2022, Number 4
Giant inguinal hernia repair with loss of dominance
Full text
10.35366/109895
Language: English/Spanish [Versi?n en espa?ol]
References: 14
Page: 197-201
PDF size: 167.83 Kb.
ABSTRACT
Giant inguinal hernia with loss of domain is a rare. It is diagnosed when the hernial sac extends below the midpoint of the inner thigh in standing position. Repair of these defects represent a surgical challenge due to the risk of developing an abdominal compartment syndrome. We present the case of a 32-year old man with a giant inguinal hernia with loss of domain that was successfully managed with preoperative progressive pneumoperitoneum and hernioplasty with the Lichtenstein technique. No treatment has been adopted as standard procedure designated for this disease. Regardless of approach, we must prepare the abdominal cavity before surgical treatment to decrease the risk of abdominal compartment syndrome.INTRODUCTION
Giant inguinal hernia (GIH) with loss of dominance is uncommon and results from neglect and fear of the surgical procedure. The social impact is significant; it can cause social isolation, fear of seeking medical attention, and subsequent worsening of the condition.1 A GIH is established when the hernia sac extends below the midpoint of the inner thigh with the patient standing.2 The designation of loss of dominance is subjective. Its management represents a challenge due to the risk of developing abdominal compartment syndrome (ACS), produced by suddenly reintroducing the herniated contents into an abdominal cavity with decreased capacity.3 No treatment has been adopted as a standard procedure for this condition. The literature describes several surgical repair strategies. This paper aims to present the case of a patient with GIH with loss of dominance, successfully treated with prior progressive pneumoperitoneum (PPP) and tension-free plasty with the Lichtenstein technique.
PRESENTATION OF THE CASE
A 32-year-old male Mexican patient of mestizo ethnicity, a cab driver with a personal history of a sedentary lifestyle, and morbid obesity (body mass index [BMI] = 57), came for consultation for presenting a left inguinoscrotal hernia of 10 years of evolution. Physical examination confirmed that the patient had an inguinoscrotal hernia exceeding the upper border of the left patella and trophic changes of the scrotal skin (Figure 1). Inguinal ultrasound showed a hernial sac with intestinal and omental contents. He was started on NPP during his hospital stay by inserting a Veress needle at Palmer's point. 200 cm3 of room air was insufflated with a 100 cm syringe.3 Subsequently, a double-lumen catheter (subclavian) was placed with the Seldinger technique. An 800 cm3 of room air was insufflated, and a standing chest X-ray corroborated pneumoperitoneum. 1,000 cm3 were administered every 24 hours for 21 days up to a total volume of 21,000 cm3.
Under regional anesthesia, a left inguinal approach was performed through a standard transverse incision. A direct hernial sac was identified, dissected, and separated from the spermatic cord. After opening the hernia sac, small bowel loops, sigmoid colon, and omentum were identified (Figures 2, 3 and 4), which were manually introduced into the abdominal cavity without difficulty. The anatomical defect was repaired according to the Lichtenstein technique; there were no restrictive pulmonary changes during the transoperative and postoperative periods. The patient was discharged on the fourth day of hospital stay due to improvement. There was no hernia recurrence after clinical and ultrasound follow-ups for 1.5 years (Figure 5). The patient reports that his quality of life has improved notably, increasing his personal and sexual relationships.
