Emergency Repair of Giant Inguinoscrotal Hernia in a Septic Patient
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. ) 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.\nWithin 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. ).\nDuring 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.