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Clinical case: Giant inguinal hernia

This article is based on a case report published in the Journal "Case Reports in Surgery" in 2015, by Caroline C. Jadlowiec, Beata E. Lobel, Namita Akolkar, Michael D. Bourque, Thomas J. Devers, and David W. McFadden.

It has been modified and reviewed by Joel A. Vilensky PhD, Carlos A. Suárez-Quian PhD, Aykut Üren, MD.

  1. Objectives
  2. Case description
    1. History and physical exam
    2. Imaging
    3. Management and evolution
  3. Anatomical considerations
  4. Objective explanations
    1. Objectives
    2. Association between morbid obesity and respiratory distress
    3. Differences between indirect and direct inguinal hernias
    4. Contributions of a megacolon to the development of inguinal hernias
    5. Radiological densities in CT images
  5. Sources
+ Show all


After reviewing this case you should be able to describe or do the following:

  • Why morbid obesity is associated with respiratory distress.
  • The difference between an indirect and a direct inguinal hernia.
  • What is megacolon and how does it sometimes contribute to the development of inguinal hernias.
  • The underlying basis of the appearance of structures of differing radiological densities on a CT image. The explanation should include whether these identical densities are relevant to other imaging modalities such as radiography, MRI and ultrasound.
Figure 1. Cadaver image showing that a direct inguinal hernia typically emerges from the abdominal cavity in the region of or through the superficial inguinal ring whereas an indirect hernia passes through the deep inguinal ring. Note how the path of the inferior epigastric artery can be used to differentiate between the two types of inguinal hernias.

Case description

History and physical exam

A 48-year-old morbidly obese man, without any significant surgical/medical history, presented with respiratory distress. Physical examination revealed abdominal distension without abdominal pain and a very enlarged scrotum containing herniated abdominal viscera, fluid and fat (Figure. 2).

Figure 2. Photo of the patient showing hernias within the scrotum, it shows how the penis and scrotum have almost become a single cavity. This occurred in this patient because of the continuity of the Dartos fascia, which lines both. This continuity is very difficult to appreciate in cadaver dissections but in this photograph of this obese patient, the effects of the continuity are very apparent.


Electrocardiogram, echocardiography, and chest X-ray were normal.

CT imaging revealed giant bilateral inguinal hernias (GIH) and an elevated diaphragm, which was presumably associated with the patient’s respiratory distress (Figures 3 and 4).

Figure 3. Coronal CT at the level of sternum showing very enlarged scrotum with herniated intra-abdominal contents (mainly fat at this level).

Management and evolution

Further examination at surgery revealed the GIH’s to be indirect hernias (personal communication from author). Upon admission to the hospital, the patient underwent emergency surgery, which found widespread necrosis within the inguinal canal. Unfortunately, the patient died after the surgery in the intensive care unit. A subsequent autopsy excluded toxic megacolon as a cause of death.

Figure 4. Coronal mid-axillary level CT showing herniated contents inside the scrotum. Right scrotum [2] has mainly viscera (small bowels loops, fluid, and herniated abdominal fat), whereas left scrotum [1] contains mainly abdominal fat at this level.

Anatomical considerations

Despite the patient’s obesity and massive hernias, this patient’s primary complaint was respiratory distress. Thus, his obesity presumably put pressure on his diaphragm precluding full inspiration and eventually contributed to his death. Giant inguinal hernia (GIH) is defined as hernia extending below the midpoint of the inner thigh in the standing position. Clearly, this definition applied to this patient. The hernias were diagnosed as indirect hernias, thus all of the herniated viscera passed through the inguinal canal, which is unusual for his age group. Indirect hernias are more common in younger patients commonly associated with congenital malformation. Direct hernias are more common in older patients (Figure 2).

Inguinal canal - ventral view

Inguinal hernias are more frequently observed in male patients, compared to female patients who suffer from femoral hernias at a higher frequency. The patient did not also suffer from megacolon, which often contributes to the development of hernias by increasing the intra-abdominal pressure. Any condition that may increase intra-abdominal pressure including pregnancy, chronic obstructive pulmonary disease (COPD, constant coughing), heavy weight lifters, obesity, and chronic constipation may increase the risk of inguinal hernias.

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