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CASE REPORT
Year : 2019  |  Volume : 12  |  Issue : 4  |  Page : 367-369  

Giant inguinoscrotal hernia repaired by combined Bassini and Lichtenstein technique


1 Department of Urology, Urmia University of Medical Sciences, Urmia, Iran
2 Student Research Committee, Urmia University of Medical Sciences, Urmia, Iran

Date of Submission16-Jun-2018
Date of Acceptance12-Nov-2018
Date of Web Publication8-Jul-2019

Correspondence Address:
Sina Dindarian
Orjhans Street, Resalat Blvd, Postal Code: 571478334, Urmia
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_96_18

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  Abstract 


Giant inguinal hernia is a very rare event nowadays and occurs after years of neglect. We reported an unusual case of an elderly man with a giant left-sided inguinoscrotal mass containing not only the urinary bladder but also the small bowel loops and the omentum. We managed the hernia just by inguinal incision with extension to the internal ring, using the combined Bassini and Lichtenstein hernioplasty technique. As the hernia was giant and contained the major part of the bowels and the urinary bladder, we considered the risks of various hernia repairs and conducted combined Bassini and Lichtenstein technique to repair the posterior wall of the inguinal canal due to higher stability. After performing this method, the patient had a satisfactory postoperative status and we did not observe any specific problems or complications. Lichtenstein method has been approved to be a safe and efficient method to repair the hernia and is extensively used by surgeons. We suggest combined Bassini and Lichtenstein method in giant inguinoscrotal hernias, especially in those with great adhesions. However, we recommend further studies to compare this method with other techniques.

Keywords: Bassini method, inguinoscrotal hernia, Lichtenstein method


How to cite this article:
Farshid S, Eghbal M, Abyar B, Mohammadi S, Dindarian S. Giant inguinoscrotal hernia repaired by combined Bassini and Lichtenstein technique. Med J DY Patil Vidyapeeth 2019;12:367-9

How to cite this URL:
Farshid S, Eghbal M, Abyar B, Mohammadi S, Dindarian S. Giant inguinoscrotal hernia repaired by combined Bassini and Lichtenstein technique. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2019 Jul 17];12:367-9. Available from: http://www.mjdrdypv.org/text.asp?2019/12/4/367/262240




  Introduction Top


Although inguinal hernias are the most common among all hernia types and their surgical treatment is easily achievable especially in developed countries, giant inguinal hernias are very rare and occur after years of neglect.[1] Giant inguinoscrotal hernia containing the urinary bladder, also known as a scrotal cystocele, is defined as a hernia extending below the midpoint of the inner thigh in the standing position.[2] Weakness of the detrusor and abdominal wall muscles, increased intra-abdominal pressure, and a history of previous inguinal surgeries might be the pathophysiology of the condition.[3] Patients may experience various complications such as scrotal swelling, symptoms of bladder outlet obstruction, and episodes of urinary tract infection (UTI).[4] In this report, we described an unusual case of an elderly man with a giant left-sided inguinoscrotal mass containing not only the urinary bladder but also the small bowel loops and the omentum. We managed it using the combined Bassini and Lichtenstein hernioplasty technique.


