Scientific letter
En Masse Reduction of an Incarcerated Inguinal Hernia. Emergency Laparoscopic Management
Reducción en masa de una hernia inguinal incarcerada. Abordaje urgente por laparoscopia
Javier Maupoey Ibáñez
, Omar Carreño Sáenz, Homero Beltrán Herrera, Amparo Moya Sanz, Fernando Carbonell Tatay
Corresponding author
Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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Abordaje urgente por laparoscopia" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1691 "Ancho" => 977 "Tamanyo" => 217087 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Reduction and exploration of incarcerated small bowel segment and hernia repair by means of transabdominal preperitoneal hernioplasty (TAPP technique).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Reduction <span class="elsevierStyleItalic">en masse</span> of an incarcerated inguinal hernia occurs when the hernia sac is reduced in the preperitoneal space after a taxis manoeuvre or during hernia repair surgery. The intestinal loops remain incarcerated in the sac, so the intestinal obstruction continues despite the apparently successful hernia reduction.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> Reported for the first time by Luke<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> in 1843, reduction <span class="elsevierStyleItalic">en masse</span> is an extremely rare complication. In 1908, its frequency was estimated by Corner and Howitt<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> at approximately 0.3% of incarcerated hernias, although the current incidence is probably lower due to the increase in early-stage hernia repairs.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 40-year-old intellectually disabled man. He came to the Emergency Department due to abdominal pain associated with a painful left inguinal mass, but he was not able to specify when the symptoms had appeared. Upon examination, the abdomen was soft with no signs of peritoneal irritation; peristalsis was audible. In the left inguinal area, there was a painful mass, compatible with incarcerated inguinal hernia. The mass was spontaneously and completely reduced during a slight exploratory manoeuvre in the Emergency Room. Blood workup and simple abdominal radiograph showed no pathologic findings, so the need for urgent surgical treatment was ruled out; management was planned with hernioplasty scheduled for a later date. Notwithstanding, we decided to keep the patient overnight for observation. Twelve hours later, the patient's condition clearly worsened and he presented symptoms of occlusion and distended small bowel loops on simple abdominal radiograph. However, there was no palpable hernia in the inguinal canal upon examination.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Emergency laparoscopic surgical exploration was indicated. Previous computed tomography was not ordered because the results would not modify the indication for surgery given the worsening symptoms. A 3-port approach was used: 12<span class="elsevierStyleHsp" style=""></span>mm umbilical incision, and two 5<span class="elsevierStyleHsp" style=""></span>mm incisions in both iliac fossae on the midclavicular lines. An indirect inguinal hernia was observed with a segment of the incarcerated ileum in a hernia sac situated in the preperitoneal space, over the deep inguinal orifice (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). This was released by means of traction manoeuvres; the affected loop had a congested appearance, with no signs of irreversible ischaemia. Afterwards, hernia repair was performed using the transabdominal preperitoneal (TAPP) hernioplasty technique with a 15<span class="elsevierStyleHsp" style=""></span>cm×10<span class="elsevierStyleHsp" style=""></span>cm polypropylene mesh placed in the preperitoneal space and attached with a spiral endostapler; closure was done with a peritoneal flap. Before the conclusion of the procedure, we once again verified the viability of the affected bowel segment, which had good colour and had recovered peristalsis. The patient had an uneventful recovery, and he was discharged 3 days after the intervention.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Reduction <span class="elsevierStyleItalic">en masse</span> of an inguinal or femoral hernia should be suspected in patients with persistent obstructive symptoms after the apparently effective reduction of an incarcerated hernia. Examination of the inguinal canal will show no evidence of hernia. The diagnosis is confirmed by computed tomography or during surgery, as in the case of our patient. It is important for surgeons to know about this complication because, as it is an uncommon phenomenon, its diagnosis and urgent surgery can be delayed, which can negatively affect prognosis.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Three conditions are necessary for the reduction <span class="elsevierStyleItalic">en masse</span> phenomenon to occur: a relatively lax deep inguinal ring, a narrow and fibrous neck of the hernia and a space for the preperitoneal sac.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> These factors usually coincide in cases of hernias that have progressed over a long period of time, with a previous history of repeated forced reductions.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> In this case, we have no idea how long the hernia had been evolving or when the acute symptoms had started. We believe that the decision to keep the patient under observation was correct, as was the indication for urgent surgery, which provided a diagnosis and treatment at the same time.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Several authors have used the laparoscopic approach in this phenomenon to verify the visibility of the affected loop<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> as well as to provide definitive treatment.