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Reduction en masse of incarcerated inguinal hernia
Reduction en Masse of Incarcerated Inguinal Hernia A NEW LOOK AT AN OLD PROBLEM MICHAEL P. BRADY,
M.B. AND
FRANK J. VEITH,
From the Departments of Surgery, Harvard Medical School and Peter Bent Brigbam Hospital, Boston, Massachusetts.
1702 Saviard [I] reported the postmortem findings after an operation for stranguIated inguina1 hernia. He noted that the hernia1 sac had been reduced within the abdomen without reIief of the stranguIation. From that date unti1 1931, when Pearse [2] pubIished a r&sum6 of reduction en masse, onIy 190 cases were to be found in the surgica1 Iiterature. In 1941 Casten and Bodenheimer [3] were abIe to report another seventeen cases incIuding two of their own. Since then nine additiona cases have appeared, the most recent being that by Renton [4]. Pearse estimated that reduction en masse occurred once in 13,000 cases of hernia. The paucity of case reports in recent years suggests that the present incidence is much Iess than that noted in 1931. This probabIy stems from a change in the cIinica1 approach to hernias, which incIudes earIy repair of most hernias and the abandonment of taxis in irreducibIe hernias. The present case is reported because it seems to be an unusua1 variant of an already unusua1 condition. It aIso serves to remind us of a condition which might be caIIed an old deceiver. Cooper [T] in 1823 wrote, “A hernia may be
I
N
reduced by the empIoyment of taxis, and stranguIation stiI1 exist.” He goes on to describe the case of a direct hernia which was reduced through HesseIbach’s triangIe by taxis. “The symptoms of stranguIation, however, stiI1 continued, and in two or three days the man died. On examination of his body, the hernia was found pIaced immediateIy behind the externa1 ring, with a stricture stiI1 existing at the mouth of the sac.” American Journal
of Surgery,Volume
107,
June1961
M.D.,
Boston,
Massachusetts
CASE REPORT The patient (P.B.B.H. No. o-61-96) was a seventy-six year oId man who had a Iong history of a reducibIe Ieft inguina1 hernia for which he had worn a truss. After a common femoral vein Iigation six years ago, his hernia had remained reduced and he had discarded his truss. Twenty-four hours prior to admission, coIicky mid- and Iower abdominal pain developed with nausea but no vomiting. The pain persisted except for a three hour interva1 of reIief after an enema which resuIted in a norma stoo1. He complained of chronic cough, constipation and urinary hesitancy. He had been unable to pass urine for ten hours prior to admission. Past history included two previous hospital admissions, one for myocardial infarction six years ago and one for a right middle cerebra1 thrombosis four years ago. He had made a good recovery from both these episodes and was receiving Iong-term anticoaguIant therapy with DicumaroI.@ PhysicaI examination reveaIed a thin, edentuIous, eIderIy man. Temperature was g8”F., puIse IOO and regular, respiration 24, bIood pressure 100/70 mm. Hg. The chest was miIdIy emphysematous. The abdomen was sIightIy distended in the infraumbiIica1 region, with marked tenderness and some guarding in both Iower quadrants. No rigidity or rebound tenderness was noted. Percussion revealed an area of suprapubic duIIness corresponding to a fuI1 bIadder. BoweI sounds were present but hypoactive. He had a Ieft indirect inguina1 hernia which extended into the upper third portion of the scrotum. This was sIightIy tender but was easiIy reduced by two fingertips’ pressure over its fundus. Both testicIes were normaI. Recta1 examination reveaIed benign hypertrophy of the prostate. Laboratory examination was as foIIows: urinary specific gravity, 1,015; protein and sugar, negative for abnormaIities; Ieukocytes, 5 to 6 per high power heId. Hematocrit was 54 per cent; white bIood ceII count, 12,600 per cu. mm.; stoo1 benzidine, 4 PIUS.
