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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Emergency Repair of Giant Inguinoscrotal Hernia in a Septic Patient</title><author><name sortKey="Gaedcke, J" sort="Gaedcke, J" uniqKey="Gaedcke J" first="J." last="Gaedcke">J. Gaedcke</name><affiliation><nlm:aff id="Aff1">Department of General and Visceral Surgery, University Medical Center Göttingen, Göttingen, Germany</nlm:aff></affiliation></author><author><name sortKey="Schuler, P" sort="Schuler, P" uniqKey="Schuler P" first="P." last="Schüler">P. Schüler</name><affiliation><nlm:aff id="Aff1">Department of General and Visceral Surgery, University Medical Center Göttingen, Göttingen, Germany</nlm:aff></affiliation></author><author><name sortKey="Brinker, J" sort="Brinker, J" uniqKey="Brinker J" first="J." last="Brinker">J. Brinker</name><affiliation><nlm:aff id="Aff1">Department of General and Visceral Surgery, University Medical Center Göttingen, Göttingen, Germany</nlm:aff></affiliation></author><author><name sortKey="Quintel, M" sort="Quintel, M" uniqKey="Quintel M" first="M." last="Quintel">M. Quintel</name><affiliation><nlm:aff id="Aff2">Department of Anaesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Göttingen, Germany</nlm:aff></affiliation></author><author><name sortKey="Ghadimi, M" sort="Ghadimi, M" uniqKey="Ghadimi M" first="M." last="Ghadimi">M. Ghadimi</name><affiliation><nlm:aff id="Aff1">Department of General and Visceral Surgery, University Medical Center Göttingen, Göttingen, Germany</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">23299222</idno><idno type="pmc">3599162</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3599162</idno><idno type="RBID">PMC:3599162</idno><idno type="doi">10.1007/s11605-012-2136-7</idno><date when="2013">2013</date><idno type="wicri:Area/Pmc/Corpus">000D64</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000D64</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Emergency Repair of Giant Inguinoscrotal Hernia in a Septic Patient</title><author><name sortKey="Gaedcke, J" sort="Gaedcke, J" uniqKey="Gaedcke J" first="J." last="Gaedcke">J. Gaedcke</name><affiliation><nlm:aff id="Aff1">Department of General and Visceral Surgery, University Medical Center Göttingen, Göttingen, Germany</nlm:aff></affiliation></author><author><name sortKey="Schuler, P" sort="Schuler, P" uniqKey="Schuler P" first="P." last="Schüler">P. Schüler</name><affiliation><nlm:aff id="Aff1">Department of General and Visceral Surgery, University Medical Center Göttingen, Göttingen, Germany</nlm:aff></affiliation></author><author><name sortKey="Brinker, J" sort="Brinker, J" uniqKey="Brinker J" first="J." last="Brinker">J. Brinker</name><affiliation><nlm:aff id="Aff1">Department of General and Visceral Surgery, University Medical Center Göttingen, Göttingen, Germany</nlm:aff></affiliation></author><author><name sortKey="Quintel, M" sort="Quintel, M" uniqKey="Quintel M" first="M." last="Quintel">M. Quintel</name><affiliation><nlm:aff id="Aff2">Department of Anaesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Göttingen, Germany</nlm:aff></affiliation></author><author><name sortKey="Ghadimi, M" sort="Ghadimi, M" uniqKey="Ghadimi M" first="M." last="Ghadimi">M. Ghadimi</name><affiliation><nlm:aff id="Aff1">Department of General and Visceral Surgery, University Medical Center Göttingen, Göttingen, Germany</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Gastrointestinal Surgery</title><idno type="ISSN">1091-255X</idno><idno type="eISSN">1873-4626</idno><imprint><date when="2013">2013</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Introduction</title><p>Giant inguinoscrotal hernias are rare but still exist even in developed countries. Although accompanied by a higher perioperative mortality, an elective surgical approach should be undertaken. In critically ill patients, however, the surgical intervention requires specific demands.</p></sec><sec><title>Methods</title><p>We report a case of a 45-year-old man who was referred to the hospital after perforation of the hernia with concomitant peritonitis and sepsis.