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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)01003-4
10.1016/j.ijscr.2024.110222
110222
Case Report
Reduction en masse of incarcerated inguinal hernia: A case report
Cross Ashton cross.ashton@mayo.edu
⁎
Yonkus Jennifer yonkus.jennifer@mayo.edu

Turay David Turay.David@mayo.edu

Schiller Henry J. Schiller.Henry@mayo.edu

Heller Stephanie Heller.Stephanie@mayo.edu

Department of General Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
⁎ Corresponding author. cross.ashton@mayo.edu
29 8 2024
10 2024
29 8 2024
123 11022213 8 2024
27 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

Reduction en masse is a rare diagnosis in which an inguinal hernia is reduced; however, the bowel remains entrapped inside the hernia sac within the preperitoneal space. Although this occurs infrequently, missed diagnosis can significantly affect patient outcomes.

Presentation of case

A 73-year-old male presented with obstructive symptoms in the setting of no prior abdominal operations and recently self-reduced inguinal hernia. Diagnosis of reduction en masse of an inguinal hernia was made with history and cross-sectional imaging. The patient remained obstructed following reduction and underwent urgent laparoscopic exploration. The small bowel was reduced from a preperitoneal hernia sac and appeared viable, negating the need for resection. The patient subsequently underwent inguinal hernia repair and was discharged home.

Discussion

Although rare, clinicians should be aware of the possibility of reduction en masse of herniae as the cause of intestinal obstruction. This case presentation emphasizes the need for thorough history-taking and imaging to assist in diagnosis. When reduction en masse is diagnosed, proceeding urgently to the operating room is critical. When feasible, it is acceptable to start with laparoscopic exploration to free the bowel and assess for viability. Laparoscopic repair is even an option. Timely diagnosis and operative intervention can preserve the bowel.

Conclusion

Reduction en masse of an inguinal hernia is a rare but potentially morbid cause of intestinal obstruction as the incarcerated inguinal hernia is essentially converted to an internal hernia with ongoing risk of bowel strangulation. Knowledge of this rare diagnosis and its associated imaging findings is essential for appropriate and timely intervention.

Highlights

• 73-year-old male with no prior abdominal operations who presented with small bowel obstruction

• Reduction en masse is a rare cause of intestinal obstruction.

• CT imaging in conjunction with patient history is key in diagnosis.

• Knowledge of diagnosis and urgent operative intervention are imperative for improved patient outcomes.

Keywords

Reduction en masse
Inguinal hernia
Bowel incarceration
Case report
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pmc1 Introduction

Acute small bowel obstruction is one of the most common indications for general surgery consultation. As is well established, in the United States this is most commonly caused by adhesive disease [1]. Reduction en masse has been described but is an uncommon cause of intestinal obstruction [[2], [3], [4]]. This is a rare diagnosis in which a hernia is reduced; however, the bowel remains entrapped inside the hernia sac within the preperitoneal space. Although this occurs infrequently, missed diagnoses can significantly affect patient outcomes as reduction of the sac through the abdominal wall defect does not relieve the bowel obstruction and risk of strangulation persists now as essentially an internal hernia. In this case report, we describe one way en masse reduction may present and discuss diagnosis and management.

This case report has been reported in line with the SCARE Criteria [8].

2 Presentation of case

A 73-year-old male presented to the emergency department with abdominal pain and obstipation. He experienced worsening abdominal pain that he described as gas pain for 2–3 days; however, he became obstipated in the 24 h before presentation. The patient wore a truss for a known right-sided inguinal hernia that had been progressively increasing in size. The patient was able to reduce the hernia on his own at home. His last bowel movement occurred two days prior to presentation. He denied nausea and vomiting. He had no history of prior abdominal surgery. On physical exam, there was no palpable hernia in the right or left inguinal regions on either supine or standing evaluations. Computed tomography (CT) of the abdomen pelvis in axial, coronal, and sagittal planes with IV contrast was obtained in the emergency department, showing small bowel obstruction with what appeared to be small bowel trapped within a hernia sac in the preperitoneal space [Fig. 1]. The patient underwent NG tube decompression and proceeded to the operating room urgently for laparoscopic exploration. Intraoperatively, en masse reduction was confirmed, as 15 cm of small bowel was seen incarcerated within a hernia sac [Fig. 2]. The small bowel was carefully removed from the sac [Vid 1]. The small bowel mesentery was edematous; however, the small bowel appeared viable, and no resection was required. After the small bowel was freed, a 3 cm hernia defect was visible, leading to the right inguinal canal. This defect was reapproximated with Vicryl suture. The patient subsequently underwent formal open right inguinal hernia mesh repair the following day. Intraoperatively, a large fatty indirect hernia sac was identified [Fig. 3]. The previously placed laparoscopic sutures were seen at the base of the sac. The hernia sac was opened and explored before high ligation and amputation of the sac were performed [Fig. 4]. A Lichtenstein tension-free mesh repair was completed. The patient tolerated diet advancement, had return of bowel function, and was discharged home without complications.

