A rare case of reduction en masse of incarcerated inguinal hernia: A case report

Introduction and importance Reduction en masse is a rare complication of incarcerated inguinal hernias, occurring when the herniated sac, along with the trapped hernia, returns to the preperitoneal space. Case presentation In this study, we describe a 74-year-old male patient who presented to the hospital with a history of manual hernia reduction and complaints of nausea, vomiting, and constipation for two weeks. After undergoing paraclinical tests, he underwent open surgery with a diagnosis of hernia reduction en masse, during which the hernia sac was separated from the surrounding structures. Abdominal and peritoneal defects were also repaired intra-abdominally. After his condition stabilized, the patient was discharged with prescription medications. Discussion Reduction en masse in inguinal hernia cases is rare, where the hernia sac and intestinal contents are reduced while the intestine remains incarcerated. Computed tomography (CT) scans can aid in diagnosis, revealing characteristic features such as closed-loop obstruction and inguinal soft tissue changes. Treatment options include open laparotomy and laparoscopy, with laparoscopy being preferred depending on surgeon expertise, assessment of intestinal viability post-reduction, and patient stability. Conclusions The potential complications of hernia reduction en masse should be emphasized to patients who choose not to remain under medical supervision, as well as to physicians and surgeons when patients re-present following manual hernia reduction. Increasing awareness about this condition at relevant times is crucial.


Introduction and importance
Reduction en masse is a rare complication of incarcerated inguinal hernias [1].Incarceration is a condition where external hernias do not reduce back into the abdomen, thereby increasing the risk of intestinal obstruction, strain, and strangulation [2].Delayed detection of incarceration may result in necrosis of the incarcerated intestine [3].The incidence of this complication is approximately 1 in 13,000 hernias [4].As a sporadic event, reduction en masse can be difficult to diagnose before surgery, and its definitive surgical treatment is unclear [5].However, a computed tomography (CT) scan and a thorough medical history are useful for an accurate preoperative diagnosis of this complication [6].This study describes a 74-year-old male patient who presented to the hospital with complaints of nausea, vomiting, and constipation for two weeks.After undergoing paraclinical tests, he underwent open surgery with a diagnosis of hernia reduction en masse.This case report follows the Surgical CAse REport (SCARE) and Consensus Preferred Reporting Of CasE Series in Surgery (PROCESS) guidelines [7,8].

Case presentation
A 74-year-old man presented with a history of hypertension (HTN), chronic obstructive pulmonary disease (COPD), and oral opium addiction.He had also undergone left-sided inguinal hernia repair three years previously.One month prior to the current visit, he developed a right-sided inguinal hernia, which could be reduced manually.However, on the morning of the visit, the bulge did not reduce manually, whereby the patient was referred to the hospital.An intravenous (IV) line and fluid therapy were immediately administered, and the hernia was reduced using the taxis maneuver.However, after the hernia was reduced, despite the medical team's advice to undergo surgery, the patient was discharged with personal consent and did not continue treatment.After discharge, the patient experienced abdominal pain, constipation, and vomiting twice, although there was flatus excretion.Consequently, the patient returned to the hospital one week later for continued treatment and a definitive diagnosis.On initial examination, the patient's abdomen was soft, with no (rebound) tenderness or hernia; no bloody stool or melena was observed on the rectal examination.The patient had no perianal pain but complained of anorexia, nausea, and vomiting.Since the patient had no visible abdominal mass and showed signs of small bowel obstruction on the abdominal X-ray (Fig. 1), a CT scan was requested.The CT scan revealed dilated intestinal loops (Fig. 2); thus, the diagnosis was hernia reduction en masse, given the patient's history of hernia with mass reduction one week prior to referral.
Given the patient's age and respiratory issues, the aneasthesia team recommended that laparoscopic surgery not be performed.They believed that the gas entering the abdomen could exacerbate the patient's condition and respiratory problems.The patient underwent spinal anesthesia, and a lower midline incision was made.The small bowel was dilated in the proximal portion and was found within the right inguinal hernia sac.There was a sac in the abdomen with no swelling in the inguinal area.The contents of the hernia sac were discolored, so the sac was incised, and the contents were removed (Fig. 3).The hernia sac was separated from the surrounding structures, and abdominal and peritoneal defects were repaired intra-abdominally.The suture site was repaired using a proline suture.No mesh was used to repair the defect, and the repair was done through the abdomen.Hemostasis was checked, and the abdominal layers were closed.Subsequently, the patient was transferred to the intensive care unit (ICU).The surgical procedure was performed by an attending surgeon and assistant professor at Birjand University of Medical Sciences.One day after surgery, the patient's constipation was restored, and no further problems were observed.On the second day, the patient initiated an oral ingestion regimen and tolerated it well.The patient was transferred from the ICU to the surgical ward after his condition stabilized.On the fourth day post-surgery, the patient was discharged with prescriptions for antibiotics, laxatives, and analgesics.
After the patient was discharged, long-term follow-up showed no signs of hernia recurrence or related complications.The patient was monitored for 12 months and reported no abdominal pain, nausea, or other gastrointestinal symptoms.Regular check-ups confirmed the  success and durability of the surgical intervention.

