Hernia (2023) 27:1611–1615

https://doi.org/10.1007/s10029-023-02870-4

CASE REPORT

A case of giant inguinoscrotal hernia managed by preoperative

pneumoperitoneum with an unforeseen complication and outcome:
a case report and review of literature
A. H. El Shamarka1,3 · M. H. Zidan1,3 · M. S. Youssef2,3 · A. H. El Banna1,3 · M. Mourad1,3

Received: 3 June 2023 / Accepted: 19 August 2023 / Published online: 6 September 2023
© The Author(s) 2023

Abbreviations fear, limited access to healthcare, and socioeconomic dis-

GISH Giant inguinoscrotal hernia parities. The considerable size of the hernia can result in
CT Computerized tomography compression of adjacent structures, leading to symptoms
BTX Botulinum toxin A such as pain, discomfort, and impaired mobility. These mas-
IAH Intra-abdominal hypertension sive hernias pose significant problems, as the replacement
ACS Abdominal compartment syndrome of the herniated viscera causes an abrupt rise in the intra-
CRP C-reactive protein abdominal pressure, which compromises the cardiorespira-
PPP Progressive preoperative pneumoperitoneum tory system [2]. In addition to the typical hernia symptoms,
these patients frequently experience trouble voiding, urine
retention, and the possibility of pressure ulcers along the
Mega hernias or giant inguinoscrotal hernias (GISH) are lateral area of the scrotum, infection, and decreased mobility.
peculiar presentations of inguinoscrotal hernias, that can Moreover, the penis is buried inside the scrotum, permit-
attain extraordinary proportions. GISHs are defined as her- ting urine to drip into the already thin and delicate skin of
nias that extend below the midpoint of the inner thigh in the the scrotum, which is swollen from lymphatic and venous
standing position [1]. These hernias are distinguished by edema, leading to excoriation, ulceration, and secondary
a substantial and massive hernial sac, causing significant infection, these issues have a significant psychological
morbidity, and posing unique diagnostic and management impact and cause social isolation [3]. Therefore, the man-
challenges. agement of giant inguinoscrotal hernias necessitates meticu-
GISHs are often associated with chronicity and neglect, lous evaluation, surgical expertise, and a multidisciplinary
with patients presenting late due to various factors including approach involving general surgeons, urologists, interven-
tional radiologists, and/or plastic surgeons.
Despite advancements in surgical techniques and tech-
* A. H. El Shamarka nology, the management of giant inguinoscrotal hernias
ahmed.hesham1302@alexmed.edu.eg remains complex, and the literature on this topic is limited.
M. H. Zidan Therefore, the objective of this case report is to present a
dr.mohamedzidan1992.alexea@gmail.com challenging case of a GISH and provide a comprehensive
M. S. Youssef review of the current literature on the diagnosis, evaluation,
Dr.sanshy1993@gmail.com and management of this rare condition. By elucidating the
A. H. El Banna clinical features, diagnostic considerations, and treatment
a_elbanna21@alexmed.edu.eg modalities, this paper aims to contribute to the existing sci-
M. Mourad entific knowledge and enhance the understanding of this
m_morad09243@alexmed.edu.eg complex condition among healthcare professionals.
1
We are presenting a case of a 43-year-old male patient,
General Surgery Department, Main University Hospital,
who presented to the general surgery clinic with a large
Alexandria University, Alexandria 21568, Egypt
2
inguinal hernia that has been present since childhood, the
General Surgery Department, Alexandria Medical Research
patient had no significant medical or surgical history. His
Institute Hospital, Alexandria University, Alexandria, Egypt
3
symptoms included bouts of constipation, skin irritation,
Faculty of Medicine, Alexandria University,
and difficulty in micturition, these symptoms progressed in
Alexandria 21568, Egypt

