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International Journal of Case Reports in Medicine

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Vol. 2013 (2013), Article ID 692094, 5 pages
DOI: 10.5171/2013.692094

Case Report
Giant Inguinal Hernia: A Case Report
Imtiaz Wani, Mubashir Shah, Ajaz A. Malik and Sameer H. Naqash

Department of General Surgery, SKIMS, Srinagar, Kashmir, India

Correspondence should be addressed to: Imtiaz Wani; imtazwani@gmail.com

Received 10 March 2013; Accepted 4 April 2013; Published 24 September 2013

Academic Editor: Ahmet Ziya Anadol

Copyright © 2013 Imtiaz Wani, Mubashir Shah, Ajaz A. Malik and Sameer H. Naqash. Distributed under
Creative Commons CC-BY 3.0

Abstract

Giant inguinal hernia is rare. This may be asymptomatic or present with the complications. Contents
vary from colon, small gut, vermiform appendix, mesentery, to omentum. A case of giant inguinal
hernia in a 62-year-old male who presented with features of intestinal obstruction is reported.
Patient had giant inguinoscrotal hernia which was tender, irreducible, and had no cough impulse.
Emergency exploration via inguinoscrotal approach revealed that contents were small and large
intestines, omentum, mesentery, and vermiform appendix. Right orchidectomy, reduction of contents
into abdominal cavity after enlarging internal ring with a double layer closure of wall, and the
reconstruction of scrotal skin were done. Giant inguinal hernia presenting as intestinal obstruction is
rare.

Keywords: Giant; Inguinal; Hernia; Enlarging; Internal ring.

Introduction et al. 1986 and Veihelmann et al. 2001).

Reduction of contents in giant inguinal hernia
Giant inguinal hernias are seen much less may lead to cardiopulmonary arrest due to
these days. In the West, they are almost not elevation of intra-abdominal pressure and
seen now. When inguinal hernia extends elevation of diaphragm. Elective repair
below the midpoint of inner thigh in standing employs usually creating of
position, it is a giant inguinal hernia (Sarkarbi pneumoperitoneum before repair. Emergency
et al. 2005). In a developing country, repair of giant inguinoscrotal hernia remains
unseeking of medical advice and reluctance to always challenging and may lead to morbidity.
get examined lead to gradual enlargement Reduction of contents via enlarging internal
evolving into a giant hernia. These are always ring in giant inguinal hernia is rarely reported
longstanding, present for years, and remain (Coetzee et al. 2011).
asymptomatic or present with an atypical
presentations. Rarely, a giant hernia presents Case Report
as an intestinal obstruction. Contents of giant
inguinal hernia are gut, mesentery, or A 62-year-old male presented with abdominal
omentum. Surgical repair is often challenging pain, vomiting, and constipation of 2 days
and difficult because of loss of domain (King duration. He had recurrent attacks of lower

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Cite this Article as: Imtiaz Wani, Mubashir Shah, Ajaz A. Malik and Sameer H. Naqash (2013), “Giant Inguinal
Hernia: A Case Report,” International Journal of Case Reports in Medicine, Vol. 2013 (2013), Article ID 692094,
DOI: 10.5171/2013. 692094
International Journal of Case Reports in Medicine 2

urinary tract infection and was a smoker. distension gut. Scrotal ultrasonography
There was no history of chronic cough or revealed distended gut loops in inguinoscrotal
constipation. General physical examination as region. Patient had emergency exploration via
well as systemic examination could not reveal inguinoscrotal approach. Peroperative
any significance. Patient was afebrile. findings revealed contents being terminal
Abdominal examination revealed distension ileum, caecum with appendix, ascending
and mild tenderness in abdomen. Bowel colon, omentum, and mesentery (Figure 3).
sounds were exaggerated. Examination of Ipsilateral testis was markedly reduced in
inguinal area revealed an inguinoscrotal size. There were no signs of ischemia or any
swelling (34×17.7×9.7 centimeters) being adhesions. Widening of deep inguinal ring was
present for the last 6 years which was done, and reduction of contents into
asymptomatic and had gradual increase in abdominal cavity was achieved. Right
size with thickened scrotal skin which had orchidectomy with the double-layered closure
bluish discoloration. Left inguinal canal was by prolene was done followed by
normal and left testis was palpable. Penis was reconstruction of the scrotal wall.
buried and right testis was not palpable. Postoperatively, patient had massive scrotal
Inguinoscrotal swelling had no cough impulse edema which was managed conservatively,
and was tender and irreducible (Figures 1 and and he was regularly attending our follow-up
2). Serum electrolytes were normal. X-ray and clinics for the last 2 years.
ultrasonography abdomen were showing

Figure 1: Giant Hernia with Buried Penis

Figure 2: Giant Hernia with Inguinal Contents

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Imtiaz Wani, Mubashir Shah, Ajaz A. Malik and Sameer H. Naqash (2013), International Journal of Case Reports in
Medicine, DOI: 10.5171/2013. 692094
3 International Journal of Case Reports in Medicine

