Massive Scrotal Hernia: A Surgical Challenge Revisited

1
Massive Scrotal Hernia A Surgical Challenge
Revisited

• J. Espinel M.D., M. deMoya M.D., S. Young M.D.,
  S. Lalla M.D., S. Feldman M.D.
• Department of Surgery, Saint Barnabas Medical
  Center. Livingston, NJ, 07052.

DISCUSSION The problem dealing with giant hernias
has brought a number of suggestions, such as
resection of some intestine held in the hernia
sac. Potentially fatal cardiorespiratory failure
can develop following reduction of giant hernia
contents that have lost their right of domain
in the abdominal cavity, due to sudden increase
in intra-abdominal pressure and elevation of the
diaphragm.1,4 Preoperative pneumoperitoneum was
described by Moreno in 1940.2 The distention of
the abdominal cavity can be developed at any pace
desired, and can be interrupted and restarted at
any stage if the patient is disturbed. Air
should be injected slowly, as diffuse abdominal
pain, nausea, or pain in the shoulders may
appear. The usual amount of air injected in the
abdominal cavity mentioned by most authors is 2-3
liters daily.2 Contraindications to the use of
pneumoperitoneum include abdominal wall
infection, decompensated cardiac conditions, and
the presence of strangulated hernia.
Pneumoperitoneum may mask acute abdominal
conditions such as perforating peptic ulcer,
diverticulitis, and appendicitis.2 The use of
preoperative, artificially induced
pneumoperitoneum is a technique that the general
surgeon should keep as part of his armamentarium
to repair giant inginoscrotal hernias.
INTRODUCTION Massive inguinal hernias are not
commonly seen in the Western world today because
of the availability and acceptability of early
elective operation. 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. As shown in this
case report, the management of a giant
inguinoscrotal hernia can be greatly facilitated
by the use of preoperative pneumoperitoneum.
CASE REPORT 46 year old white male presented to
the emergency room with a massive right
inguinoscrotal hernia which extended below his
knees. (Fig. 1) The patient was 58 and weighed
210 lbs. He had bilateral lower extremity edema.
The patients admitting laboratory findings
included a WBC of 5,400, hemoglobin of 3.5 gm/dl,
hematocrit of 13.5, and indices consistent with
severe microcytic anemia. A CT scan of the
abdomen and pelvis showed hepatosplenomegaly and
a massive right scrotal hernia which contained
the entire small bowel, right colon, and half of
the transverse colon. (Fig.2) The patient was
transfused over a several day period. A
peritoneal dialysis catheter (Tenckhoff) was
inserted and a pneumoperitoneum developed over 7
days. A total of 10,250 ml. of air was
insufflated. The patient was taken to the
operating room where the hernia was reduced and a
Bassini repair was performed. The cord was not
sacrificed, nor was the testicle removed. (Fig. 3
and 4) The patient was followed in the ICU for
risk of respiratory problems or signs of bowel
ischemia. None of which developed, although the
patient did develop a sharp rise in his liver
function tests on the second day post op which
gradually resolved spontaneously. The patient
was tolerating oral intake on post op day three ,
and was discharged eight days post op. The
scrotum has continued to contract, and the
patient continues to do well.

• CONCLUSIONS
• The preoperative induction of pneumoperitoneum
  allows adequate time for the patient to
• compensate for it and dimish intraoperative
  difficulty and postoperative morbidity.3
• The reasons are as follows
• The abdominal wall is stretched, thus creating a
  larger cavity to accommodate the hernia contents.
• The volume of hollow viscera to be replaced is
  reduced.
• Mesenteric and omental edema caused by chronic
  hernia are reduced.
• Stretching of the hernia sac causes elongation of
  adhesions, making dissection easier.
• Preoperative respiratory and circulatory
  adjustment to the elevated position of the
  diaphragm occurs.

Fig. 3
Fig. 1
Fig. 2
Fig. 4

• REFERENCES
• El-Dessouki N. (2002) Prepeitoneal mesh
  hernioplasty in giant inguinoscrotal hernias a
  new technique with dual benefit in repair and
  abdominal rooming. Hernia 5177-181.
• Barst H. (1972) Pneumoperitoneum as an Aid in the
  Surgical Treatment of Giant Herniae. Brit. J.
  Surg. 59360-364.
• Forrest J.(1979) Repair of Massive Inguinal
  Hernia, with Pneumoperitoneum and without Using
  Prostetic Mesh. Arch. Surg. 1141087-1088.
• Mehendale F., Taams K., Kingsnorth A. (2000)
  Repair of Giant Inguinoscrotal Hernia. Brit. J.
  Plastic Surg. 53525-529.