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1612 Hernia (2023) 27:1611–1615

severity and frequency over time until he sought medical

advice.
Physical examination revealed a huge right-sided ingui-
noscrotal hernia extending to mid-thigh, Type II as per
Trakarnsagna classification [4]. Computerized tomography
(CT) scan of the abdomen and pelvis demonstrated a large
hernial sac containing the caecum, ascending colon, trans-
verse colon, ileal bowel loops, and marked fluid collection.
The patient was admitted to Alexandria Main University
Hospital and was planned for artificial pneumo-peritoneum
to facilitate reduction of the content and avoid postopera-
tive abdominal compartmental syndrome. A target volume
of 10 L of air gradually introduced over the course of 20 to
25 days was deemed sufficient for the hernia’s safe reduction.
A 12 French pigtail catheter was inserted intra-abdominally
by the intervention radiologist and we proceeded with infla-
tion of the abdomen with 400–500 cc of air daily depending
on the patient’s tolerance using a sterile syringe and manual
daily bedside inflation (Figs. 1, 2 and 3).
Serial CT scans of the abdomen were used to assess the
pneumoperitoneum’s progression and ensure the intra- Fig. 2  CT scan of the patient’s abdomen after PPP
abdominal volume was sufficient for the complete reduction
of the hernia. With the gradual introduction of air into the
peritoneal cavity the patient developed progressing dyspnea refused to remove the pigtail and left the hospital in hopes to
with every session. The maximum volume that was tolerated get re-admitted in the following days for surgery. After two
by the patient in the provided timeline was 7 L. The decision weeks, the patient returned to the hospital with abdominal
was made to proceed with hernioplasty; however, on the pain, fever, vomiting, and signs of peritonitis. Laboratory
morning of the surgery, the patient refused the surgery and investigations revealed a white count of 4.8 × 1­ 03/uL and
CRP 202, indicating early sepsis. ulc.
A follow-up CT scan of the abdomen revealed moder-
ate collection all over the abdomen and multiple loculated
collections, the largest at the sub-hepatic region and the
pelvis, The patient’s pigtail which was seen ending in the
collection, was opened into a retrieval collection bag, the
bag was immediately filled with 1 L of pus. Cultures were
drawn from the collection for culture and sensitivity and
serial drainage of the loculated collections was performed by
interventional radiologists and another pigtail was inserted
in the pelvic collection.
Daily assessment of the drain output was performed in
addition to serial ultrasound assessment of the intra-abdom-
inal collection in combination with culture-based antibiotics
used for the treatment of the intra-abdominal infection. Over
a period of 8 weeks, the abdominal drains’ output showed
marked regression, and the drains were removed, leaving
only the pelvic drain.
A follow-up CT scan showed near total resolution of the
intra-abdominal collections; however, marked regression of
the artificial pneumoperitoneum, and progression of a mod-
erate scrotal collection were noted compared to the first CT
scan on the patient. The progression of the scrotal collec-
tion led to the reduction of the hernial sac contents, and as
Fig. 1  CT scan of the patient’s abdomen before PPP such a final drain was placed in the scrotal collection, and