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Hernioplasty using the TAPP technique can be used to manage incarcerated hernias with satisfactory results.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> First of all, the incarceration is released, which will occasionally require a small herniotomy on the fibrous neck and later hernia repair<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Although it was not the case in this patient, if there were irreversible ischaemia of the affected loop, bowel resection can be done by mini-laparotomy after concluding the hernioplasty. We should also mention the option of an open preperitoneal approach (which allows for the affected loop to be evaluated), bowel resection without midline laparotomy (if needed), and hernia repair (which could also be done with locoregional anaesthesia).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion, reduction <span class="elsevierStyleItalic">en masse</span> is an uncommon complication that requires a high rate of suspicion for early diagnosis and treatment. We suggest the laparoscopic surgical approach and hernia repair with the TAPP technique as an effective, less invasive method that accelerates the recovery process, which justifies its use in these patients.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare having no conflict interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of Interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Maupoey Ibáñez J, Carreño Sáenz O, Beltrán Herrera H, Moya Sanz A, Carbonell Tatay F. Reducción en masa de una hernia inguinal incarcerada. Abordaje urgente por laparoscopia. Cir Esp. 2015;93:603–605.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1852 "Ancho" => 2333 "Tamanyo" => 299519 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Schematic diagram of the reduction <span class="elsevierStyleItalic">en masse</span> phenomenon: the small bowel loop was incarcerated in the hernia sac located within the preperitoneal space.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1691 "Ancho" => 977 "Tamanyo" => 217087 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Reduction and exploration of incarcerated small bowel segment and hernia repair by means of transabdominal preperitoneal hernioplasty (TAPP technique).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reduction en-masse of inguinal hernia with strangulated obstruction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 230 | 20 | 250 |
| 2024 September | 210 | 34 | 244 |
| 2024 August | 148 | 24 | 172 |
| 2024 July | 137 | 15 | 152 |
| 2024 June | 139 | 20 | 159 |
| 2024 May | 140 | 5 | 145 |
| 2024 April | 118 | 19 | 137 |
| 2024 March | 146 | 30 | 176 |
| 2024 February | 172 | 33 | 205 |
| 2024 January | 212 | 35 | 247 |
| 2023 December | 170 | 25 | 195 |
| 2023 November | 240 | 34 | 274 |
| 2023 October | 263 | 45 | 308 |
| 2023 September | 140 | 11 | 151 |
| 2023 August | 139 | 6 | 145 |
| 2023 July | 163 | 21 | 184 |
| 2023 June | 129 | 3 | 132 |
| 2023 May | 186 | 9 | 195 |
| 2023 April | 133 | 2 | 135 |
| 2023 March | 150 | 12 | 162 |
| 2023 February | 96 | 7 | 103 |
| 2023 January | 97 | 8 | 105 |
| 2022 December | 126 | 11 | 137 |
| 2022 November | 102 | 17 | 119 |
| 2022 October | 100 | 5 | 105 |
| 2022 September | 90 | 22 | 112 |
| 2022 August | 107 | 13 | 120 |
| 2022 July | 81 | 15 | 96 |
| 2022 June | 101 | 11 | 112 |
| 2022 May | 64 | 10 | 74 |
| 2022 April | 94 | 13 | 107 |
| 2022 March | 122 | 15 | 137 |
| 2022 February | 123 | 11 | 134 |
| 2022 January | 126 | 12 | 138 |
| 2021 December | 104 | 14 | 118 |
| 2021 November | 134 | 22 | 156 |
| 2021 October | 111 | 18 | 129 |
| 2021 September | 79 | 24 | 103 |
| 2021 August | 73 | 16 | 89 |
| 2021 July | 52 | 23 | 75 |
| 2021 June | 55 | 11 | 66 |
| 2021 May | 71 | 11 | 82 |
| 2021 April | 211 | 42 | 253 |
| 2021 March | 134 | 9 | 143 |
| 2021 February | 117 | 10 | 127 |
| 2021 January | 130 | 17 | 147 |
| 2020 December | 125 | 15 | 140 |
| 2020 November | 124 | 19 | 143 |
| 2020 October | 89 | 12 | 101 |
| 2020 September | 121 | 21 | 142 |
| 2020 August | 144 | 13 | 157 |
| 2020 July | 96 | 16 | 112 |
| 2020 June | 102 | 17 | 119 |
| 2020 May | 82 | 20 | 102 |
| 2020 April | 91 | 7 | 98 |
| 2020 March | 96 | 14 | 110 |
| 2020 February | 101 | 6 | 107 |
| 2020 January | 92 | 15 | 107 |
| 2019 December | 89 | 9 | 98 |
| 2019 November | 94 | 10 | 104 |
| 2019 October | 108 | 23 | 131 |
| 2019 September | 102 | 10 | 112 |
| 2019 August | 99 | 20 | 119 |
| 2019 July | 94 | 35 | 129 |
| 2019 June | 126 | 22 | 148 |
| 2019 May | 130 | 56 | 186 |
| 2019 April | 152 | 33 | 185 |
| 2019 March | 63 | 12 | 75 |
| 2019 February | 74 | 8 | 82 |
| 2019 January | 40 | 10 | 50 |
| 2018 December | 38 | 11 | 49 |
| 2018 November | 49 | 14 | 63 |
| 2018 October | 48 | 9 | 57 |
| 2018 September | 37 | 24 | 61 |
| 2018 August | 35 | 13 | 48 |
| 2018 July | 39 | 9 | 48 |
| 2018 June | 36 | 5 | 41 |
| 2018 May | 53 | 16 | 69 |
| 2018 April | 44 | 6 | 50 |
| 2018 March | 30 | 0 | 30 |
| 2018 February | 36 | 5 | 41 |
| 2018 January | 26 | 5 | 31 |
| 2017 December | 40 | 2 | 42 |
| 2017 November | 32 | 5 | 37 |
| 2017 October | 33 | 9 | 42 |
| 2017 September | 39 | 9 | 48 |
| 2017 August | 49 | 10 | 59 |
| 2017 July | 56 | 22 | 78 |
| 2017 June | 67 | 33 | 100 |
| 2017 May | 58 | 12 | 70 |
| 2017 April | 39 | 13 | 52 |
| 2017 March | 51 | 42 | 93 |
| 2017 February | 69 | 3 | 72 |
| 2017 January | 31 | 5 | 36 |
| 2016 December | 36 | 11 | 47 |
| 2016 November | 46 | 4 | 50 |
| 2016 October | 45 | 11 | 56 |
| 2016 September | 59 | 6 | 65 |
| 2016 August | 37 | 5 | 42 |
| 2016 July | 26 | 1 | 27 |
| 2016 June | 25 | 7 | 32 |
| 2016 May | 41 | 13 | 54 |
| 2016 April | 45 | 9 | 54 |
| 2016 March | 37 | 15 | 52 |
| 2016 February | 16 | 4 | 20 |
| 2015 December | 1 | 1 | 2 |
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