Obstructed hepatic flexure contained in a right-sided inguinoscrotal hernia resulting in caecal perforation

Abstract

Southern Health and Social Care Trust, UK aBstract Inguinal hernia often presents as an emergency with obstruction and subsequent strangulation. We report a unique case where an inguinoscrotal sliding type hernia contained the entire hepatic flexure as its lead point, resulting in acute colonic obstruction and caecal wall perforation.Inguinal hernia is one of the recognised dynamic, extramural causes of intestinal obstruction, where peristalsis works against a physical barrier. Initially, proximal peristalsis increases to overcome the obstruction. When the obstruction is not relieved, the proximal segment dilates, causing reduction in peristaltic strength, resulting in flaccidity and paralysis. Further proximal distension results from gas and fluid accumulation. In the setting of complete obstruction, perforation from back pressure on the proximal segment is inevitable with time. We report a case of an inguinoscrotal sliding type hernia with the hepatic flexure of the colon and omentum as its lead point, resulting in acute colonic obstruction and caecal wall 'pistol shot' perforation. case historyA 63-year-old man with a history of chronic obstructive pulmonary disease, hypertension and ischaemic heart disease presented with a 3-day history of abdominal distension and vomiting, with absolute constipation for 5 days. He had had no previous abdominal surgery. A non-tender large irreducible right-sided inguinoscrotal hernia was found, with concomitant tenderness in the left iliac fossa. Demonstrating tachycardia, tachypnoea and hypotension, he received fluid resuscitation, and was investigated further with plain abdominal radiography and rigid sigmoidoscopy. The radiography found acute colonic distension (Fig 1). The rigid sigmoidoscope was inserted to 18cm from the anal verge. This did not demonstrate a cut-off point, therefore making diagnosis of sigmoid volvulus unlikely.

Strangulated inguino‐scrotal hernia with caecal perforation

“…Obstructed inguino‐scrotal hernias containing a perforated caecum is a rare entity. To our knowledge, only three cases have been reported, and all cases described an open operative approach with either midline laparotomy and/or inguinal incision 5–7 . In some instances, bowel resections can be performed solely via the inguinal incision without an additional midline incision.…”

“…To our knowledge, only three cases have been reported, and all cases described an open operative approach with either midline laparotomy and/or inguinal incision. [5][6][7] In some instances, bowel resections can be performed solely via the inguinal incision without an additional midline incision. Although this patient required an additional incision, he was fortunate as the perforation was contained, and he did not have intra-abdominal sepsis.…”

Incarcerated Ventral Hernia of T-colon Resulting in Colon Perforation and Intraabdominal Abscess

“…If the incarceration is not reduced, strangulation might occur and may lead to perforation. 5,6 In patients with an acutely incarcerated or strangulated ventral hernia, emergent surgical consultation is warranted. An open rather than a laparoscopic approach is suggested.…”