Hernia DOI 10.1007/s10029-014-1215-y
Beware of spontaneous reduction ‘‘en masse’’ of inguinal hernia C. R. Berney
Received: 5 May 2013 / Accepted: 5 January 2014 Ó Springer-Verlag France 2014
Abstract Reduction ‘en masse’ of inguinal hernia is a rare entity defined as manual reduction of an external hernia sac back through the abdominal wall but where its content still remains incarcerated or strangulated into a displaced position, most often in the pre-peritoneal space. Small bowel obstruction habitually follows requiring urgent repair, preferentially via a transabdominal approach. Pre-operative clinical diagnosis is difficult and abdominal CT-scan imaging is the investigation of choice. Keywords Inguinal hernia Hernia sac Reduction ‘en masse’ Pre-peritoneal space Mechanical obstruction
Introduction Reduction ‘en masse’ of inguinal hernia is a rare condition that generally occurs in patients reporting several previous attempts at reducing a lump in their groin, with progressive difficulty. Unusually, it may reduce spontaneously. In this situation, the diagnosis may be easily overlooked resulting in delayed surgical intervention and potential disaster. We report the case of a missed spontaneous reduction ‘en masse’ of inguinal hernia initially treated by open herniorrhaphy and subsequently requiring laparoscopic exploration for persistent mechanical small bowel obstruction.
C. R. Berney (&) Department of Surgery, University of New South Wales, Bankstown-Lidcombe Hospital, Eldridge Road, Bankstown, NSW 2200, Australia e-mail: [email protected]
Case report A 46-year-old male was admitted on emergency with a diagnosis of incarcerated left inguinal hernia. He was consented on the same day for a left groin exploration and hernia repair plus/minus small bowel resection. Just prior to induction of anaesthesia, his hernia spontaneously reduced. An open herniorrhaphy was performed, showing the presence of a direct inguinal hernia. The operative report mentioned ‘‘no evidence of bowel ischaemia’’ and the patient underwent a standard Lichtenstein onlay mesh repair of the hernia defect. After an uncomplicated post-operative recovery, the patient was discharged home the following morning. He represented on the same day in the evening to the Emergency Department with lower abdominal pain and vomiting. An urgent abdominal CT-scan showed evidence of small bowel obstruction with a transition point in the region of the left iliac fossa (Fig. 1a) and keeping with the diagnosis of mechanical obstruction secondary to adhesions. The patient had undergone laparoscopic appendicectomy 5 months prior to this event. Despite adequate conservative management he did not make significant improvement and we were asked to review him on his fifth post-operative day. The patient underwent a diagnostic laparoscopy that confirmed the CT-scan findings, with a transition point situated at the site of his previous inguinal hernia repair. The distal small bowel was collapsed. A segment of intestine was entrapped in a hernia sac that was protruding in the pre-peritoneal space between the parietal peritoneum and the anterior abdominal wall, and medial to the left epigastric vessels (Fig. 1b). The neck of the hernia sac was thickened and constrictive, causing strangulation and closed loop obstruction of the small bowel. The neck of the
Fig. 1 a Computed tomography scan image showing evidence of small bowel obstruction with a transition point in the region of the left iliac fossa (black arrow). b Intraoperative photograph showing a segment of intestine entrapped in a hernia sac that extends in the preperitoneal space (white arrow left spermatic cord). c Division of the
constrictive neck of the hernia sac. d Reduction of the incarcerated loop of small bowel. e Complete inversion of the hernia sac. f Base of the hernia sac tied up with Endoloop of PDS and excess peritoneum excised
hernia sac was divided by sharp dissection and the incarcerated loop of small bowel was completely reduced (Fig. 1c, d). No bowel resection was necessary. The hernia sac was inverted and a pre-tied suture loop of Polydioxanone (EndoloopÒ Ligature of PDSÒII, Ethicon Endo-Surgery, Inc., CA, USA) was applied at its base as described elsewhere for plication of the lax transversalis fascia during endoscopic repair of direct inguinal hernia (Fig. 1e) . The excess hernia sac was then excised (Fig. 1f). The patient made an uneventful recovery and was eventually discharged home on the fourth post-operative day, mainly due to a prolonged ileus. Unexpectedly, he was
readmitted 3 weeks later to our Institution with an acute cholecystitis and underwent subsequent laparoscopic cholecystectomy.
Discussion An incarcerated hernia can reduce spontaneously or following administration of muscle relaxants during induction of anaesthesia. This does not necessarily indicate that the hernia sac itself will also be emptied of its content and such entity is known as a spontaneous reduction of hernia ‘‘en
masse’’ meaning that the reduced hernia sac could still contain, for instance, a retained loop of incarcerated bowel . Such event is quite rare and estimated to occur in approximately 1 of 13,000 hernias . Pre-operative diagnosis is often difficult as the hernia is, by definition, clinically reduced. It relies on a careful medical history (any previous difficulties to reduce a groin lump) but mainly on CT Imaging that might demonstrate the presence of a pre-peritoneal hernia sac containing dilated and thickened bowel loop . Plain abdominal X-ray is of limited diagnostic value. Early surgical exploration via a trans-abdominal approach is the preferred option as it offers perfect visualisation of the entire abdominal content and is also ideal if small bowel resection is needed. In this case report although the patient initially underwent what seemed to be a straightforward open herniorrhaphy, unrecognition of the related hernia ‘‘en masse’’ led to unresolved post-operative mechanical obstruction and delayed re-exploration that could have had a much worse outcome. This event demonstrates why in such situation of emergency hernia repair systematic opening, inspection and final resection of the hernia sac are essential steps to avoid unwanted complication. The choice of a laparoscopic exploration was motivated by the CT-scan findings demonstrating a single transition point towards the left iliac fossa, the fact that the patient had stable vital signs and finally the limited morbidity of a minimally invasive approach, as compared to laparotomy, if the underlying pathology can be easily fixed that way or in case of negative findings.
Conclusion Following any emergency repair of incarcerated inguinal or femoral hernias, surgeons should keep a high index of suspicion and low threshold to surgical reintervention in any unusual, even mild, history of recurrent abdominal symptoms. Indeed, this could represent the first sign of an early post-operative complication as clearly demonstrated in this case. In those situations a diagnostic laparoscopy should be offered promptly to the patients as the procedure of choice, due to its safety and negligible risk in case of a negative finding .
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