complications. Various modalities have been described to assist in hernia reduction including debulking, or, as in this case, aspiration of the hernia sac and a preperitoneal incision. Although the Lichtenstein tension free repair is commonly used, no standard approach has been accepted.

Joint venture surgery of a giant inguinoscrotal hernia in a patient suffering from trisomy 21 and Eisenmenger's syndrome

A 44-year-old man with Trisomy 21 and Eisenmenger's syndrome underwent surgery due to a life-threatening scrotal hernia, containing the bladder, bilateral hydroceles and part of the sigmoid colon. Joint venture plastic and urologic surgery was performed with reposition of the bladder and sigmoid colon into the abdominal cavity, bilateral inguinal hernial mesh repair, left sided orchiectomy, excision of bilateral hydroceles and excision of a major part of the scrotum and recreation of the original anatomy of the penis and scrotum. This Case presents a successful outcome achieved as the patient after one-step-surgery was left to normal condition.

Review with video of a laparoscopic transabdominal preperitoneal (TAPP) repair for giant inguinoscrotal hernia

BACKGROUND

Giant inguinoscrotal (GIS) hernias are rarely encountered in clinical settings and are often associated with mental neglect for many years. This type of hernia is defined as "giant" if it descends below the mid-point of the inner thigh of a patient in an upright position. The laparoscopic repair approach of a GIS hernia is technically challenging. It has been claimed that laparoscopic surgery has several advantages over the open surgical approach, with less pain and an earlier recovery. The aim of this video is to evaluate the efficacy of TAPP (laparoscopic transabdominal preperitoneal) in order to treat a GIS hernia.

CASE PRESENTATION

A 65-year-old male without a relevant past medical history was admitted to the emergency service with abdominal pain, belching and nausea. He denied any other symptoms, and no previous surgical operations were recorded. Physical examination showed a large mass in the left scrotum below the mid-point of the inner thigh of the patient in an upright position. A CT scan confirmed the diagnosis of a GIS. A laparoscopic TAPP procedure was decided upon as the best course of treatment.

RESULTS

The patient underwent a successful repair procedure. The operation time was 150 min. No intraoperative blood transfusion was necessary. The patient's diet was resumed on the first day post surgery, and the postoperative hospital stay was three days.

CONCLUSIONS

Laparoscopic TAPP repair is a safe and feasible method for surgically managing GIS hernias.

PRIMARY ABANDON-OF-THE-SAC (PAS) TECHNIQUE: PRELIMINARY RESULTS OF A NOVEL MINIMALLY INVASIVE APPROACH FOR INGUINOSCROTAL HERNIA REPAIR

BACKGROUND

Laparoscopic best approach of repairing inguinoscrotal hernias are still debatable. Incorrect handling of the distal sac can possibly result in damage to cord structures and negative postoperative outcomes as ischemic orquitis or inguinal neuralgia.

AIM

To describe a new technique for a minimally invasive approach to inguinoscrotal hernias and to analyze the preliminary results of patients undergoing the procedure.

METHODS

A review of a prospectively maintained database was conducted in patients who underwent minimally invasive repair using the "primary abandon-of-the-sac" (PAS) technique for inguinoscrotal hernias. Patient´s demographics, as well as intraoperative variables and postoperative outcomes were also analyzed.

RESULTS

Twenty-six male were submitted to this modified procedure. Mean age of the case series was 53.8 years (range 34-77) and body mass index was 26.8 kg/m2 (range 20.8-34.2). There were no intraoperative complications or conversion. Average length of stay was one day. No surgical site infections, pseudo hydrocele or neuralgia were reported after the procedure and two patients presented seroma. No inguinal hernia recurrence was verified during the mean 21.4 months of follow up.

CONCLUSION

The described technique is safe, feasible and reproducible, with good postoperative results.