3 Discussion

Although the presentation of reduction en masse of an inguinal hernia is rare, missed diagnosis can significantly affect patient outcomes as reduction of the sac through the abdominal wall defect does not relieve the bowel obstruction and risk of strangulation persists now as essentially an internal hernia. It is difficult to predict which patients will present with a hernia prone to en masse reduction. A major risk factor described in prior case reports is the presence of a chronically reducible hernia. There is often a history of increasingly difficult reductions due to fibrosis from repeated reductions [5]. If diagnosed early, the bowel may remain viable, negating the need for resection. Often, the diagnosis is delayed, and patients present with strangulation of bowel.Fig. 1 Coronal cross-sectional computerized tomographic image demonstrating small bowel and gastric dilation with decompressed bowel loop in the right lower quadrant.

Fig. 1

Fig. 2 Laparoscopic view of reduced right inguinal hernia into pre-peritoneal space containing incarcerated small bowel.

Fig. 2

Fig. 3 Hernia sac identified and dissected free of cord structures to the level of the internal ring.

Fig. 3

Fig. 4 Hernia sac open and explored before high ligation.

Fig. 4

In this case, the patient presented with obstructive symptoms of obstipation in the setting of no prior abdominal surgery. It is important to note that the patient had no physical exam findings of a right-sided inguinal hernia. A thorough history is essential as this patient self-reported a right-sided inguinal hernia that he was able to reduce at home.

Another critical piece to diagnosis in this case presentation was imaging findings on CT. As this is uncommon, providers may not look specifically for a reduction en masse of an inguinal hernia as the cause of obstruction. In a prior case report by Kitami et al., they report that key findings on CT scan which may clue one into a reduction en masse diagnosis is the presence of a closed loop obstruction with a ball-like bowel loop adjacent to the inguinal fossa [2]. In this case, a closed loop obstruction within a possible hernia sac on CT raised suspicions for reduction en masse [Fig. 1]. In conjunction with no prior abdominal surgery, these imaging findings should raise suspicion for reduction en masse rather than an adhesive process. It is essential to look out for these imaging findings, as reduction en masse cannot be managed conservatively. Attempts at conservative management in this case would undoubtedly have led to bowel ischemia.

Such as in this case, reduction en masse can occur following self-reduction of hernia by patients [3,4]. This can also occur following reduction by clinicians in settings such as the emergency department. If physicians reduce an inguinal hernia and reduction en masse occurs, there may be a false sense of reassurance, and the patient may be discharged home. It is important to assess patients for resolution of symptoms. Additionally, it is important to counsel patients on warning signs and symptoms and advise them when to return for clinical assessment.

When reduction en masse is diagnosed, it is important to proceed urgently to the operating room. It is acceptable to start with a laparoscopic assessment of bowel viability [6,7]. In this case, the small bowel could be freed before it became ischemic, and resection was not required. The peritoneal defect was closed in the initial procedure to prevent recurrence of incarceration. Formal hernia repair was delayed for 48 h to allow for the resolution of inflammation before mesh placement for definitive hernia repair to reduce the risk of infectious complications. Early diagnosis and operative intervention allowed the patient to undergo formal inguinal hernia repair with ligation and amputation of the hernia sac during the same admission.

4 Conclusion

Reduction en masse of an inguinal hernia is a rare but clinically significant cause of intestinal obstruction. Knowledge of this rare diagnosis and its associated imaging findings is crucial to preventing poor patient outcomes from unrelieved bowel obstruction and bowel strangulation.

The following is the supplementary data related to this article.Video 1

Laparoscopic reduction of incarcerated hernia that had been reduced en masse.

Video 1

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical clearance was not necessary by the Mayo Clinic Institutional Review Board as the format of this paper is a case report.

Funding

There were no sources of funding for this case report.

Author contribution

Ashton Cross: Writing original draft, conceptualization, project administation.

Jennifer Yonkus: Writing – review and editing, conceptualization, project administration.

David Turay: Writing – review and editing.

Henry Schiller: Writing – review and editing.

Stephanie Heller: Writing – review and editing.

Guarantor

All authors of the article have approved its publication and supervised its writing.

Research registration number

This is not a “First in Man” study and therefore not does require registration.

Conflict of interest statement

The authors do not have any conflicts of interest.
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