</p></sec><sec><title>Results</title><p>After initial stabilization of the patient, a subtotal colectomy and a partial small bowl resection was performed. In a second step after stabilization of organ functions, the hernia sac was resected, and the abdominal cavity was reconstructed. The patient was discharged and is doing well until today but still refuses any plastic surgery.</p></sec><sec><title>Conclusion</title><p>Resection of giant inguinoscrotal hernia is feasible even in patients being administered in an emergency setting. Especially in case of an intra-abdominal infection, intestinal resection is the therapy of choice to allow the reconstruction of the abdominal cavity. A two-step approach should be considered to allow a successful recovery.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Hodgkinson, Dj" uniqKey="Hodgkinson D">DJ Hodgkinson</name></author><author><name sortKey="Mcilrath, Dc" uniqKey="Mcilrath D">DC McIlrath</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mcadory, Rs" uniqKey="Mcadory R">RS McAdory</name></author><author><name sortKey="Cobb, Ws" uniqKey="Cobb W">WS Cobb</name></author><author><name sortKey="Carbonell, Am" uniqKey="Carbonell A">AM Carbonell</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Caldironi, Mw" uniqKey="Caldironi M">MW Caldironi</name></author><author><name sortKey="Romano, M" uniqKey="Romano M">M Romano</name></author><author><name sortKey="Bozza, F" uniqKey="Bozza F">F Bozza</name></author><author><name sortKey="Pluchinotta, Am" uniqKey="Pluchinotta A">AM 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Gastrointest Surg</journal-id><journal-id journal-id-type="iso-abbrev">J. Gastrointest. Surg</journal-id><journal-title-group><journal-title>Journal of Gastrointestinal Surgery</journal-title></journal-title-group><issn pub-type="ppub">1091-255X</issn><issn pub-type="epub">1873-4626</issn><publisher><publisher-name>Springer-Verlag</publisher-name><publisher-loc>New York</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">23299222</article-id><article-id pub-id-type="pmc">3599162</article-id><article-id pub-id-type="publisher-id">2136</article-id><article-id pub-id-type="doi">10.1007/s11605-012-2136-7</article-id><article-categories><subj-group subj-group-type="heading"><subject>GI Image</subject></subj-group></article-categories><title-group><article-title>Emergency Repair of Giant Inguinoscrotal Hernia in a Septic Patient</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Gaedcke</surname><given-names>J.</given-names></name><address><email>j.gaedcke@gmail.com</email></address><xref ref-type="aff" rid="Aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Schüler</surname><given-names>P.</given-names></name><xref ref-type="aff" rid="Aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Brinker</surname><given-names>J.</given-names></name><xref ref-type="aff" rid="Aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Quintel</surname><given-names>M.</given-names></name><xref ref-type="aff" rid="Aff2"></xref></contrib><contrib contrib-type="author"><name><surname>Ghadimi</surname><given-names>M.</given-names></name><xref ref-type="aff" rid="Aff1"></xref></contrib><aff id="Aff1"><label></label>Department of General and Visceral Surgery, University Medical Center Göttingen, Göttingen, Germany</aff><aff id="Aff2"><label></label>Department of Anaesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Göttingen, Germany</aff></contrib-group><pub-date pub-type="epub"><day>9</day><month>1</month><year>2013</year></pub-date><pub-date pub-type="pmc-release"><day>9</day><month>1</month><year>2013</year></pub-date><pub-date pub-type="ppub"><month>4</month><year>2013</year></pub-date><volume>17</volume><issue>4</issue><fpage>837</fpage><lpage>839</lpage><history><date date-type="received"><day>4</day><month>9</month><year>2012</year></date><date date-type="accepted"><day>19</day><month>12</month><year>2012</year></date></history><permissions><copyright-statement>© The Author(s) 2013</copyright-statement><license license-type="OpenAccess"><license-p><bold>Open Access</bold> This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.