  Case Report Top


A 68-year-old man was referred to the Urology Department, Imam Khomeini Hospital, Urmia, Iran, with a history of inguinoscrotal mass in his left inguinal region since 20 years ago. He stated that the bulge had been disappeared spontaneously and he did not feel any pain thereafter. During the last 3 years, the hernia became irreducible and reached below the mid-thigh [Figure 1]. He also felt more intensive inguinal pain without radiation into any part of his body. He did not mention any episodes of abdominal pain or history of difficult urination and any lower urinary tract symptoms. However, this condition caused him difficulty in walking and sexual activity. The patient only described a history of hypertension. The medications that he was currently taking were hydrochlorothiazide (25 mg daily) and aspirin (80 mg daily). Clinical examination revealed a large nontender bulge which was 30 cm in size. The left testis was also impalpable. The bulge was irreducible, and cough impulse test was negative. Furthermore, the patient had genital warts in his inguinal region, but a dermatologist did not diagnose it as an emergency. He was only recommended to attend a clinic of dermatology after the surgical operation. The laboratory tests showed a low platelet count of 112,000/μL, but other laboratory parameters were normal. The echocardiography was performed before surgery and revealed occasional premature ventricular complexes. After consulting with a cardiologist, the patient underwent surgical repair. In the operating room, despite injections of midazolam, fentanyl, and lidocaine, the patient did not respond to medication, and the surgery was canceled due to arrhythmia. Thus, 25 mg of metoprolol was injected every 8 h when systolic blood pressure and pulse rate exceed 100 mmHg, and 60/min, respectively. Three days later, his ejection fraction was higher than 55%. After checking the results of myocardial perfusion imaging, the operation was performed. Under general anesthesia, a Foley catheter was inserted. Then, a transverse groin incision was made and extended upward over the internal ring, and dissection of the hernia sac was accurately performed. The hernia was a combined direct and indirect inguinal hernia. The herniating component consisted major part of the small bowel with its mesentery, descending colon, and major part of the greater omentum [Figure 2]a. Furthermore, the hernia sac contained the urinary bladder [Figure 2]b. Due to the chronic process of hernia, adhesion of the greater omentum to the left scrotum was seen, but we observed no evidence of ischemia. Development of adhesion made the reduction so difficult when we opened the hernia sac to release the contents. After the partial omentectomy, repositioning of the hernia contents into the abdominal cavity was performed. The hernia sac was repaired with nonabsorbable sutures (silk 1–0) and the remaining parts of the hernia sac were reduced. Then, the urinary bladder was repositioned to its normal anatomical position without any injury. After that, we repaired the posterior wall of the inguinal canal with combined Bassini and Lichtenstein tension-free hernioplasty technique. Finally, a polypropylene mesh was placed over the repaired defect. Furthermore, in the scrotum, we placed a suction drain on the mesh. Priorly, written informed consent form was obtained from the patient.
Figure 1: Preoperative photograph demonstrating the giant inguinoscrotal hernia extending below the midpoint of the inner thigh (supine position)

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Figure 2: Intraoperative photograph demonstrating the part of the hernia sac containing (a) the mesentery and (b) the urinary bladder

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  Discussion Top


In cases of several years of self-neglect or lack of facilities, giant inguinoscrotal hernias may be seen. Hence, in countries with high socioeconomic status, it is so rare to see these hernias due to early diagnosis and surgical correction of an inguinal hernia.[4] In addition to the classical complication of hernias, some complications occurring in giant inguinoscrotal hernias may also be observed. UTI is a very common complication which usually occurs several years after neglecting the hernia.[5] Other complications include difficulty in walking, sitting, and lying down due to massive size of the hernia.[6] Furthermore, voiding difficulties because of the presence of the urinary bladder in the hernia cause inappropriate social and psychological status in these patients that exacerbates the quality of life.[7] In the current case, most of the small bowel with its mesentery, descending colon, large part of the greater omentum, and urinary bladder were found in a left-sided inguinoscrotal hernia which is very rare.

Due to low incidence of giant inguinoscrotal hernias, the surgical procedure of these hernias is so challenging.[8] Several methods have been used to repair inguinal hernia. Bassini method was the first modern hernia surgery which was introduced in 1884. In this method, an inguinal incision is made. Then, the defect in the posterior wall of the inguinal canal is closed by placing the musculoaponeurotic edges of the canal.[9] Furthermore, Lichtenstein method is a tension-free method which is widely used due to its ease of operation.[10],[11] Furthermore, laparoscopic inguinal hernia repair is another method for repairing these kinds of hernias. Before the introduction of laparoscopic methods, open conventional hernia repair was widely used.[12] Studies show that there is no significant difference between open conventional, tension-free, and laparoscopic hernia repairs.[13],[14] However, nowadays, the Lichtenstein method is the most favorable repair which is widely used throughout the world.[15] As the hernia in our case was giant and contained most of the bowels and the urinary bladder, we considered the risks of various hernia repairs and conducted combined Bassini and Lichtenstein technique to repair the posterior wall of the inguinal canal because of its stability. Hence, we have observed that using Bassini method in addition to Lichtenstein method would increase the stability and we recommend it in giant inguinoscrotal hernias, especially in those with great adhesions. The patient had a satisfactory postoperative status, and we did not observe any specific problem or complication.