868
Incarcerated Bloc~i urea nitrogen l\as 10 mg. per cent; sodium, 143 mEq. I..; potassium, 3.8 mEq./L.; chloride, I 05 nl Eq. I>.; carbon dioxide, 20 mm., L.; serum :lutamic oxalacctic transaminase, 50 Hcnl-y units; lactic dehy-drogznasc activity, 168 Wackcr units; ~~rotlirombin timr, 15 per cent. Initial elcctrocarcliogram suggested the presence of a rcccnt antcroscptal myocardial infarction. Chest rocntgenopram was lvithin normal limits. An upright tilm of the abdomen showed some loops of small intestine \vith air-fluid levels. No definite cvidencc of obstruction was seen. A large soft tissue mass \vas present in the pelvis consistent with a distended bladder. There was extensive vascular calcification. The patient n-as admitted with a working diagnosis of mesentcric vascular accident in vie\\ of his previous vascuIar history, extensive evidence of arterioscIerosis, abdominal pain and benzidinepositive stools. A Foley catheter was inserted, resulting in the evacuation of 1,200 ml. of clear urine, with some relief of the patient’s pain. Because some abdominal pain and tenderness persisted, a four-quadrant abdominal tap was performed which was negative for abnormalities. For this reason and because of worrisome electrocardiographic findings, the patient was observed for a day. The hernia was still easily reducible thirty-six hours after the patient’s admission; this finding bvas confirmed by several observers. Lower abdominaI pain persisted, however, and gastric aspiration produced 360 m1. of benzidine-positive, fecal smelling material. The white bIood ceI1 count of rose to 14,000 per cu. mm. X-ray examination the abdomen showed more distended loops of small bowel, and even though the electrocardiogram showed evidence of an evoIving myocardial infarction, abdominal exploration was undertaken. At operation some cloudy peritoneal fluid was noted. The cccum and terminal ileum were not distended, but the small intestine was distended to within 2 feet of the iIeocoIic junction, where a knuckle of ileum was found to be incarcerated within a left inguinal hernial sac. The sac was capabIe of being compIeteIy reduced from its extraperitonea1 inguinal position to a position within the abdominal cavity without giving up its intestinal content, which was heId by the constrict ing ring of peritoneum at the neck of the sac. At this point a left inguina1 incision was made. Considerable edema was present. On exploring the spermatic cord, it was apparent that the sac was free from the other cord structures and couId be freely displaced in and out of the abdomina1 cavity through the internal inguinal ring. The neck of the sac was incised. Serosanguineous fluid escaped and IO cm. of dusky i1eum were liberated. The pink coIor of this segment returned after a period of
Inguinal
Hernia
FIG. I. The us& type of en masse reduction, with the intestine incarcerated in the internal locu1us of the biIocuIar sac. observation, and it was returned to the peritonea1 cavity. Left orchidectomy was performed and the Ieft internal ring was cIosed completely. The conjoined tendon was approximated to the inguina1 Iigament. The remainder of the groin and abdominaI incisions were closed in routine fashion. The patient tolerated the procedure weI1. His postoperative course was uncomphcated, and he has remained we11 for six months subsequently. COMMENTS Zimmerman and Anson [6] made the foIIowing statements: “The diffIcuIty of separating obIique inguina1 hernias from the structures of the cord renders true spontaneous or traumatic reduction en masse unIikeIy,” and “It is extremeIy probabIe that most, if not all, cases of en masse reductions are actuaIIy biIocuIar hernias in which the stranguIated viscera are mereIy forced from the main portion of the sac into its preperitonea1 diverticuIum.” The type of Iesion which is present in most instances of en masse reduction is depicted in Figure I. In 1958 Murdock [7] described two cases. One of these was a biIocuIar hernia. The other was a uniIocuIar hernia in which the processus vaginaIis was obIiterated and the hernia was
869
Brady Peritoneum
and Veith be mobiIe and capabIe of being separated from the cord structures; (2) there must be Iaxity of the tissues between the interna ring and parieta1 peritoneum; (3) the interna ring, a defect in the transversaIis fascia, must be sufficiently Iarge to aIIow the sac pIus its contents to be reduced through it. The diagnosis in a case such as ours may be suspected preoperativeIy. UsuaIIy the hernia has been present for severa years and successfuIIy reduced many times during this period. A truss may have been worn. The onset of symptoms and signs of intestina1 obstruction may coincide with manua1 reduction of the hernia1 mass. These manifestations do not subside as expected after reduction or may subside for onIy a brief interva1. PhysicaI examination, except for estabIishing the presence of intestina1 obstruction, wiI1 not usuaIIy aid in estabIishing the causative factor. A paIpabIe mass by recta1 or abdominal examination is a reIativeIy uncommon finding. The externa1 ring may be enIarged and tenderness deep in the inguina1 cana may be present after reduction; there may be a feebIe impuIse on coughing. The treatment is surgica1 and the Iesion is best approached by a combined abdomina1 and inguina1 route.
