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Clinical case: Giant Inguinal Hernia - want to learn more about it?

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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.

Objectives

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. Illustration 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 & Physical Exam

A 48-year-old extremely 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.

Imaging

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 & 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.

Objective Explanations

Objectives

  • 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.

Association Between Morbid Obesity and Respiratory Distress

Morbid obesity is associated with a reduction in lung volume as body fat occupies an increasing percentage of body cavities. Further, as illustrated in Figure 3, excess intra-abdominal fat causes elevation of the diaphragm and restricts its movements during respiration. The cause of death in this patient is not clearly identified in the case description but there is no doubt that respiratory difficulties contributed to it.

Differences Between Indirect and Direct Inguinal Hernias

This patient’s scrotum was massively distended due to the presence in the scrotum of herniated abdominal fat, fluid and viscera (Figure 3). In an indirect inguinal hernia, the spermatic cord and inguinal canal form a passageway allowing the abdominal contents to herniate out of the abdominal cavity and pass into the scrotum (Figure 4). The sac of an indirect inguinal hernia emerges from the abdominal cavity lateral to the inferior epigastric artery.

Inferior epigastric artery

In a direct inguinal hernia, the herniated material emerges from the abdominal cavity directly through the abdominal wall, often passing through the superficial inguinal ring, but it does not pass through the deep inguinal ring.

Superficial inguinal ring

A direct inguinal hernia can also enter the scrotum but it passes medial to the inferior epigastric artery as it exits the abdominal cavity. In the case described here, the surgeon was able to confirm that both right and left GIH’s were indirect hernias by their relationship to the inferior epigastric artery.

Deep inguinal ring

Contributions of a Megacolon to the Development of Inguinal Hernias

Megacolon (Figure 5) refers to extreme dilation of the colon (large bowel). It has multiple causes (congenital and acquired) and is associated with chronic constipation. Although this patient did not have megacolon, in some patients megacolon can contribute to the development of GIH because of the chronic straining that occurs during bowel movements.

Figure 5. Photograph of megacolon at surgery.

Radiological Densities in CT Images

CT imaging is based on x-ray technology and thus the apparent density (typically represented by “whiteness”) of a structure on a CT image is based on the physical nature of the structure’s molecule’s ability to scatter x-ray photons. Thus, bone is radiographically dense and its molecules scatter more photons than fat. In plain radiography and CT, metal and contrast material provides the brightest white image, followed by bone and calcification. The darkest images come from air, followed by adipose tissue and soft tissues.

The radiographic density of a structure is not transferable to ultrasound or MRI. In ultrasound, bright (hyperechoic) structures are more reflective of sound waves than dark (hypoechoic) structures. In MRI, the intensity (typically brightness) of a structure is dependent on the state of its hydrogen atoms and on the specific magnetic sequence used to produce that particular image.

Clinical case: Giant Inguinal Hernia - want to learn more about it?

Our engaging videos, interactive quizzes, in-depth articles and HD atlas are here to get you top results faster.

Sign up for your free Kenhub account today and join over 852,397 successful anatomy students.

“I would honestly say that Kenhub cut my study time in half.” – Read more. Kim Bengochea Kim Bengochea, Regis University, Denver

Show references

References:

  • Chida Y, Inokucki R, Kumada Y, Shinohara S. A case of lethal giant inguinal hernia. Clinical Case Reports 2015; 6(3): 301-302. Modified by Joel A. Vilensky PhD, Carlos A. Suárez-Quian PhD, Aykut Üren, MD

Layout:

  • Abdulmalek Albakkar
  • Adrian Rad

Illustrators:

  • Inguinal canal - ventral view - Hannah Ely
  • Inferior epigastric artery - Abdulmalek Albakkar
  • Superficial inguinal ring - Abdulmalek Albakkar
  • Deep inguinal ring - Abdulmalek Albakkar
© Unless stated otherwise, all content, including illustrations are exclusive property of Kenhub GmbH, and are protected by German and international copyright laws. All rights reserved.

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Inguinal canal

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