</license-p></license></permissions><abstract id="Abs1"><sec><title>Introduction</title><p>Giant inguinoscrotal hernias are rare but still exist even in developed countries. Although accompanied by a higher perioperative mortality, an elective surgical approach should be undertaken. In critically ill patients, however, the surgical intervention requires specific demands.</p></sec><sec><title>Methods</title><p>We report a case of a 45-year-old man who was referred to the hospital after perforation of the hernia with concomitant peritonitis and sepsis.</p></sec><sec><title>Results</title><p>After initial stabilization of the patient, a subtotal colectomy and a partial small bowl resection was performed. In a second step after stabilization of organ functions, the hernia sac was resected, and the abdominal cavity was reconstructed. The patient was discharged and is doing well until today but still refuses any plastic surgery.</p></sec><sec><title>Conclusion</title><p>Resection of giant inguinoscrotal hernia is feasible even in patients being administered in an emergency setting. Especially in case of an intra-abdominal infection, intestinal resection is the therapy of choice to allow the reconstruction of the abdominal cavity. A two-step approach should be considered to allow a successful recovery.</p></sec></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>Giant inguinoscrotal hernia</kwd><kwd>Emergency repair</kwd></kwd-group><custom-meta-group><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© The Society for Surgery of the Alimentary Tract 2013</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="Sec1"><title>Introduction</title><p>A well-known complication of groin hernias is the increase in size advocating an early surgical treatment. However, in rare cases, patients refuse operative procedures. As a consequence, giant inguinoscrotal hernias develop. Over the past, different surgical repairs have been suggested. In this report, we now present a patient who initially refused surgery with subsequent scrotal perforation and septic complication followed by emergency hernia repair.</p></sec><sec id="Sec2"><title>Case Report</title><p>A 45-year-old man was taken to the emergency ward. Fourteen months before, he presented with a giant inguinoscrotal hernia but refused surgery. He was now recovered from his apartment due to his inability to walk by a gradually loss of strength and progressive increase of his hernia that now reached the calves. Within the last months, he used a small wagon to transport his hernia leading to an ulcer continuously discharging putrid liquid. Clinical and blood tests revealed a systemic inflammatory response syndrome with impairment of coagulation, anemia, severe hyponatremia, and a complete left-sided pleural effusion. Within the following hours, intubation and catecholamine therapy became necessary, and the patient was transferred to the intensive care unit. Excluding acute ischemia, the CT scan (Fig. <xref rid="Fig1" ref-type="fig">1</xref>) revealed a complete dislocation of the small and the large bowel, descending of the duodenum and the pancreas, and intra- and extrahepatic cholestases and confirmed the congestion of the right kidney as initially seen on ultrasound. The ureter descended into the hernia sac and was dilated up to its return into the abdominal cavity.<fig id="Fig1"><label>Fig. 1</label><caption><p>Representative CT scan showing dislocation of intra-abdominal organs from ventral to dorsal (<italic>left to right</italic>)</p></caption><graphic xlink:href="11605_2012_2136_Fig1_HTML" id="MO1"></graphic></fig></p><p>Within the next 5 days, the patient was further stabilized, and surgery was attempted. Exploration of the abdominal cavity showed signs of peritonitis. Within the hernia sac, purulent liquid remained, and the penis was identified intra-abdominally. In a first step, the majority of the mobile large bowel (ascendens down to the sigmoideum) and distal parts of the ileum (200 cm behind the ligament of Treitz) were resected. After 48 h of stabilization, the majority of the hernia sac was resected. Identification of the testes was not possible. Due to the inability to close the fascia and due the inflammatory situation, the abdominal cavity was reconstructed using absorbable mesh grafts (Fig. <xref rid="Fig2" ref-type="fig">2</xref>).