Inguinal hernia repairs comprise a large portion of general surgical procedures. There are more than 20 million hernias estimated to be repaired annually around the world [2, 8]. In the USA, an inguinal herniorrhaphy is the most common elective operation performed with approximately 700,000 cases annually [2, 8].
The vast majority of hernias are repaired electively to prevent complications. Although complications are rare, they might be severe if not promptly addressed. Incarceration, strangulation and bowel perforation are known complications of inguinal hernias. Expectedly, intestinal perforation is higher in patients with inguinal hernias compared with the general population . This is typically the result of an incarcerated hernia leading to strangulation. Small bowel tears and perforations have been reported in the setting of an inguinal hernia, usually following direct trauma to the patient’s abdomen or groin [12, 13]. To the best of our knowledge, small bowel perforation or transection has not been reported following a non-traumatic insult to the hernia such as coughing.
Non-traumatic events leading to intestinal transection are rare events. Experimental models demonstrated that blunt trauma to an inguinal hernia could produce enough force (300mmHg) to lead to intestinal pressures of 260mmHg that can cause intestinal disruption . By contrast, urodynamic testing comparing voluntary cough to laryngeal cough reflex revealed that the maximal intraluminal pressure generated was only 110mmHg . This pressure is not generally sufficient to cause intestinal disruption.
In the present case, it is possible that the chronic incarceration of the hernia might have led to bowel edema, weakening of the bowel wall and the observed transection. There were no other identifiable risk factors in this patient that could have led to this outcome.
In the present report, we elected to proceed with the repair of the inguinal hernia during the same operation. Although the timing of hernia repair in regards to the index operation is controversial, the status of the patient is a universal issue of concern in determining whether to proceed with a repair or not. However, if hemodynamic stability is well established, some authors favor a delayed repair [12, 16] and others prefer a repair in the same setting [17, 18]. Because the patient in this report had physical examination findings consistent with peritonitis, there was a clear need for operative intervention and the hernia was repaired because the patient was hemodynamically stable. In addition, the patient did not have any comorbid conditions that could lead to cardiopulmonary morbidity related to increased operative times. A balance between two operations and increased morbidity in a lengthy operation must be carefully considered on a case-to-case basis.
This operation would be classified as a contaminated case based on wound infection classification. Thus, the use of synthetic mesh was considered a poor option as this leads to high rates of infection, bleeding and fistula formation . A tissue repair has been advocated in this setting . However, tissue repair is associated with a high rate of recurrence. Because the transversalis fascia in this patient was obliterated, a tissue repair was not optimal. We thus elected to repair the floor with biologic mesh (AlloDerm®), which has been described in similar settings .