Figure 3: Contents of Giant Inguinoscrotal Hernia

Discussion tailored to the individual situation of the

patient using all therapeutic options (Zippel et
Giant hernias are rare in present times. They al. 2001). Loss of domain, recurrence and
are present due to neglect (Patsas et al. 2010). residual scrotal skin, and scrotal hematoma
The use of local anesthesia for hernioplasty are the major problems encountered in
techniques that encourage patients to management of such hernias (Coetzee 2011).
undergo an operation shortly after diagnosis A proper preoperative preparation for
leads to rare occurrence of giant inguinal surgery in patients with giant hernias is
hernia today. The patient may remain desirable, especially involving respiratory
asymptomatic or present with acute renal status.
failure, perforation with concomitant
peritonitis (Goonetille et al. 2010 and In elective repair, preoperative use of
Gaedecke et al. 2013). In such giant hernia, progressive pneumoperitoneum is effective in
ulceration, dermatitis, or candidiasis of scrotal the treatment of large inguinal hernias (Piskin
skin could usually lead patients to seek et al. 2010). Creation of pneumoperitoneum
medical care. There is a case report in which leads to optimal space for reduction of
the incident of a gastric rupture in context herniated contents into abdominal cavity and
with a giant left scrotal hernia has occurred avoids abdominal morbidity in form of bowel
(Walgenbach et al. 2001). Walking, sitting, resection, abdominal compartment, and
simply lying down, and voiding may become extended abdominal wall reconstruction by
extremely difficult for the patient. Penis could the use of mesh (Vasiliadis et al. 2010).
be buried, and only one testicle could be Laparoscopic component separation
palpated. Usual content is gut, and sometimes technique has been recommended to increase
the entire mesenteric small bowel and the the capacity of the abdominal cavity to
entire colon may be lodged appendix, facilitate closure and reduce postoperative
omentum, or bladder (Conda Sanchez et al. complications in patients who had loss of
2001 and Tahir et al. 2008). Rarely domain (Hamad et al. 2013).
malrotated intestine could be present in a
giant inguinal hernia (Lee 2012). El-Dessouki (2001) presented a technique for
giant inguinal hernia in which hernia sac is
Due to rarity of condition, repair of giant pulled up to the abdomen and fashioned as a
inguinal hernia is always challenging, rotation flap to augment and close the
demanding to the surgeon, and stressful to the peritoneum over the replaced contents; a
patient. Surgical management has to be giant polypropylene mesh is inserted in the

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Imtiaz Wani, Mubashir Shah, Ajaz A. Malik and Sameer H. Naqash (2013), International Journal of Case Reports in
Medicine, DOI: 10.5171/2013. 692094
International Journal of Case Reports in Medicine 4

preperitoneal space to cover the midline References

defect created and to buttress both inguinal
regions. Zuvela et al. (2003) described the Bierca, J., Kosim, A., Małgorzata, K., Zmora, J. &
Rives technique (direct inguinal approach) in Kultys, E. (2013). “Effectiveness of
the treatment of large inguinoscrotal and Lichtenstein Repairs in Planned Treatment of
recurrent hernias. Merret et al. (2009) Giant Inguinal Hernia – Own Experience,”
advocated a technique for giant inguinal Videosurgery Miniinv, 8 (1) 36-42.
hernia involving the reduction of hernia; the
repair of hernial orifices with Marlex mesh Coetzee, E., Price, C. & Boutall, A. (2011).
and the creation of a midline abdominal wall “Simple Repair of a Giant Inguinoscrotal
defect to increase the intra-abdominal Hernia,” International Journal of Surgery Case
capacity followed by covering this defect with Reports, 2(3)32-5
Marlex mesh with a rotation flap of
inguinoscrotal skin. Lichtenstein technique Conde Sánchez, J. M., Espinosa Olmedo, J.,
has also been advocated for repair of giant Salazar Murillo, R., Vega Toro, P., Amaya
inguinal hernia (Bierca et al. 2013). A Gutiérrez, J., Alonso Flores, J. & García Pérez,
multistage operation for giant inguinal hernia M.(2001). “Giant Inguino-Scrotal Hernia of the
with scrotal ulcer has been recommended Bladder. Clinical Case and Review of the
where insufflation and prosthetic mesh are Literature,” Actas Urologicas Espanolas,
not available. In first stage, resection of ulcer 25(4)315-9.
and surrounding scrotal skin and partial
reduction of hernia sac content are done. El-Dessouki, N. (2001). “Preperitoneal Mesh
Partial reduction of hernia sac contents and Hernioplasty in Giant Inguinoscrotal Hernias:
resection of scrotal skins are done in stage A New Technique with Dual Benefit in Repair
two. In the last stage, bowel resection, andAbdominal Rooming,” Hernia, 5(4)177-81.
ileocolic anastomosis, hernia repair, and
resection of scrotal skin are done (Groen et al. Gaedcke, J., Schüler, P., Brinker, J., Quintel, M.
2011). & Ghadimi, M. (2013). “Emergency Repair of
Giant Inguinoscrotal Hernia in a Septic
In an emergency, surgical treatment of giant Patient,” Journal of Gastrointestinal
abdominal hernias includes reduction of the Surgery,17(4)837-9.
hernia content and tension-free closure of the
abdominal wall. Surgical treatment in Goonetilleke, K. & McIlroy, B. (2010). “Giant
complicated cases may require debulking the Inguinoscrotal Hernia Presenting with Acute
contents of the hernia sac by performing a Renal Failure: A Case Report and Review
right hemicolectomy and a small bowel ofLiterature,” Annals of The Royal College of
resection and reconstruction of the abdominal Surgeons of England, 92(4) W21-3.
wall using Marlex mesh and a tensor fasciae
latae flap (Mehendal et al. 2000 and Groen, R., Sesay, S., Kushner, A. & Dumbuya, S.
Goonetilleke et al. 2010). Inguinal incision (2011). “Three-stage Repair of a Giant
aided by midline infraumbilical incision aids Inguinal Hernia in Sierra Leone: A
in the reduction of contents into abdominal Management Technique for Low-Resource
cavity in giant inguinal hernia (Tahir et al. Settings,” Journal of Surgical Case Reports.
2010). (12): 8