/
FIG. 2. True en masse reduction, with sac pIus contents dispIaced through the interna inguinal ring.
incarcerated in a preperitonea1 sac. He aIso stated that true reduction en masse did not occur and that most cases recorded were, in fact, biIocuIar hernias. In our patient, using a combined abdomina1 and inguina1 approach, it was possibIe to demonstrate that the hernia1 sac was uniIocuIar, descended into the upper haIf of the scrotum, and couId be readiIy separated from the cord structures. It couId be dispIaced through a diIated interna ring into a retroinguina1 properitonea1 position, from which it invaginated itseIf into the genera1 peritonea1 cavity with an appearance suggesting the invagination of the vagina by the cervix. (Fig. 2.) A carefu1 review of the literature showed that in many cases the anatomic detaiIs could not be gIeaned from the operative descriptions. This was due to the fact that up unti1 the 1930’s a pureIy abdomina1 approach was made to these Iesions. In 1939, however, WooIf [8] described a case simiIar to ours and said he was abIe to find onIy three such cases of true reduction en masse reported previousIy. CooIey’s [g] case in 1942 and Renton’s [4] case in 1962, which was the onIy direct hernia of the series, aIso appear to satisfy our criteria. The foIIowing factors are probabIy necessary for the deveIopment of findings such as those which occurred in our patient: (I) the sac must
SUMMARY I. A case of true reduction en masse of an incarcerated inguina1 hernia is described, making a tota of seven such cases in the Iiterature. 2. The pathoIogic anatomy, diagnosis and treatment are discussed. REFERENCES I. SAVIARD, B. Observations
2. 2. 4. 5. 6.
7. 8.
9.
870
de chirurgie. Paris, 1702. Quoted by Pearse, H. E. [z]. PEARSE, H. E., JR. StranguIated hernia reduced en masse. Surg. Gynec. &+Gbst., 53: 822, 1931. CASTEN, D. and BODENHEIMER. M. StranguIated hernia reduced en masse. Surgery, g: 561, 1941. RENTON, C. G. Reduction en masse of direct inguinal hernia. Brit. M. J., 5293: 1671, 1962. COOPER, A. Lectures on Surgery. - _ PhiIadeIphia, 1839. HanwelI, Barrington & HanweII. ZIMMERMAN,L. M. and ANSON, B. J. Anatomy and Surgery of Hernia. BaItimore, 1953. WiIIiams & WiIkins Co. MURDOCK, C. E., JR. Preperitoneal hernia. Ann. SUr&, 147: 531; 1958. WOOLF, H. R. I. StranguIation of inguina1 hernia from auto reduction en masse. Brit. J. Surg.. 27: 421, 1939. COOLEY, G. G. Auto reduction en masse of an inguinaI hernia. Brit. J. Surg., 29: 352, 1942.
M.B. AND
FRANK J. VEITH,
From the Departments of Surgery, Harvard Medical School and Peter Bent Brigbam Hospital, Boston, Massachusetts.
1702 Saviard [I] reported the postmortem findings after an operation for stranguIated inguina1 hernia. He noted that the hernia1 sac had been reduced within the abdomen without reIief of the stranguIation. From that date unti1 1931, when Pearse [2] pubIished a r&sum6 of reduction en masse, onIy 190 cases were to be found in the surgica1 Iiterature. In 1941 Casten and Bodenheimer [3] were abIe to report another seventeen cases incIuding two of their own. Since then nine additiona cases have appeared, the most recent being that by Renton [4]. Pearse estimated that reduction en masse occurred once in 13,000 cases of hernia. The paucity of case reports in recent years suggests that the present incidence is much Iess than that noted in 1931. This probabIy stems from a change in the cIinica1 approach to hernias, which incIudes earIy repair of most hernias and the abandonment of taxis in irreducibIe hernias. The present case is reported because it seems to be an unusua1 variant of an already unusua1 condition. It aIso serves to remind us of a condition which might be caIIed an old deceiver. Cooper [T] in 1823 wrote, “A hernia may be
I
N
reduced by the empIoyment of taxis, and stranguIation stiI1 exist.” He goes on to describe the case of a direct hernia which was reduced through HesseIbach’s triangIe by taxis. “The symptoms of stranguIation, however, stiI1 continued, and in two or three days the man died. On examination of his body, the hernia was found pIaced immediateIy behind the externa1 ring, with a stricture stiI1 existing at the mouth of the sac.” American Journal
of Surgery,Volume
107,
June1961
M.D.,
Boston,
Massachusetts
