Long-Standing Asymptomatic Inguinoscrotal Hernia

A 67-year-old man presented to the emergency department of Kuwait Hospital, Sharjah, United Arab Emirates, in 2016 after multiple episodes of biliary vomiting with abdominal pain over the preceding 24 hours. He had had no bowel motion during the previous 10 days. On examination, he was found to have a long-standing asymptomatic inguinoscrotal mass which had first been noticed 30 years before; since then, it had been increasing in size and had recently become irreducible. He was retired and had a history of atrial fibrillation, hypertension, scoliosis, gout and peptic ulcer disease. In addition, he had smoked one pack of cigarettes daily for 25 years and sometimes drank alcohol socially. An abdominal X-ray revealed degenerative changes in his right hip [Figure 1]. Computed tomography showed a hugely dilated stomach with the distal part of the stomach herniating through the left inguinal canal to the scrotum, along with loops of the small bowel and sigmoid colon [Figures 2 and 3]. The patient refused surgery and was subsequently lost to follow-up.

A 67-year-old man presented to the emergency department of Kuwait Hospital, Sharjah, United Arab Emirates, in 2016 after multiple episodes of biliary vomiting with abdominal pain over the preceding 24 hours.He had had no bowel motion during the previous 10 days.On examination, he was found to have a long-standing asymptomatic inguinoscrotal mass which had first been noticed 30 years before; since then, it had been increasing in size and had recently become irreducible.He was retired and had a history of atrial fibrillation, hypertension, scoliosis, gout and peptic ulcer disease.In addition, he had smoked one pack of cigarettes daily for 25 years and sometimes drank alcohol socially.An abdominal X-ray revealed degenerative changes in his right hip [Figure 1].Computed tomography showed a hugely dilated stomach with the distal part of the stomach herniating through the left inguinal canal to the scrotum, along with loops of the small bowel and sigmoid colon [Figures 2 and 3].The patient refused surgery and was subsequently lost to follow-up.

Comment
Hernias are usually treated with surgical repair in order to prevent possible complications (i.e.hernia incarceration or strangulation) which can lead to bowel obstruction and, eventually, to intestinal ischaemia. 1he estimated annual risk of a hernia is approximately three per thousand patients. 1Direct inguinal hernias usually occur only among older men, as ageing and stress/strain weaken the abdominal muscles around the inguinal canal; in comparison, women rarely suffer from this type of hernia. 2    has suggested that inguinal hernias develop as a result of changes at the tissue level involving matrix metalloproteinases. 3The current case describes a patient with an asymptomatic inguinal hernia in which a large part of the abdominal content had herniated into the scrotum without strangulation.In such cases, surgery is indicated to relieve the symptoms, cosmetically correct the defect and to prevent future complications. 4,5.

Figure 1 :
Figure 1: Pelvic X-ray of a 67-year-old man with a long-standing asymptomatic inguinoscrotal mass showing extensive inguinal herniation (arrow) in addition to degenerative changes in the right hip joint (asterisk).

Figure 2 :
Figure 2: Horizontal computed tomography of a 67-year-old man with a long-standing asymptomatic inguinoscrotal mass showing large bowel loops passing into the scrotum (arrow).

Figure 3 :
Figure 3: Three-dimensional reconstructed computed tomography of a 67-year-old man with a long-standing asymptomatic inguinoscrotal mass showing a hugely dilated fluid-filled stomach with the distal part of the stomach herniating through the left inguinal canal into the left scrotum.In addition, the stomach displaced the small bowel loops on the right side which, along with most of the sigmoid, descending and transverse colon, passed through the left inguinal canal.