Laparoscopic Transabdominal Preperitoneal Approach with Negative Pressure Drainage for Giant Inguinal Hernia

Background: Giant inguinal hernia (GIH) is a rare disease but it can cause serious complications, such as intestinal obstruction and strangulation. Few studies have explored surgical treatment with respect to the transabdominal preperitoneal (TAPP) approach or measures to reduce the occurrence of postoperative seroma. Purpose: To investigate the safety and efficacy of the TAPP approach with negative pressure drainage in GIHs. Methods: From January 2017 to December 2019, 32 patients who underwent TAPP procedures with negative pressure drainage for GIHs at our hospital were reviewed. Demographic information, surgical characteristics, and follow-up data were obtained. Results: The mean age of the patients was 66, and more than half of them had medical comorbidities. All GIHs were defined as Type 1 and were successfully repaired through the TAPP approach with negative pressure drainage. The mean operative time was 146 minutes (range 122-251). After surgery, the mean drainage time was 7 days (range 5-10 days), and the mean volume of drainage in each patient was 820 mL (range 655-1020 mL). Complications occurred in 3 cases. For 1 case, the inferior epigastric artery was injured during surgery. A seroma was observed in 1 patient, which occurred 2 days after removal of the drainage tube. Finally, 1 patient developed an umbilical puncture site infection, and the wound healed after changing the dressing. The mean follow-up was 13 months (range 1-32), and there was no recurrence or mesh infection during that time. Conclusion: TAPP is a safe and effective approach for treating Type 1 GIHs with low operative complications. Negative pressure drainage through the scrotum to the preperitoneal space may reduce the incidence of seroma. Recurrence of hernias was not observed, and chronic pain seldom occurred during the follow-up period in our study.

Giant intraparietal inguinal hernia misdiagnosed as spigelian hernia in an old woman

Intraparietal inguinal hernias are a rare variant of inguinal hernia in which the hernia sac lies between the layers of the abdominal muscles. Intraparietal inguinal hernias mimic Spigelian hernias clinically; the diagnosis presents superior difficulties than its treatment. We report a case of a giant intraparietal hernia misdiagnosed as a Spigelian hernia clinically. The patient was 83 years old woman presented with complain of a large swelling over right abdomen for around 25 years. The patient had a huge mass of 25 x 30 cm occupying right flank, right lumbar region extending up to the umbilicus and inguinal region, partially reducible with gurgling sounds. Surgery started with transversal incision over the mass, it was found to be an interstitial variety of intraparietal inguinal hernia with a long viable segment of the small bowel with their mesentery as content of the sac. Hernioplasty with a polypropylene mesh was achieved satisfactorily. The patient was discharged on third postoperative day without complications. It is challenging to diagnose intraparietal hernias preoperatively; intraoperative findings defined its definitive diagnosis and its surgical technique.

Giant recurrent left inguinal hernia with femoral nerve injury: a report of a rare case

Background

Giant inguinal hernia(GIH), a rare disease, has brought great challenges to surgeons. GIH is defined as an inguinal hernia that extends below the midpoint of the inner thigh in standing position. However, a giant recurrent inguinal hernia resulting from previous operations that destroy the anatomical structure of the inguinal region is extremely rare. Nerve injury, a complication following inguinal hernia repair, is mostly found in ilioinguinal nerve and iliohypogastric nerve, which often presents as numbness and acute or chronic pain, while postoperative muscular dysfunction results from femoral nerve injury is rare.

Case presentation

A 77-years-old woman presented with a complaint of a reducible mass in the left inguinal of duration 1 year. The patient had three previous inguinal hernia repairs. Physical examination and auxiliary examination indicated a giant inguinal hernia with femoral nerve injury. After preoperative evaluation and preparation, a transabdominal partial extraperitoneal(TAPE) repair have performed. Finally, the patient recovered and was discharged.

Conclusions

In conclusion, we reported a rare case of a giant recurrent inguinal hernia with femoral nerve injury and made a successful treatment for the patient via transabdominal partial extraperitoneal(TAPE) repair.

Laparoscopic transabdominal preperitoneal approach for giant inguinal hernias

BACKGROUND

Many surgical techniques have been developed to treat inguinal hernia. In recent years, the laparoscopic transabdominal preperitoneal (TAPP) approach has been widely performed to repair inguinal hernia. Giant inguinal hernia (GIH) is an extremely rare disease that is a challenge for general surgeons. GIH appears when patients neglect the treatment for many years and it is defined as an inguinal hernia that extends below the midpoint of inner thigh in standing position. According to previous publications, the Lichtenstein tension-free hernioplasty is recommended to repair GIH. In this article, we describe consecutive four cases of GIH repaired via the TAPP approach.