Discussion and conclusion
The occurrence of reduction en masse is infrequent in cases of inguinal hernia [1].This complication arises when the hernia sac, along with the contents of the intestine, is reduced into the abdomen while the intestine remains incarcerated in the sac [9].This can be caused by the manual reduction of the hernia [10], as in the case of our patient, where manual reduction entrapped intestinal loops within the sac.Repetitive inguinal herniation and its reduction can cause fibrotic changes at the hernia orifice, leading to a narrow neck that makes it difficult for the bowel to withdraw from the sac [11].The cause of this particular condition is still not well understood, but logically, fibrotic changes can develop in both bowel and sac tissue due to prolonged asymptomatic incarceration.As a result, the bowel becomes trapped and cannot move freely within the sac.Although the neck is not tight enough to cause ischemia, fibrotic changes can still occur in the neck region.Eventually, the neck becomes tighter, and ischemia begins as fibrotic changes persist [12].
Mings et al. conducted a review of more than 200 cases of en masse hernia in 1965.Although a few cases have been reported since then, the frequency of such cases remains low [13].To the best of our knowledge, only two similar cases [12,14] have been reported in Iran, which may indicate that the physician's initial diagnosis of the patients was incorrect.Therefore, reduction en masse should be considered as a differential diagnosis if a patient presents with these symptoms after hernia reduction.However, sometimes the symptoms may be delayed, appearing up to three years later, as reported in Parvey et al.'s study [9].
After reviewing the literature in PubMed and Google Scholar databases, we conducted a comprehensive diagnostic and therapeutic review of 9 cases of reduction en masse as a rare condition.The findings from these 9 case reports were compared with our patient's case and are summarized in Table 1 [4][5][6]11,12,[14][15][16][17].
Diagnosing a reduction en masse of an inguinal hernia can be challenging because it is uncommon but has specific CT findings.In the vast majority of cases, CT scans are used by medical professionals for diagnosing.Kitami et al. described the CT findings associated with reduction en masse.These include closed-loop obstruction with a balllike bowel loop, a location near the inguinal fossa, a circular funicular structure at the site of obstruction, the presence of a bladder beak along the closed loop, and the appearance of a noticeable unilateral inguinal soft tissue [18].In 2019, Baik et al. presented a case of en masse reduction.They noted that although the clinical symptoms of these patients are not specific, CT scan imaging can show a distinctive feature called the preperitoneal hernia sac sign.In this specific feature, the hernia sac, which contains an incarcerated bowel, is located in the preperitoneal space of the lower quadrant near the inguinal fossa [11].Characteristic CT findings were present in our case, enabling a straightforward diagnosis of reduction en masse and facilitating prompt corrective surgery.
Furthermore, for the treatment and also diagnosis of this type of hernia, open laparotomy and laparoscopy are two alternatives, with laparoscopic surgery receiving more attention in recent reports.However, several factors are important when considering laparoscopic surgery as the procedure of choice for patients with reduction en masse hernia.These include the surgeon's experience, especially for treatment, which involves careful observation and removal of non-viable parts of the intestine and closure of the hernia sac [17], the difficulty of using a laparoscope to check the viability of the intestines after reducing an incarcerated hernia [6] and the patient's condition and stability, as the patient must be stable enough to undergo laparoscopic surgery [17].
What matters, according to our patient and other cases, is that all entrapped hernias should be repaired as soon as possible, and maintenance therapy is not recommended.Confirming the hernia sac and sifting through it is of particular importance.Repairing the hernia and resolving inguinal swelling does not necessarily indicate no obstruction, as demonstrated in our patient's case.
The potential complication of hernia reduction en masse should be emphasized to patients who choose not to remain under medical supervision, as well as to physicians and surgeons when patients re-present following manual hernia reduction.Raising awareness about this condition at relevant times is crucial.Abbreviations: Ph/E = physical examination; CT = computed tomography; R = references; M = male; F = female; yo = years old; m = months; TAPP = transabdominal preperitoneal; PDS = polydioxanone suture.

Fig. 1 .
Fig. 1.Supine (AP) and upright (PA) radiographs of the abdomen showing visible dilatation and multiple fluid levels in the intestine, suggesting obstruction.

Fig. 2 .
Fig. 2. CT scan of the patient's abdomen; Flash A indicates dilated bowel loops, Flash B indicates normal bowel loops.

Fig. 3 .
Fig. 3. Part of the intestine trapped in the sac and discolored.

Table 1
Comparison of clinical, diagnostic, and surgical aspects in cases of inguinal hernia reduction en masse.