Conclusion Hamad, A., Marimuthu, K., Mothe , B. & Hanafy,

M. (2013). “Repair of Massive Inguinal Hernia
Giant inguinal hernia presenting as intestinal with Loss of Abdominal Domain
obstruction is rare. Reduction of contents into UsingLaparoscopic Component Separation
abdominal cavity in giant inguinal hernia may Technique,” Journal of Surgical Case Reports. 3
be done by enlarging internal ring. (3pages)

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Imtiaz Wani, Mubashir Shah, Ajaz A. Malik and Sameer H. Naqash (2013), International Journal of Case Reports in
Medicine, DOI: 10.5171/2013. 692094
5 International Journal of Case Reports in Medicine

King, J. N., Didlake, R. H. & Gray, R. E. (1986). Walgenbach, K.- J., Lauschke, H., Brünagel, G. &
“Giant Inguinal Hernia,” Southern Medical Hirner, A. (2001). “An Uncommon Form of
Journal, 79(2) 252-3. Gastric Rupture in Giant Scrotal Hernia,”
Zentralblatt für Chirurgie, 126(12)1015-7.
Lee, S. E. (2012). “A Case of Giant Inguinal
Hernia with Intestinal Malrotation,” Zippel, R., Meyer, L., Kube, R. & Gastinger, I.
International Journal of Surgery Case Reports, (2001). “Elective Surgical Treatment of a
3(11)563-4 Giant Scrotal Hernia,” Zentralblatt für
Chirurgie, 126(12)1021-3.
Mehendal, F. V., Taams, K. O. & Kingsnorth, A.
N. (2000). “Repair of a Giant Inguinoscrotal Zuvela, M., Milićević, M., Lekić, N., Raznatović,
Hernia,” British Journal of Plastic Surgery, 53 Z., Palibrk, I., Bulajić, P., Petrović, M., Basarić,
(6)525-9. D. & Galun, D., (2003). “The Rives Technique
(Direct Inguinal Approach) in Treatment of
Merrett, N. & Biankin, A. (2009). “Giant Large Inguino-Scrotal and Recurrent Hernias,”
Inguinal Hernia Containing Right “Colon Acta Chirurgica Iugoslavica, 50(2)37-48.
Repaired Using the Prolene Herniasystem,”
ANZ Journal of Surgery, 79(1-2) 92-3.

Patsas, A., Tsiaousis, P., Papaziogas, B.,

Koutelidakis. I., Goula, C. & Atmatzidis, K.
(2010). “Repair of a Giant Inguinoscrotal
Hernia,” Hernia,14(3)305-7.

Piskin, T., Aydin, C., Barut, B., Dirican, A. &

Kayaalp, C. (2010). “Preoperative Progressive
Pneumoperitoneum for Giant Inguinal
Hernias,” Annals of Saudi Medicine, 30(4)317-
20.

Sarkarbi, W., Al. Agrawal, A. & Taffinder, N.

(2005). “A Giant Inguinoscrotal Hernia: A Case
Report and Review of the Literature,” Grand
Rounds, 5:46-48

Tahir, M., Ahmed, F. U. & Seenu, V. (2008).

“Giant Inguinoscrotal Hernia: Case Report and
Management Principles,” International Journal
of Surgery, 6(6)495-7.

Vasiliadis, K., Knaebel, H. P., Djakovic, N.,

Nyarangi-Dix, J., Schmidt. J. & Büchler, M.
(2010). “Challenging Surgical Management of
a Giant Inguinoscrotal Hernia: Report of a
Case,” Surgery Today, 40(7)684-7.

Veihelmann, A., Ungeheuer, A. & Feussner, H.

(2001). “Case Report: Emergency Surgery of a
Giant Scrotal Hernia,” Zentralblatt für
Chirurgie, 126(12) 1018-20.

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Imtiaz Wani, Mubashir Shah, Ajaz A. Malik and Sameer H. Naqash (2013), International Journal of Case Reports in
Medicine, DOI: 10.5171/2013. 692094