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Hernia (2023) 27:1611–1615
Fig. 3  Preoperative photo of
the patient’s hernia compared to
post-operative photo
a 3–4 L of a turbid serous scrotal aspirate was drained ini-
tially. Over the following two weeks, there was a regression
of the drain output, and a serial ultrasound was done until
total regression of the scrotal collection, and the patient was
rescheduled for hernioplasty.
An inguinal incision was made, along the whole length
of the inguinal ligament, and the opening of the inguinal
canal revealed a large sac with its contents partially reduced.
Reduction of the sac was undergone, and a large previously
drained abscess cavity was seen adherent to the cord. Dissec-
tion of the abscess cavity was done, with complete excision.
There was no spillage or pus content inside the cavity; there-
fore, Liechtenstein tension-free mesh repair was done, and a
negative suction drain was inserted before the closure of the
wound. Scrotal skin excision has its complications and thus
the redundant scrotum was left for conservative treatment.
The postoperative course was unremarkable, the patient
was mobile on the same day of the operation, oral feed-
ing was started the following day with no signs of obstruc-
tion or increased intra-abdominal pressure, no tachypnea
or decrease in the patient’s oxygen saturation was noted,
also measurement of urine output and renal function tests
was performed daily and where within normal range, the
drain showed less than 100 ccs of serous fluid daily and the
patient had mild scrotal skin edema. The patient was dis-
charged 5 days postoperatively with the drain still in place
and instructions on wound care and daily drain evacuation
and assessment of its output.
The patient was on a weekly follow-up schedule for the
first two weeks postoperatively. In the first week, there was a
marked regression of the redundant scrotal skin with residual
scrotal skin edema, and the drain output was below 50 ccs
of serous fluid daily. The drain was removed in the sec-
ond post-operative week. No wound-related complications
were noted in the follow-up. The one-month follow-up was
1613
unremarkable with the patient having improved mobility and
dramatic improvement in daily activities where previously
hindered by the hernia, no skin irritation or infections were
noted with an overall improvement in the patient’s quality
of life.
Reduction and repair of a GISH is a challenging surgi-
cal procedure and is linked with substantial morbidity and
mortality, resulting from returning the herniated organs to
the empty abdominal cavity [5]. A giant inguinal hernia is
associated with psychological and social impact due to the
patient’s discomfort, difficult mobilization, non-fitting of
clothes, and sexual discomfort.
The terms “loss of domain (LOD)”, or “loss of abdomi-
nal domain”, have recently been widely used in literature to
describe the distribution of abdominal content between the
hernia and residual abdominopelvic cavity [6]. A recently
written definition consensus to the term has been proposed.
LOD defines large hernias with difficult irreducibility due to
lack of intra-abdominal space, which entails reconstructive
surgery that would increase the risk of complications due to
raised intra-abdominal pressure [7]. Intraabdominal hyper-
tension (IAH) or abdominal compartment syndrome (ACS)
could develop due to the disproportion of the abdominal
cavity domain and the large content of the reduced hernial
sac, posing an increased risk of morbidity and mortality in
the peri-operative period [8]. Furthermore, reduction of the
hernial content would affect the integrity, and elasticity of
the abdominal wall muscles, resulting in possible atrophy
and fibrosis of the abdominal wall; thus, increasing the risk
of IAH [9].
Although there is not yet a consensus regarding the clas-
sification and management of GISH; Trakarnsagna proposed
a simple grading system to describe GISH [4]. Trakarnsagna
classification has not yet been applied to a systematic study,
nor has it been tested in literature to carefully depict GISH.
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Trakarnsagna proposed management options for his grades;
however, there are no current guidelines, nor systematic
reviews that recommend a specific management modality
for any of his grades.
Many management options have been proposed through-
out the literature, but none have been carefully studied as
to which would be the best options. All the management
options proposed were through case reports or series, and
no comparative studies have yet been conducted.
Surgical reduction of GISH without preoperative inter-
ventions such as the “hug” technique presented by Cavalli
in 2015 [10], has not been tested in clinical practice. The
risk of postoperative cardiorespiratory compromise and IAH
should still be taken into consideration.
Surgical resection or debulking of the hernial contents is
an option for treatment to decrease intra-abdominal pressure.
However, debulking surgeries may entail bowel resection,
omentectomy, and/or colectomy with or without cover-
ing ileostomies. Resection and anastomosis are associated
with the risk of anastomotic leakage, and infection of the
prosthesis from resected bowel. Furthermore, the need for
ileostomies would entail further operations. Thus, resection
of the hernial content might be associated with high mor-
bidity rates, in terms of ileostomies, leakage, post-reduction
