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False reduction of an inguinal hernia treated by Kugel patch repair via an
anterior approach
BMC Surgery 2015, 15:9
doi:10.1186/1471-2482-15-9
Naoya Yamada (yn708@jichi.ac.jp)
Atsushi Akai (atsuakai@gmail.com)
Akihiko Seo (a.seo0424@gmail.com)
Yukihiro Nomura (nomura@asahi.chiba.jp)
Nobutaka Tanaka (nbtanaka@hospital.asahi.chiba.jp)
ISSN
Article type
1471-2482
Case report
Submission date
21 August 2014
Acceptance date
22 January 2015
Publication date
2 February 2015
Article URL
http://www.biomedcentral.com/1471-2482/15/9
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False reduction of an inguinal hernia treated by
Kugel patch repair via an anterior approach
Naoya Yamada1*
*
Corresponding author
Email: yn708@jichi.ac.jp
Atsushi Akai1
Email: atsuakai@gmail.com
Akihiko Seo1
Email: a.seo0424@gmail.com
Yukihiro Nomura1
Email: nomura@asahi.chiba.jp
Nobutaka Tanaka1
Email: nbtanaka@hospital.asahi.chiba.jp
1
Department of Surgery, Asahi General Hospital, 1326 I, Asahi-shi, Chiba 2892511, Japan
Abstract
Background
Reduction en masse of inguinal hernia is a rare condition following manual reduction of an
unrecognized incarcerated inguinal hernia. The preoperative diagnosis and surgical treatment
via an inguinal approach has been considered difficult.
Case presentation
A 59-year-old man with lower abdominal pain was presented to our hospital. He was
diagnosed reduction en masse of an inguinal hernia based on his CT findings which showed
the presence a pre-peritoneal hernia sac containing the small bowel. An emergency operation
via an anterior approach was performed and we found a hernial sac containing an
incarcerated small bowel at the cranial and internal sides of the internal inguinal ring.
Opening of the hernial sac revealed necrosis of the incarcerated small bowel and bowel
resection was performed. Kugel patch was inserted into the pre-peritoneal space and the
patient made an uneventful recovery.
Conclusion
When it is accurately diagnosed, reduction en masse of an inguinal hernia can be treated with
direct Kugel repair via an anterior approach.
Keywords
Incarcerated inguinal hernia, Reduction en masse, CT imaging, Kugel patch repair
Background
False reduction of an inguinal hernia, also known as “reduction en masse”, is an extremely
rare condition of an incarcerated inguinal hernia in which a hernia sac reduces into the
preperitoneal space with its contents, but the retained bowel remains incarcerated and the
obstruction persists [1-3]. Although the condition requires urgent surgical treatment, an
accurate preoperative diagnosis has been difficult and a delay in diagnosis sometimes occurs
because the inguinal hernia appears to be reduced [4-8].
Surgical treatment for reduction en masse of an inguinal hernia consists of relief of
strangulation and hernia repair. In many reported cases of reduction en masse, exploratory
laparotomy or laparoscopy was used because patients were preoperatively diagnosed with
strangulated ileus of unknown origin. In those cases, reduction en masse was diagnosed on
the basis of intraoperative findings.
However, recognition of cases and recent utilization of computed tomography (CT) imaging
have made progress in accurate preoperative diagnosis of reduction en masse [1,7,8].
Accordingly, we herein report our experience of reduction en masse of inguinal hernia which
was treated by Kugel patch repair via an anterior approach.
Case presentation
A 59-year-old man presented to our hospital with lower abdominal pain and vomiting.
During a detailed interview, he said that he had noted a lump over his left groin for
approximately 3 years that had initially been reducible by manipulation but had become
progressively more difficult to reduce. Abdominal CT scan showed small bowel obstruction
with a transition point in the left inguinal region (Figure 1). A segment of the intestine was
entrapped within a hernial sac that was protruding into the pre-peritoneal space between the
parietal peritoneum and anterior abdominal wall. The patient was diagnosed with a reduction
en masse of an inguinal hernia and secondary mechanical small bowel obstruction.
Figure 1 CT findings scan of the patient. Preoperative computed tomography findings of
case showing small bowel obstruction with a transition point in the left inguinal groin. A
segment of intestine is entrapped in a hernial sac protruding into the pre-peritoneal space; a
horizonal view, b frontal view.