DISCUSSION
The surgical treatment of a GIH with loss of dominance differs significantly from the usual cases of inguinal hernia due to the technical difficulty of repair and the high risk of morbidity and mortality, which implies a challenge for the surgeon. Forced reduction of the viscera to the abdominal cavity can produce a sudden increase in intra-abdominal pressure (IAP) and trigger an acute coronary syndrome (ACS), defined as a sustained IAP > 20 mmHg associated with multiple organ failure.4,5 Several techniques have been proposed to avoid these complications and obtain satisfactory results after surgical repair. Among the pre-surgical techniques are the creation of PPP and the application of botulinum toxin A (BTA), which aim to increase the abdominal cavity volume.6 In 1940, Goñi Moreno7 described the PPP, which consists of placing an intraperitoneal catheter, through which an average of 14,000-20,000 cm3 of ambient air is progressively insufflated to enlarge the abdominal cavity and thus achieve an adequate visceral reduction of the hernial sac. On the other hand, it stabilizes diaphragmatic shape and function and improves ventilatory function by allowing elongation of the abdominal wall muscles, adhesiolysis, and pneumatic dissection of the hernia sac.8,9 There is no consensus in the literature on the optimal duration and volume of insufflation. Goñi-Moreno7 described that the procedure ends when the abdominal flanks are found to be prominent and under tension by palpation. On the other hand, Mayagoitia-Gonzalez JC10 recommends maintaining the pneumoperitoneum for nine to 15 days for a GIH. In this case, it was decided to perform PPP for 21 days as described by Goñi-Moreno, where 1,000 cm3 of room air was administered every 24 hours for approximately 20,000 cm3 of room air.
Today, PPP and BTA are mainly used for giant abdominal incisional hernias, and some isolated cases of these techniques for treating a GIH have been reported in the literature.4,6,9,11
BTA causes a reversible flaccid paralysis of the abdominal wall muscles by blocking the synaptic release of acetylcholine, achieving an increase in the transverse diameter of the abdomen, a decrease in the thickness, and an increase in the length of the abdominal muscles, which facilitates the reduction of the hernial contents into the abdominal cavity.6,11,12 It has been observed that BTA complements the objective of PPP since it allows for handling larger insufflation volumes.8
Other techniques reduce the content of the hernial sac, also known as debulking, which consists of resection of the colon, small intestine, omentum, and spleen, among others; however, they are associated with a high rate of complications such as dehiscence, abdominal sepsis, and intestinal fistulas.8-12 In our case, there was no difficulty in reducing the hernial content. Therefore, a debulking procedure was not necessary.
Given the complex nature of GIHs, we chose to perform an open repair with the Lichtenstein technique, considered the technique of choice for most surgeons and is recommended by international guidelines for this type of hernia.13
Other surgical alternatives are the transabdominal preperitoneal approach (TAPP) and the totally-extraperitoneal approach (TEP), which are safe therapeutic options for scrotal hernia repair when performed by surgeons with a higher level of experience in either technique, obtaining favorable results and the benefits of minimally invasive surgery.9,13,14
CONCLUSION
There is no standard technique for the surgical repair of giant inguinal hernias with loss of dominance. The approach should be adapted to the surgeon's experience, the hernia's characteristics, and each hospital's resources. Whatever the approach, preparation of the abdominal cavity should be performed before surgical treatment to reduce the risk of abdominal compartment syndrome and the need for visceral resection or anatomic separation of components, either by PPP, BTA, or a combination of both.
ACKNOWLEDGMENTS
To Hospital General No. 450 for the support provided for the publication of this case and to the patient for granting consent for its publication.
REFERENCES
Kirkpatrick AW, Roberts DJ, De Waele J, Jaeschke R, Malbrain MLNG, De Keulenaer B, et al. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the world society of the abdominal compartment syndrome. Intensive Care Med. 2013; 39: 1190-1206.
AFFILIATIONS
1 General Surgery Service, General Hospital No. 450 of Durango, Durango, Mexico.
2 General Surgery Service, General Hospital of Ciudad Juarez, Chihuahua, Mexico.
3 Department of Plastic and Reconstructive Surgery. Jalisco Institute of Reconstructive Surgery. Reconstructive Surgery "Dr. José Guerrero Santos", Guadalajara, Jalisco, Mexico.
4 Clinical Research Unit. General Hospital No. 450 of Durango, Durango, Mexico. Biotechnology Academy. Faculty of Chemical Sciences, Universidad Juárez del Estado de Durango.
Ethical considerations and responsibility: according to the protocols established in our work center, we declare that we have followed the protocols regarding the privacy of patient data and preserved their anonymity.
Funding: no financial support was received for this work.
Disclosure: the authors have no conflicts of interest to declare.
CORRESPONDENCE
Fernando Vázquez-Alaniz. E-mail: feralaniz1@hotmail.comReceived: 08/25/2020. Accepted: 01/09/2022.