ePoster #4 | Clinical Science | General Surgery

Tyler Davis DO, Giri Movva, Lutfi Barghuthi MD, Mohamed Abdelgawad MD, Hishaam Ismael MD

Presenter: Tyler Davis, DO, The University of Texas Health Science Center at Tyler

Introduction/Objective: Abdominal wall hernias are extremely common with an estimated prevalence of 1.7% of all ages, 75% of which being inguinal in nature. If left untreated, a simple inguinal hernia can develop into a giant inguinal hernia. This rare presentation is defined as an inguinal hernia that extends below the midpoint of the inner thigh when the patient is in the standing position or an anteroposterior diameter of at least 30cm or a laterolateral diameter of about 50cm with non-reducibility for more than 10 years. Hernia contents can range from isolated peritoneal fat and bowel to more extreme cases which include stomach, ovaries, bladder, and kidneys. Surgical management can be challenging due to numerous associated complications. Though several repair techniques have been suggested in published case reports, no single treatment has been adopted as the standard approach to dealing with this unusual disease.

Case Presentation: This patient is a 77-year-old male with uncontrolled diabetes and giant left sided inguinal hernia initially presenting for intractable nausea, vomiting, hypotension, hypothermia, and lactic acidosis associated with gastric outlet obstruction. Patient was adequately resuscitated, and a nasogastric tube (NGT) was placed with immediate output of 3 liters. Initial CT showed massive enlargement and obstruction of the fluid-filled stomach extending to a large left inguinal hernia measuring 14.6 x 19.5 cm with a 6.2 cm defect that contains loops of small bowel and colon. Due to failure of non-operative management with two recurrences of gastric outlet obstruction, the decision for operative management was made.Using a generous left inguinal incision, the patient underwent inguinal hernia repair with mesh. Intraoperative examination revealed the left testicle to be mildly atrophic (likely due to age) but attached to the scrotal wall with intact blood supply, thus orchiectomy was not performed. The hernia sac was not violated and the hernia was reduced with no additional incisions or debulking required. The inguinal floor was reinforced by two meshes in a Lichtenstein tension-free fashion. The patient tolerated the procedure well with no post-operative complications.

Discussion: Literature review of 11 cases from 2008 to 2019 revealed 63.6% (7/11) only required a standard inguinal transverse incision with the remaining required addition of an open transabdominal approach. Roughly half of the cases required debulking to aid in reduction of the hernia. By far, the most common hernia repair technique was the Lichtenstein’s tension free repair.

Conclusion: Surgical repair of giant inguinal hernias can be challenging and is associated with a variety of complications. Various modalities have been described to assist in hernia reduction including debulking. Although the Lichtenstein’s tension free repair seemed to be the most common technique (utilized in this case), no single treatment has been adopted as the standard approach to managing this uncommon presentation.

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