CASE REPORT The patient (P.B.B.H. No. o-61-96) was a seventy-six year oId man who had a Iong history of a reducibIe Ieft inguina1 hernia for which he had worn a truss. After a common femoral vein Iigation six years ago, his hernia had remained reduced and he had discarded his truss. Twenty-four hours prior to admission, coIicky mid- and Iower abdominal pain developed with nausea but no vomiting. The pain persisted except for a three hour interva1 of reIief after an enema which resuIted in a norma stoo1. He complained of chronic cough, constipation and urinary hesitancy. He had been unable to pass urine for ten hours prior to admission. Past history included two previous hospital admissions, one for myocardial infarction six years ago and one for a right middle cerebra1 thrombosis four years ago. He had made a good recovery from both these episodes and was receiving Iong-term anticoaguIant therapy with DicumaroI.@ PhysicaI examination reveaIed a thin, edentuIous, eIderIy man. Temperature was g8”F., puIse IOO and regular, respiration 24, bIood pressure 100/70 mm. Hg. The chest was miIdIy emphysematous. The abdomen was sIightIy distended in the infraumbiIica1 region, with marked tenderness and some guarding in both Iower quadrants. No rigidity or rebound tenderness was noted. Percussion revealed an area of suprapubic duIIness corresponding to a fuI1 bIadder. BoweI sounds were present but hypoactive. He had a Ieft indirect inguina1 hernia which extended into the upper third portion of the scrotum. This was sIightIy tender but was easiIy reduced by two fingertips’ pressure over its fundus. Both testicIes were normaI. Recta1 examination reveaIed benign hypertrophy of the prostate. Laboratory examination was as foIIows: urinary specific gravity, 1,015; protein and sugar, negative for abnormaIities; Ieukocytes, 5 to 6 per high power heId. Hematocrit was 54 per cent; white bIood ceII count, 12,600 per cu. mm.; stoo1 benzidine, 4 PIUS.
868
Incarcerated Bloc~i urea nitrogen l\as 10 mg. per cent; sodium, 143 mEq. I..; potassium, 3.8 mEq./L.; chloride, I 05 nl Eq. I>.; carbon dioxide, 20 mm., L.; serum :lutamic oxalacctic transaminase, 50 Hcnl-y units; lactic dehy-drogznasc activity, 168 Wackcr units; ~~rotlirombin timr, 15 per cent. Initial elcctrocarcliogram suggested the presence of a rcccnt antcroscptal myocardial infarction. Chest rocntgenopram was lvithin normal limits. An upright tilm of the abdomen showed some loops of small intestine \vith air-fluid levels. No definite cvidencc of obstruction was seen. A large soft tissue mass \vas present in the pelvis consistent with a distended bladder. There was extensive vascular calcification. The patient n-as admitted with a working diagnosis of mesentcric vascular accident in vie\\ of his previous vascuIar history, extensive evidence of arterioscIerosis, abdominal pain and benzidinepositive stools. A Foley catheter was inserted, resulting in the evacuation of 1,200 ml. of clear urine, with some relief of the patient’s pain. Because some abdominal pain and tenderness persisted, a four-quadrant abdominal tap was performed which was negative for abnormalities. For this reason and because of worrisome electrocardiographic findings, the patient was observed for a day. The hernia was still easily reducible thirty-six hours after the patient’s admission; this finding bvas confirmed by several observers. Lower abdominaI pain persisted, however, and gastric aspiration produced 360 m1. of benzidine-positive, fecal smelling material. The white bIood ceI1 count of rose to 14,000 per cu. mm. X-ray examination the abdomen showed more distended loops of small bowel, and even though the electrocardiogram showed evidence of an evoIving myocardial infarction, abdominal exploration was undertaken. At operation some cloudy peritoneal fluid was noted. The cccum and terminal ileum were not distended, but the small intestine was distended to within 2 feet of the iIeocoIic junction, where a knuckle of ileum was found to be incarcerated within a left inguinal hernial sac. The sac was capabIe of being compIeteIy reduced from its extraperitonea1 inguinal position to a position within the abdominal cavity without giving up its intestinal content, which was heId by the constrict ing ring of peritoneum at the neck of the sac. At this point a left inguina1 incision was made. Considerable edema was present. On exploring the spermatic cord, it was apparent that the sac was free from the other cord structures and couId be freely displaced in and out of the abdomina1 cavity through the internal inguinal ring. The neck of the sac was incised. Serosanguineous fluid escaped and IO cm. of dusky i1eum were liberated. The pink coIor of this segment returned after a period of
Inguinal
Hernia
