Giant inguinal hernias present are uncommon in developed countries. Generally, they are of a recurrent nature, and in addition to the classical complications of inguinal hernias, they pose problems that dramatically impair quality of life. The massive size of these hernias can interfere with walking and routine work.2
In addition, the penis can be buried inside the scrotum causing urine to dribble over scrotal skin, already congested by lymphatic and venous edema, causing excoriation, ulceration, and secondary infection.3
These problems have considerable psychological impact and often lead to social isolation, which happened to our patient. In general, the problems associated with the management of giant inguinal hernias are threefold. First, the loss of domain within the abdominal cavity makes reduction of the contents difficult. Diaphragmatic splinting decreases tidal volume and vital capacity and can cause respiratory compromise, and postoperative increases in abdominal tension heighten the risk of abdominal dehiscence. Second, when a hernia is large, the risk of recurrence is high, and third, the large amount of residual scrotal skin might need excision for cosmetic reasons. For successful surgery and to overcome these problems, several techniques such as distending the abdominal wall progressively4
or debulking the abdominal contents3
have been reported. However, the success of these techniques has only been reported in single case reports or small case series and no consensus has been reached on a standard surgical procedure for the management of giant inguinoscrotal hernias. After herniated bowel reduction and closure of the inguinal defect, fortunately, my patient did not experience postoperative morbidity including respiratory distress. Thus, the management of giant inguinal hernia poses unique challenges and proper surgical management should be chosen after carefully considering the patient's condition.
Intestinal malrotation is a congenital anomaly that concerns either a lack of or incomplete rotation of the fetal intestines around the axis of the superior mesenteric artery during fetal development. Intestinal malrotation is a diagnosis usually made early in life.5
However, because most patients remain asymptomatic, the condition is never diagnosed.6
of the English and German language literature from 1923 to 1992 revealed only 40 adults with symptomatic intestinal malrotation and no report of inguinal hernia with malrotation. One case report was found of incomplete fixation of the colon ascendens and an unusually located peritoneal fold together with a direct inguinal hernia.8
Although I did not identify abnormal peritoneal folds in my case, the unusually located peritoneal fold was interpreted as the result of fixation anomaly and a predisposing factor for the accompanying direct inguinal hernia.8
The peritoneal fold would be thought to contributing to the herniation of the intestine due to the medial inguinal fossa mechanically. Further study is needed to confirm the relationship between fixation anomaly and inguinal hernia.
This was the first reported case of giant inguinal hernia containing malrotated intestine.