<fig id="Fig2"><label>Fig. 2</label><caption><p>Patient prior to first (<italic>above</italic>) and after second operation (<italic>below</italic>)</p></caption><graphic xlink:href="11605_2012_2136_Fig2_HTML" id="MO2"></graphic></fig></p><p>During the following days, the patient recovered slowly. Mobilization was complicated by an a priori existing lesion of the nervus peroneus and a polyneuropathia. Five weeks after the initial surgery, the patient could be discharged from the hospital. In the following rehabilitation program, he regained the ability to walk and care for himself again. Until today, he refused any further plastic reconstruction.</p></sec><sec id="Sec3" sec-type="discussion"><title>Discussion</title><p>Giant inguinoscrotal hernias might be considered as negligible. However, they still occur, even in developed countries, and then present a challenging surgical problem. Defined as the extension below the midpoint of the inner thigh in the standing position,<xref ref-type="bibr" rid="CR1">1</xref> giant inguinoscrotal hernias still vary widely in their size and appearance. Depending on the comorbidities of the patients, different surgical approaches have been reported. They are all sharing the same strategy of relocating the organs into the abdominal cavity that have lost their “right of domain” without increasing the abdominal pressure excessively and thus reducing the venous return or a compromising of the pulmonary or cardiac function. In the past, two general principles have been advocated. On the one hand, the abdominal space is increased by (1) progressive pneumoperitoneum,<xref ref-type="bibr" rid="CR2">2</xref>,<xref ref-type="bibr" rid="CR3">3</xref> (2) abdominal wall separation,<xref ref-type="bibr" rid="CR4">4</xref> or (3) combined mesh and flap techniques (including mesh repair to create an abdominal wall defect for increasing the intra-abdominal capacity).<xref ref-type="bibr" rid="CR5">5</xref>,<xref ref-type="bibr" rid="CR6">6</xref> On the other hand, abdominal organs are resected to reduce the size of organs that need to be relocated.<xref ref-type="bibr" rid="CR7">7</xref> Endoscopic techniques have been reported but should be assessed very critically.<xref ref-type="bibr" rid="CR8">8</xref> The enlargement of the abdomen by pneumoperitoneum, in general, showed to be a valid method. However, in very large giant hernias, it failed several times.<xref ref-type="bibr" rid="CR9">9</xref>,<xref ref-type="bibr" rid="CR10">10</xref> In situations of infected hernia sac, pneumoperitoneum should be avoided,<xref ref-type="bibr" rid="CR11">11</xref>,<xref ref-type="bibr" rid="CR12">12</xref> and a stepwise procedure has previously been suggested.<xref ref-type="bibr" rid="CR13">13</xref> In these special situations, nonabsorbable meshes should be avoided due to their potential infection.<xref ref-type="bibr" rid="CR14">14</xref></p><p>Orchiectomy of non-necrotic testis is still controversy discussed as chances of testicular torsion or infection, or even recurrence is increased if left in place.<xref ref-type="bibr" rid="CR15">15</xref> With regard to the resection of the hernial sac, the development of scrotal hematoma and/or massive lymphedema is possible.<xref ref-type="bibr" rid="CR9">9</xref> Otherwise, redundant scrotal skin has the possibility to save as a safety net in case of recurrence of increased intra-abdominal pressure.<xref ref-type="bibr" rid="CR10">10</xref></p></sec><sec id="Sec4" sec-type="conclusions"><title>Conclusion</title><p>Accompanied by an increased mortality rate, surgery should be advocated even for giant inguinoscrotal hernias. In septic patients, the inflammatory focus needs to be resected. An initial stabilization is advantageous if incarceration can be ruled out. To reconstruct the abdominal cavity, a two-step procedure should be pursued to allow a recovery from the initial resection and to regain organ function. 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