A case report of a gastric perforation in a giant inguinoscrotal hernia: A two-step approach

Gastric Outlet Obstruction from Stomach-Containing Groin Hernias: Case Report and a Systematic Review

Most abdominopelvic structures can find their way to a groin hernia. However, location, and relative fixation are important for migration. Gastric outlet obstruction (GOO) from a stomach-containing groin hernia (SCOGH) is exceedingly rare. In the current report, we present a 77-year-old man who presented with GOO from SCOGH to our facility. We performed a review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) of patients presenting with SCOGH since it was first reported in 1802. Ninety-one cases of SCOGH were identified (85 inguinal and six femoral) over the last two centuries (1802-2023). GOO from SCOGH occurred in 48% of patients in one review and 18% in our systematic analysis. Initial presentation ranged from a completely asymptomatic patient to peritonitis. Management varied from entirely conservative treatment to elective hernia repair to emergent laparotomy. Only one case of laparoscopic management was documented. Twenty-one deaths from SCOGH were reported, with most occurring in early manuscripts (1802-1896 [n = 9] and 1910-1997 [n = 10]). In the recent medical era, outcomes for patients with this rare clinical presentation are satisfactory and treatment ranging from conservative, non-operative management to surgical repair should be tailored towards patients' clinical presentation.

An inguinal hernia 'hard to stomach'

Inguinal hernias containing the stomach are extremely rare, and have never been described in females. We are reporting the case of a 79 year old female who presented in septic shock with a left inguinal hernia containing the stomach, resulting in gastric perforation and loss of abdominal domain. She underwent emergency exploratory laparotomy with manual reduction of the hernia, wedge resection of the perforated gastric segment, abdominal washout, and closure of the abdominal fascia using biological mesh. She had a complicated but successful postoperative course, and was discharged to a rehabilitation center three weeks after hospital admission.

Acute Scrotal Abdomen: An Epitome of Negligence in Rural India

An inguinoscrotal hernia is considered to be giant when it passes beyond the midpoint of the thigh in a standing position. It is a rare condition that can lead to complications such as obstruction and perforation. Here, we present the case of a 35-year-old male who was diagnosed with a giant inguinoscrotal hernia with transverse colon perforation peritonitis. The patient presented with acute abdomen and septic shock. On presentation, resuscitation was started and an emergency laparotomy was performed. Resection of the gangrenous bowel segment and end jejunostomy was done as damage control surgery. However, despite intensive care and efforts, the patient succumbed due to multiorgan dysfunction syndrome (MODS). This is a rare case of a giant inguinoscrotal hernia with transverse colon perforation peritonitis, leading to MODS and mortality.

Inguinoscrotal hernias containing stomach: risk of emergency presentation

INTRODUCTION

Inguinoscrotal hernias are the commonest form of abdominal wall hernia, but for them to contain stomach is extremely rare. The management of these hernias can be very challenging owing to their acute nature of presentation and distortion of anatomy. Our aim was to systematically review the literature for all reported cases of inguinoscrotal hernias containing stomach. In turn we analysed patient demographics, site of hernia, presentation and treatment. Outcomes were reviewed where available.

METHOD

We conducted a systematic search of the PUBMED, Embase and Medline databases with a combination of keywords: Hernia AND (inguin* OR scrot*) AND (gastric OR gastro*). An author's own case has also been included.

RESULTS

There were 20 case reports included in the review, plus the author's own case. They ranged in publication date from 1942 to 2020. Mean age at presentation was 71 years (range 49 to 87). All cases were male. In total, 62% (n = 13) of cases presented with combined symptoms of abdominal pain and vomiting, 48% (n = 10) presented with gastric outlet obstruction (GOO) and 48% (n = 10) presented with gastric perforation. All successfully treated cases with gastric perforation required a midline laparotomy approach, whereas 56% (n = 5) of patients in the GOO group were successfully treated conservatively. There were three deaths reported in this review, all in the gastric perforation group.

CONCLUSION

Stomach as a content of inguinoscrotal hernias is extremely rare. These hernias predominantly present acutely in the form of GOO or gastric perforation. All patients with gastric perforation will require a midline laparotomy. Patients with GOO can be successfully managed either surgically or in selective cases with conservative management.

Bilateral inguinoscrotal hernia with gastric contents and subsequent perforation: Lessons in operative management

INTRODUCTION

Inguinoscrotal hernias often contain bowel, but it is rare to see it contain part or all of the stomach. These patients tend to present in extremis.

PRESENTATION OF CASE

This is the case of a 74 year old gentleman who presented in obstruction and acutely unwell from giant bilateral inguinoscrotal hernias. CT scan confirmed the left hernia contained the majority of the bowel and stomach. He underwent laparotomy and repair of the left sided hernia. Intraoperatively he was also found to have a gastric perforation and underwent distal gastrectomy. 7 days post operatively he returned to theatre for repair of his right sided hernia. The patient made a full recovery.

DISCUSSION

Review of similar literature highlights numerous surgical methods in repairing these hernias. A two-stage approach appears to mitigate the risk of abdominal compartment syndrome, whilst also allowing for an interval hernia repair in a non-hostile environment. Gastric perforation repair technique also varies, with majority of literature reporting primary repair.

CONCLUSION

We hope our approach to management can help guide others faced with similar challenging cases. Moreover, it highlights some operative challenges including dealing with associated gastric perforation and mitigating the risk of abdominal compartment syndrome.