Presentation of case
A 67-year-old healthy male has been affected by long-standing, gradually enlarging of right-side inguinal hernia for the past 30 years. His symptom of abdominal discomfort after meal has worsened over time and he had lost 30 kg of weight in the past year. Physical examination revealed cachexia and large irreducible right-side inguinal hernia extending to the level of lower thigh (Fig. 1). Barium enema demonstrated ascending colon, cecum and ileum contained in hernia sac without any lesion of the large bowel (Fig. 2).
For the operation, after general anesthesia was administered, standard transverse incision at right inguinal area was performed. Hernia sac was dissected and separated from spermatic cord (Fig. 3A). After the hernia sac was opened, terminal ileum, cecum, ascending colon and omentum were found inside the hernia sac (Fig. 3B). An attempt was made at manual reduction but it was unsuccessful due to the massive size of the contents. At this point, lateral extension of internal ring was performed, followed by partial omentectomy. Manual reduction was then reattempted and on this occasion it was possible to reduce the contents into the abdominal cavity. Intra-abdominal pressure was measured and confirmed by intravesicular technique. Internal ring was repaired with interrupted Prolene #2/0. Lichtenstein’s tension-free technique was performed with polypropylene mesh. Hemostasis was checked and vacuum drain was placed due to the extent of raw surface. Patient was extubated and transferred to recovery room in stable condition.
He recovered uneventfully and the drain was removed before he was discharged on the seventh postoperative day. The patient was able to eat and has gradually regained weight. Small postoperative scrotal hematoma was treated non-operatively and resolved within few weeks. No evidence of recurrent inguinal hernia has been detected at 4 years after the operation.