In conclusion, despite the difficulty of repairing giant inguinal hernias, Lichtenstein method has been approved to be a safe and efficient method to repair the hernia and is extensively used by surgeons. We suggest combined Bassini and Lichtenstein method in giant inguinal hernias containing major part of the bowels and the bladder due to more solidity. We recommend further studies to compare this method with other techniques.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgement

This study has been approved and supported by Urmia University of Medical Science. I also would like to thank Urology Department of Imam Khomeini Hospital, Urmia, Iran.

Financial support and sponsorship

The study was supported by Urmia University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tarchouli M, Ratbi MB, Bouzroud M, Aitidir B, Ait-Ali A, Bounaim A, et al. Giant inguinoscrotal hernia containing intestinal segments and urinary bladder successfully repaired by simple hernioplasty technique: A case report. J Med Case Rep 2015;9:276.  Back to cited text no. 1
    
2.
Momiyama M, Mizutani F, Yamamoto T, Aoyama Y, Hasegawa H, Yamamoto H, et al. Treatment of a giant inguinal hernia using transabdominal pre-peritoneal repair. J Surg Case Rep 2016;2016. pii: rjw159.  Back to cited text no. 2
    
3.
Reşorlu M, Aylanc N, Toprak CA, Öztürk MÖ. Inguinal bladder herniation: A case report. J Health Sci Kocaeli Univ 2017;3:25-6.  Back to cited text no. 3
    
4.
Panagiotakis GI, Spyridakis KG, Chatziioannou MN, Kontopodis NG, Kandylakis SE. Repair of an inguinoscrotal hernia containing the urinary bladder: A case report. J Med Case Rep 2012;6:90.  Back to cited text no. 4
    
5.
Sturniolo G, Tonante A, Gagliano E, Taranto F, Schiavo M, D'Alia C. Surgical treatment of the giant inguinal hernia. Hernia 1999;3:27-30.  Back to cited text no. 5
    
6.
Karthikeyan VS, Sistla SC, Ram D, Ali SM, Rajkumar N. Giant inguinoscrotal hernia – Report of a rare case with literature review. Int Surg 2014;99:560-4.  Back to cited text no. 6
    
7.
Petersen LF, Luu MB. Giant inguinal scrotal hernia containing the sigmoid colon. Am Surg 2014;80:e185-6.  Back to cited text no. 7
    
8.
Minordi LM, Mirk P, Canadé A, Sallustio G. Massive inguinoscrotal vesical hernia complicated by bladder rupture: Preoperative sonographic and CT diagnosis. AJR Am J Roentgenol 2004;183:1091-2.  Back to cited text no. 8
    
9.
Bassini E. On the treatment of inguinal hernia. Arch Klin Chir 1890;40:429-76.  Back to cited text no. 9
    
10.
Bay-Nielsen M, Kehlet H, Strand L, Malmstrøm J, Andersen FH, Wara P, et al. Quality assessment of 26,304 herniorrhaphies in Denmark: A prospective nationwide study. Lancet 2001;358:1124-8.  Back to cited text no. 10
    
11.
Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. The tension-free hernioplasty. Am J Surg 1989;157:188-93.  Back to cited text no. 11
    
12.
Bendavid R. New techniques in hernia repair. World J Surg 1989;13:522-31.  Back to cited text no. 12
    
13.
Felix E, Scott S, Crafton B, Geis P, Duncan T, Sewell R, et al. Causes of recurrence after laparoscopic hernioplasty. A multicenter study. Surg Endosc 1998;12:226-31.  Back to cited text no. 13
    
14.
Phillips EH, Rosenthal R, Fallas M, Carroll B, Arregui M, Corbitt J, et al. Reasons for early recurrence following laparoscopic hernioplasty. Surg Endosc 1995;9:140-4.  Back to cited text no. 14
    
15.
Kulaçoǧlu H. Current options in umbilical hernia repair in adult patients. Ulus Cerrahi Derg 2015;31:157-61.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]



 

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