METHODS

From April 2015 to March 2017, 200 patients underwent hernioplasty against inguinal hernia at our hospital. Inguinal hernias were treated via the TAPP approach in principle. We performed hernioplasty via the TAPP approach in all 4 patients (2%) who met the definition of Type 1 GIH. Demographic information, maximum diameter of hernia sac, hernia orifice size, and surgical data were obtained.

RESULTS

The mean operative time was 135 min. No intraoperative complications were encountered. All patients could walk from postoperative day 1 and were discharged home early, but they all had scrotal seromas. Three patients did not need puncture or drainage, but one of them required puncture. All seromas disappeared within 6 months. There was no recurrence in the 8- to 24-month follow-up.

CONCLUSION

The TAPP approach is a feasible, safe therapeutic option that may reduce wound size and pain following surgical treatment of Type 1 GIH.

Giant Left-Sided Amyand's Hernia: A Challenging Procedure in a Rural Hospital

The finding of a vermiform appendix in the case of an inguinal hernia that extends below the midpoint of the inner thigh when the patient is in a standing position is defined as giant left-sided Amyand's hernia. It is a very rare case and significantly challenging in terms of preoperative diagnosis and surgical management. Here we present our experience with a case of a giant left-sided Amyand's hernia that was followed up for 2 months.

Loss of domain leading to intra-operative cardiorespiratory arrest during open repair of a giant inguinoscrotal hernia and hydrocele

We present the case of a 73-year-old man with a longstanding, giant inguinoscrotal hernia and hydrocele treated by an open approach, complicated intra-operatively by loss of domain leading to cardiorespiratory arrest. Surgery involved a midline approach by the general surgeons. Protruding viscera were mobilised, freed from adhesions, and returned to the abdominal cavity with closure of the internal ring, followed by reconstruction of the penis and scrotum by the plastic surgery and urology teams. Following abdominal closure, the patient developed severe cardiorespiratory instability attributed to large fluid shifts and increased intra-abdominal pressure due to loss of domain. The abdomen was therefore left open, and an ABThera negative pressure therapy system was employed. Two days later the abdomen was closed without tension. The remainder of the patient's post-operative recovery was unremarkable.

Surgical treatment strategies for giant inguinoscrotal hernia - a case report with review of the literature

BACKGROUND

An inguinoscrotal hernia is defined as "giant" if descending below the midpoint of the inner thigh of a patient in upright position. In developed countries this is a rare entity. In the literature different surgical techniques have been reported so far to achieve a successful treatment.

CASE PRESENTATION

We present the case of a 63 year-old man suffering from a giant inguinoscrotal hernia, whom we treated using a combined open transabdominal and inguinal approach following an unsuccessful laparoscopic attempt. Meshes were placed in a premuscular position (Lichtenstein's procedure) and in a preperitoneal position. In addition, a reconstruction of the abdominal wall by modified components separation technique was performed. During the early postoperative period no complications were registered. Intensive care treatment was not necessary. The patient was discharged on postoperative day 8 in an excellent condition. Six months after surgery a scrotal hematocele was diagnosed and operatively removed. After a follow-up of 1.5 years neither hernia recurrence, nor chronic groin pain were recorded. The patient reported to be sexually active. His quality of life improved notably. Additionally, a Medline and PubMed database research was performed to create an overall picture of the existing surgical treatment strategies. Included were patients with diagnosis of primary giant inguinoscrotal hernia according to the given definition. Emergency interventions and cases without details of the surgical approach were excluded.

CONCLUSIONS

Firstly, this report describes a novel, successful surgical treatment of a giant inguinoscrotal hernia without administering preoperative progressive pneumoperitoneum therapy or visceral resection. Secondly, we summarize cases previously reported as a practical guide for possible surgical therapy approaches.

Duodenal rupture due to giant inguinal hernia: A case report

INTRODUCTION

Giant inguinal hernia is unusual, and duodenal rupture accompanying it is particularly very rare and significantly hard to manage surgically.

