Slovenská chirurgia 3/2022

“Loss of domain” inguinal hernia: a case report

Giant scrotal hernias are nowadays rare entity with decreasing incidence in developed countries. Giant inguinoscrotal hernia is defined as a hernia that extends below the midpoint of the inner thigh when the patient is in standing position but also when the hernial sac contains more than 15-20% of the abdominal organs. For this types of hernia also term „loss of domain“ is used. It is an unusual disease nowadays and its management can be a challenge for surgeons. Herniolaparotomy is procedure of choice in the most causes. The most challenging aspect of procedure is reposition of organs in hernia sac back to peritoneal cavity in case of increasing intraabdominal pressure and danger of abdominal compartment syndrome presentation. This situation leads to higher morbidity and mortality. Many techniques of prevention have been described such as progressive preoperative pneumoperitoneum, injections with botulotoxin and reduction/debulking of organs in hernial sac. There is no current guideline how to manage this type of diagnose. 60 years old man with 25 years anamnesis of inguinal hernia, who underwent surgery because of giant scrotal „loss of domain“ hernia at 2nd clinic of surgery L. Pasteur University Hospital and Pavol Jozef Šafárik University, Medical Faculty is presented in this case report. Aboral part of ileum, caecum, colon ascendens, colon transversum, colon descendens, colon sigmoideum and omentum majus were identified inside hernial sac during surgery. Omentectomy with reposition of organs were done using combinied herniolaparotomy open approach. Lictenstein´s procedure with mesh placement was used and laparotomy was closed with ventrofil suture. Postoperative period was without complications. Patient underwent Winkelmann´s procedure 8 weeks after previous surgery because of hydrocele. 12 months after procedure incision of subcutaneous abscess after previous laparotomy with treatment using NPWT (negative pressure wound therapy) was indicated. Finally wound was closed by secondary suture. A patient is without any complications. No recurrence of inguinal hernia was observed.

Keywords: giant scrotal hernia, Lichtensteins procedure, laparotomy