FIG. I. The us& type of en masse reduction, with the intestine incarcerated in the internal locu1us of the biIocuIar sac. observation, and it was returned to the peritonea1 cavity. Left orchidectomy was performed and the Ieft internal ring was cIosed completely. The conjoined tendon was approximated to the inguina1 Iigament. The remainder of the groin and abdominaI incisions were closed in routine fashion. The patient tolerated the procedure weI1. His postoperative course was uncomphcated, and he has remained we11 for six months subsequently. COMMENTS Zimmerman and Anson [6] made the foIIowing statements: “The diffIcuIty of separating obIique inguina1 hernias from the structures of the cord renders true spontaneous or traumatic reduction en masse unIikeIy,” and “It is extremeIy probabIe that most, if not all, cases of en masse reductions are actuaIIy biIocuIar hernias in which the stranguIated viscera are mereIy forced from the main portion of the sac into its preperitonea1 diverticuIum.” The type of Iesion which is present in most instances of en masse reduction is depicted in Figure I. In 1958 Murdock [7] described two cases. One of these was a biIocuIar hernia. The other was a uniIocuIar hernia in which the processus vaginaIis was obIiterated and the hernia was
869
Brady Peritoneum
and Veith be mobiIe and capabIe of being separated from the cord structures; (2) there must be Iaxity of the tissues between the interna ring and parieta1 peritoneum; (3) the interna ring, a defect in the transversaIis fascia, must be sufficiently Iarge to aIIow the sac pIus its contents to be reduced through it. The diagnosis in a case such as ours may be suspected preoperativeIy. UsuaIIy the hernia has been present for severa years and successfuIIy reduced many times during this period. A truss may have been worn. The onset of symptoms and signs of intestina1 obstruction may coincide with manua1 reduction of the hernia1 mass. These manifestations do not subside as expected after reduction or may subside for onIy a brief interva1. PhysicaI examination, except for estabIishing the presence of intestina1 obstruction, wiI1 not usuaIIy aid in estabIishing the causative factor. A paIpabIe mass by recta1 or abdominal examination is a reIativeIy uncommon finding. The externa1 ring may be enIarged and tenderness deep in the inguina1 cana may be present after reduction; there may be a feebIe impuIse on coughing. The treatment is surgica1 and the Iesion is best approached by a combined abdomina1 and inguina1 route.
/
FIG. 2. True en masse reduction, with sac pIus contents dispIaced through the interna inguinal ring.
incarcerated in a preperitonea1 sac. He aIso stated that true reduction en masse did not occur and that most cases recorded were, in fact, biIocuIar hernias. In our patient, using a combined abdomina1 and inguina1 approach, it was possibIe to demonstrate that the hernia1 sac was uniIocuIar, descended into the upper haIf of the scrotum, and couId be readiIy separated from the cord structures. It couId be dispIaced through a diIated interna ring into a retroinguina1 properitonea1 position, from which it invaginated itseIf into the genera1 peritonea1 cavity with an appearance suggesting the invagination of the vagina by the cervix. (Fig. 2.) A carefu1 review of the literature showed that in many cases the anatomic detaiIs could not be gIeaned from the operative descriptions. This was due to the fact that up unti1 the 1930’s a pureIy abdomina1 approach was made to these Iesions. In 1939, however, WooIf [8] described a case simiIar to ours and said he was abIe to find onIy three such cases of true reduction en masse reported previousIy. CooIey’s [g] case in 1942 and Renton’s [4] case in 1962, which was the onIy direct hernia of the series, aIso appear to satisfy our criteria. The foIIowing factors are probabIy necessary for the deveIopment of findings such as those which occurred in our patient: (I) the sac must
SUMMARY I. A case of true reduction en masse of an incarcerated inguina1 hernia is described, making a tota of seven such cases in the Iiterature. 2. The pathoIogic anatomy, diagnosis and treatment are discussed. REFERENCES I. SAVIARD, B. Observations
2. 2. 4. 5. 6.
7. 8.
9.
870
de chirurgie. Paris, 1702. Quoted by Pearse, H. E. [z]. PEARSE, H. E., JR. StranguIated hernia reduced en masse. Surg. Gynec. &+Gbst., 53: 822, 1931. CASTEN, D. and BODENHEIMER. M. StranguIated hernia reduced en masse. Surgery, g: 561, 1941. RENTON, C. G. Reduction en masse of direct inguinal hernia. Brit. M. J., 5293: 1671, 1962. COOPER, A. Lectures on Surgery. - _ PhiIadeIphia, 1839. HanwelI, Barrington & HanweII. ZIMMERMAN,L. M. and ANSON, B. J. Anatomy and Surgery of Hernia. BaItimore, 1953. WiIIiams & WiIkins Co. MURDOCK, C. E., JR. Preperitoneal hernia. Ann. SUr&, 147: 531; 1958. WOOLF, H. R. I. StranguIation of inguina1 hernia from auto reduction en masse. Brit. J. Surg.. 27: 421, 1939. COOLEY, G. G. Auto reduction en masse of an inguinaI hernia. Brit. J. Surg., 29: 352, 1942.