PRESENTATION OF CASE

An 81-year-old man was admitted to our institution with upper abdominal pain. He had tenderness of the upper mid abdomen and a bilateral large inguinal hernia but he did not have pain in the inguinal-scrotal area. Computed tomography (CT) showed slight dilatation of the small bowel and stomach. There were no remarkable signs of incarceration of the inguinal hernia. Therefore, he was admitted to the internal ward. On the second day in hospital, he suddenly went into shock. CT revealed that there was free air and ascites in the inguinal hernia and therefore an emergency operation was performed. The tranverse colon, ascending colon, and ileum were incarcerated, and perfolation of the cecum was found. We also detected duodenal rupture at the inferior duodenal angle. We resected the terminal ileal (almost 90cm) and ileocecal area, followed by side-to-side anastomosis of duodenum and jejunum. We only repaired the peritoneum at the internal hernia ring. After the operation, despite intensive-care therapy, this patient passed away on the 18th postoperative day.

DISCUSSION

The mesocolon and third portion of the duodenum were strongly pulled down into giant inguinal hernia, probably causing the rupture of the inferior duodenal angle.

CONCLUSION

Giant inguinal hernia possibly provokes duodenal rupture and therefore should definitively be repaired if feasible.

Giant Inguinal Herniae Managed by Primary Repair: A Case Series

Giant inguinal hernia are usually found in developing countries due to delay in seeking medical attention. The management of such hernias may sometimes require procedures to increase the intra-peritoneal capacity prior to the repair of the giant hernia. Otherwise patients may develop abdominal compartment syndrome leading to various unwanted complications. Primary repair of giant hernias are possible in some cases without having significant post-operative complications. In this present case series, we have managed a total of four patients of giant inguinal hernia by primary repair without much post-operative complications.

Treatment of a half century year old giant inguinoscrotal hernia. A case report

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Giant inguinoscrotal hernias are a rare entity in modern clinical practice mainly because of the patient’s neglect.

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Our patient had a type II giant inguinoscrotal hernia extending below the midline between mid-inner thigh and suprapatellar bone lines.

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We avoided preoperative or intraoperative procedures for the lengthening of the abdominal wall.

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Despite the longevity and size of the hernia, we avoided a debulking procedure, instead we performed a lower midline incision and connected it with an extended right inguinal incision.

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Patient’s recovery was uneventful with no complications or signs of recurrence at 6 month follow up.

Introduction

Inguinal hernias, although a common medical entity, can on rare occasions present as giant inguinoscrotal hernias, mostly because of the patient’s rejection of timely surgical management.

Presentation of case

A 77 year old patient, with a giant inguinoscrotal hernia history for more than 50 years, was advised to undergo surgical treatment due to recurrent urinary tract infections and vague abdominal pain. Physical examination showed a right sided giant inguinoscrotal hernia extending below the midpoint of the inner thigh. Preoperative CT examination confirmed a giant inguinoscrotal hernia containing the whole of the small bowel along with its mesentery.

Discussion

Giant inguinoscrotal hernias are classified into three types based on size, with each one posing a challenge to treat. There are a number of surgical options and recommendations available, depending on the type of hernia. They require close postoperative observation, because the sudden increase in the intra-abdominal pressure can account for a number of complications. Our case was classified as a type II hernia, having longevity of more than 50 years. Despite this, it was treated with forced reduction and no debulking through an extended inguinal and lower midline incision, forming a ‘V shaped’ incision. Patient recovery was uneventful and he was discharged on the 10th postoperative day.

Conclusion

Preoperative management and the correct surgical plan depending on the case are key elements in the successful treatment of this rare surgical entity.

Giant inguinoscrotal hernia containing intestinal segments and urinary bladder successfully repaired by simple hernioplasty technique: a case report

Introduction

Giant inguinoscrotal hernias are extremely rare nowadays, but they may still be encountered after years or even decades of neglect. Such hernias containing both bowel loops and urinary bladder have not been reported in the medical literature to date, to the best of our knowledge.

Case presentation

We report a case of a 65-year-old Moroccan man who presented with giant right-sided and long-standing inguinoscrotal hernia with compromised quality of life due to walking difficulties and sexual discomfort. Computed tomography revealed a voluminous hernia sac containing small and large bowel loops, greater omentum, and urinary bladder. Surgical repair was done through the classical inguinal incision using the Lichtenstein tension-free hernioplasty technique. No debulking or abdominal enlargement procedure had to be performed, apart from a partial omentectomy.

Conclusions

Giant inguinoscrotal hernia containing intestinal segments and urinary bladder is a challenging surgical disease. A Lichtenstein tension-free technique seems to be the best surgical procedure for both the patient and the operating surgeon. It should be used whenever possible in such cases.