cardiopulmonary compromise, and post-operative need for
intensive care monitoring and re-operation [4, 11, 12]. More
studies are still needed to re-evaluate debulking surgeries
and their morbidity rates.
Enlarging the abdominal cavity by major procedures such
as phrenectomy, creation of a ventral hernia using mesh and
scrotal skin or dartos muscle flaps, and abdominal wall
component separation techniques have been described in
the literature in efforts to decrease the post-operative risk of
increased intra-abdominal pressure [12]; however, the usage
of such techniques may be associated with high morbid-
ity. These major operations can be replaced by less invasive
techniques, such as botulinum toxin injection, and progres-
sive pneumoperitoneum instillation.
Botulinum toxin A (BTX) injection in the abdominal wall
has been described as temporary muscle paralysis without
systemic effects. Injection of BTX, for 6 to 45 days (about 1
and a half months), into the muscle can paralyze and elon-
gate the abdominal muscles: thus, increasing the abdominal
cavity space [13]. However, BTX injection is associated with
a prolonged hospital stay, and high cost [14].
Moreno first described the use of preoperative progres-
sive pneumoperitoneum (PPP) therapy in ventral hernias
[15], and many authors have proposed its usage in GISH
as a safe modality to prevent post-operative IAH or ACS
[4, 16, 17]. Preoperative progressive pneumoperitoneum
(PPP) is a technique that has been used in the manage-
ment of giant inguinoscrotal hernias. This technique
involves daily gradual insufflation of 500 cc–2000 cc of
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Hernia (2023) 27:1611–1615
carbon dioxide gas into the peritoneal cavity for 7–14 days
(about 2 weeks) to increase the intra-abdominal pressure
and increase the size of the hernial sac [18]. The gradual
increase in intra-abdominal pressure also helps to improve
respiratory function and reduce the risk of cardiorespira-
tory peri-operative complications. However, the usage of
PPP is associated with long hospital stays and induction
of infection. Overall, PPP is a valuable technique that can
improve outcomes in the management of GISH [17].
GISH repair is associated with postoperative scrotal
skin redundancy, especially when managed by PPP, owing
to the reduction of content, and increasing the abdominal
domain; thus, replacing the scrotal space with peritoneal
collections, with the risk of abscess formation, if hernio-
plasty was delayed. The considerable drainage of scrotal
collections might be studied carefully, and its incidence
should be evaluated in GISH, and after the usage of PPP
[19, 20].
Postoperative scrotal skin redundancy can be left for fol-
low-up, as scrotal skin elasticity carries marvelous results to
retain its normal size; however, postoperative scrotal hema-
tomas can be evident after the reduction of long-standing
hernias. Formation of neo-scrotum has also been suggested
in the literature, with or without the usage of flaps [21, 22];
nonetheless, there are no studies that compare both tech-
niques regarding the postoperative results and complications.
Studies have shown that PPP can effectively increase
intra-abdominal pressure. PPP was associated with facili-
tating the reduction of the hernial content and decreased
rate of complications in patients with GISH [17, 23] . Many
case reports provide evidence to support the use of PPP as
a safe and effective technique in the management of GISH;
However, more studies and systematic reviews are needed
to evaluate the usage of PPP and compare PPP with other
modalities currently used to avoid post-operative IAH in the
management of GISH such as BTX injection in respect to
complication rates, hospital stay, and cost-effectiveness.
In conclusion, GISH is a rare presentation of all ingui-
noscrotal hernias, that is managed by various lines, as there
still is no consensus or a standard guideline. Current evi-
dence of management depends solely on a case-by-case
basis, and there is still no evidence to support which line is
better in what circumstances. A consensus should be reached
to clearly define, grade, and manage GISH.
Acknowledgements Not applicable.
Author contributions Conceptualization: AES, MHZ. Collected
consent and data: MS, AEB, and MHZ. Contributing author: AHES.
Supervision and acquisition of ethical approval: MM. Writing—origi-
nal draft: AES, MS, and AEB. Writing final manuscript edition: MHZ,
AES, MS, and AEB.
Hernia (2023) 27:1611–1615
Funding Open access funding provided by The Science, Technology &
Innovation Funding Authority (STDF) in cooperation with The Egyp-
tian Knowledge Bank (EKB). No funding.
Data availability All data generated or analyzed during this study are
included in this published article.
Declarations
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval and consent to participate The work was approved by
the ethical committee of the Alexandria Faculty of Medicine in 2023.
Consent for publication Written informed consent was obtained from
the patient for publication of this case report and any accompanying
images.
Human and animal rights The authors of this article declare that the
ethics committee and review board in our institute approved the study
and treatment protocol.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
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permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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