An emergency operation was performed under general anesthesia. A 5-cm incision was made
in the inguinal groin. The inguinal canal was opened, and the transverse fascia found to be
weak. The pre-peritoneal space was spread widely, and an Alexis wound retractor (Applied
Medical, Rancho Santa Margarita, CA, USA) was attached. We found a hernial sac
containing an incarcerated small bowel at the cranial and internal sides of the internal
inguinal ring (Figure 2a). These intraoperative findings confirmed proved the diagnosis of
false reduction en masse of an inguinal hernia. Opening of the hernial sac revealed severe
congestion and necrosis of the incarcerated small bowel (Figure 2b). The incarcerated small
bowel was strangulated at the thickend hernia neck. Therefore, the hernia neck was cut
deeply, and the small bowel was pulled out (Figure 2c). A 10-cm long portion of the small
bowel was resected, along with the excess hernial sac, and the sac was closed with sutures.
During these procedures, the pre-peritoneal space was spread wide enough to accommodate a
direct Kugel patch. After the wound was extensively washed, an oval, 8 × 12 cm Bard
Composix Kugel patch (Davol, Cranston, RI, USA) was inserted into the pre-peritoneal space
and fixed to the internal oblique muscle. The patient made an uneventful recovery and was
discharged on the fourth post-operative day. Six months have since passed with no sign of
recurrence.
Figure 2 Operational findings and surgical procedures. The hernial sac containing the
incarcerated small bowel is seen in the pre-peritonealspace at the cranial and internal sides of
the internal inguinal ring (a). Opening of the hernial sac revealed severe congestion and
necrosis of the incarcerated small bowel (b). The hernia neck is cut deeply to resect a 10-cm
long portion of the necrotic incarcerated small bowel (c).
Discussion
Reduction en masse of inguinal hernia is a rare condition and accurate preoperative diagnosis
has been difficult. In previous reported cases of reduction en masse, exploratory laparotomy
or laparoscopy was used because patients were preoperatively diagnosed with strangulated
ileus of unknown origin. In those cases, reduction en masse was diagnosed on the basis of
intraoperative findings and relief of strangulation and hernia repair could thus be performed.
In our patient, we could made an accurate preoperative diagnosis of reduction en masse due
to the careful medical history and mainly on the CT finding which showed the presence a preperitoneal hernia sac containing the small bowel and resembling to the previously reported
cases [1,7,8].
In addition to the difficulty in establishing an accurate preoperative diagnosis, surgical
treatment for reduction en masse via an inguinal approach has been considered difficult and
has rarely been reported to date [5,8]. Although transabdominal preperitoneal hernioplasty
has been reported to be useful for reduction en masse [5,7,8], we considered that if an
accurate preoperative diagnosis can be made, Kugel patch repair via an anterior approach
would be an optimal surgical treatment.
The open peritoneal repair of an inguinal hernia was first described in the late 1990s, and
Kugel patch inguinal hernia repair is one of the established treatment now, since it is less
invasive with a relatively low recurrence rate, satisfactory patient comfort, and various ideal
characteristics [9-11]. Based on our experiences, the key to the successful treatment of
reduction en masse via anterior approach consists of spreading the pre-peritoneal space
widely to fully expose the hernial sac, and then cutting down the neck of the hernial sac
deeply enough to pull out the small bowel. After these procedures are performed, the preperitoneal space is spread wide enough to accommodate insertion of the Kugel patch.
For inguinal hernia surgery, the choice of laparoscopic surgery or open surgery with an
inguinal approach is made according to an institute’s protocols. Not all institutes can perform
emergency laparoscopic surgery under general anesthesia, and some patients are not good
candidate for laparoscopic surgery. In addition, despite the development of minimally
invasive procedures, laparoscopic surgery for small bowel obstruction itself carries the risk of
perforation or other complications [12]. On the other hand, Kugel patch repair is sometimes
associated with mesh-related infections, especially when bowel resection is involved [13,14].
However, in this case, we avoided infection by using a wound retractor and extensive
washing. Thus, Kugel patch repair via an anterior approach for reduction en masse can be an
excellent choice with satisfactory outcomes.
Conclusion
In conclusion, reduction en masse is a rare disease that can be accurately diagnosed by the
collection of a detailed history and use of CT imaging and treated with direct Kugel repair via
an anterior approach.
Consent
Written informed consent was obtained from the patient for publicatin of this Case report and
any accompanying images. A copy of the written consent is available for review by the Editor
of this journal.
Abbreviations
CT, computed tomography
Competing interests
The authors declare that they have no competing interests. No financial support has been
received.
Authors’ contributions
NY performed operation, drafted the manuscript, and conducted a literature search. AA, AS
and YN performed operation, conducted a literature search, and contributed to drafting the
manuscript. TT reviewed the manuscript and gave final approval for publication. All authors
read and approved the final manuscript.
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