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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 53  |  Issue : 4  |  Page : 148-151

Pantaloon hernia with two sliding components: The appendix -ascending colon in lateral sac and the urinary bladder in medial sac


Department of Surgery, Dr. D Y Patil Medical College, Hospital and Research Center, Kolhapur, Maharashtra, India

Date of Submission02-Nov-2019
Date of Decision03-Jan-2020
Date of Acceptance01-Apr-2020
Date of Web Publication20-Aug-2020

Correspondence Address:
Thakut Gowtham
Department of Surgery, Dr. D Y Patil Medical College, Hospital and Research Center, Kolhapur-416 003, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_95_19

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  Abstract 


An inguinal hernia is quite frequent in surgical praxis. One of the rare entities sliding type of inguinal hernia with an incidence of 2%–5%, which is difficult to diagnose preoperatively, most of the time, its diagnosis is made on the operational table. We report a rare case of pantaloon-type hernia with sliding components in either side of the hernia: the appendix, ascending colon onto the lateral, indirect hernia sac, and the urinary bladder onto the medial, direct sac, respectively. The two hernia sacs were saddled on either side of the inferior epigastric vessels. A 77-year-old presented with a right inguinoscrotal swelling for 5 years and increased frequency of micturition for 8 months. The indirect sac was opened very cautiously and was found to contain an appendix, the part of urinary bladder medially and ascending colon laterally forming the sliding component, small bowel, omentum are the contents of sliding hernia. The contents were attenuated and the sac was sealed cautiously. The posterior wall of the right inguinal canal was opened in total, contents were reduced, and neo posterior wall is formed by strengthening, and reinforcement did with prolene mesh. This entity is a diagnostic dispute due to its rarity and defined clinical presentation. Pantaloons hernia with two sliding components is uncommon. The hernia consisted of two parts: a laterally-located indirect sac containing the appendix and sliding ascending colon, and a medially-located direct hernia of sliding urinary bladder. A hernia of long duration in old patients should raise a suspicion of a pantaloon-type hernia. One should be very careful to identify the contents of the hernia to avoid inadvertent injury to the structures.

Keywords: Appendix, ascending colon, hernioplasty, inguinoscrotal hernia, pantaloon hernia, sliding hernia, urinary bladder


How to cite this article:
Kadiyal AM, Gowtham T, Ghatage MN, Singh RK, Thimmegowda V. Pantaloon hernia with two sliding components: The appendix -ascending colon in lateral sac and the urinary bladder in medial sac. Formos J Surg 2020;53:148-51

How to cite this URL:
Kadiyal AM, Gowtham T, Ghatage MN, Singh RK, Thimmegowda V. Pantaloon hernia with two sliding components: The appendix -ascending colon in lateral sac and the urinary bladder in medial sac. Formos J Surg [serial online] 2020 [cited 2020 Oct 21];53:148-51. Available from: https://www.e-fjs.org/text.asp?2020/53/4/148/292729




  Introduction Top


Inguinal hernias are the most common type of primary hernia in both males and females. Pantaloon hernias are very rare, the incidence of pantaloon hernia to be 1.8% in females and 5.6% in males.[1] Sliding hernia is rare with a relative incidence of 2%–5%. A sliding hernia is an extrusion of a retroperitoneal organ's through an abdominal wall opening, with or without its mesentery and with or without a neighboring peritoneal sac. These retroperitoneal organs may be the ascending colon on the right side and the sigmoid colon on the left side, or the uterus, ureters, and bladder on either side. The urinary bladder is involved in 1%–4% of all inguinal hernias, with the incidence ascending to 10% in obese males between 50. There is a 70% male dominance, with almost occurring on the right side and are much usually direct herniations.


  Case Report Top


A 77-year-old male presented with right-sided inguinoscrotal swelling for 5 years and increased frequency of micturition for 8 months. On examination, there was a 10 cm × 10 cm × 5 cm swelling in the right inguinoscrotal region, located above and lateral to the pubic tubercle with an expansile cough impulse with a smooth surface and doughy consistency. The swelling was not completely reducible. Clinically it was diagnosed as right nonreducible indirect inguinal hernia as it was extending till the base of the scrotum. Deep ring occlusion test could not be assessed as the swelling was not completely reducible. Routine blood investigations showed hypoprotenimia. Ultrasound of abdomen and pelvis suggestive of the right obstructed inguinal hernia with suspected Strangulation. The patient was posted for surgery, right-sided inguinal crease incision taken (approximately 2 cm above inguinal ligament). The cord was then separated from the sac by blunt dissection, the sac was opened cautiously and found to comprise an appendix [Figure 1], the part of urinary bladder medially and ascending colon laterally forming the walls of sliding component, small bowel, omentum are the contents of sliding hernia. Posterior wall defect is identified and completely exposed in total, and interloop bowel adhesions were released carefully, and they are reduced back. Indirect sac was closed carefully and reduced, and then the whole of the posterior wall is newly formed by strengthening with prolene no 1. The posterior wall is reinforced with prolene mesh [Figure 2], which was anchored from conjoint tendon to unruptured part of the inguinal ligament. In the postoperative period, patients' hypoproteinemia correction was done, and the patient discharged after skin suture removal on postoperative day 10 and discharged without any postoperative complications and follow-up done up to 90 days, where there was no hernia recurrence during this period.
Figure 1: The lateral, indirect sac showing the appendix with sliding mesoappendix after dissection from the cord. Parts of the cecum and ascending colon wall were also sliding onto the hernia sac (not shown). The urinary bladder wall was sliding onto the medial, direct sac

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Figure 2: Fixation of prolene mesh for hernioplasty with special orientation

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  Discussion Top


The inguinal canal, in males, is formed due to the descent of the testes from the abdomen into the scrotum by the gubernaculum which attaches the inferior pole of the testes to the scrotum. In females, the gubernaculum attaches the ovaries to the labia majorum. Pantaloon hernias are very rare, the incidence of pantaloon hernia to be 1.8% in females and 5.6% in males.[1] It is believed that a large indirect hernia may cause dilatation of the deep ring leading to weakening of the posterior wall which may cause bulging of the hernial sac on both sides of the inferior epigastric vessels leading to the formation of pantaloon hernia.[2] There have been reports of these findings previously, and hence, a deeper dissection and identification of the inguinal structures and canal is of utmost importance during hernia surgery. Misidentification or incomplete ligation of the sac can lead to recurrence.[3] Pantaloon hernia clinically is seen almost exclusively in males and is identified by 2 distinct swellings in the inguinal region, one each medial and lateral to the pubic tubercle. In some cases, however, one of the hernias may be occult and not present clinically but identified intraoperatively. The management, however, does not change but only involves adequate repair of both the defects.[3] Although there are several hernia classification systems, perhaps, the Nyhus classification and Gilbert classification are the only ones (including the more recent European Hernia System) that may be assumed to consider pantaloon hernia as one of the subtypes, namely, Type 3b and Type 6, respectively, once again underscoring the rarity of the condition in both genders.

Hernia surgery has always been the area of interest of the general surgeon and a constantly evolving field. All techniques of repair in the past consisted of tissue closure with variations which lead to tension in the suture lines and high recurrence rates. The advent of mesh repair with tension-free hernioplasty lead to a dramatic change in practice. Laparoscopic repairs have been the most recent development with minimal scarring but require a steep learning curve.[4],[5] There has been a significant discussion worldwide regarding hernia surgery and the formation of a team of experts from various centers to develop guidelines for hernia surgery. The HerniaSurge group guidelines state that groin hernia surgery can be done either open by Lichtenstein tension-free mesh repair or laparo-endoscopic mesh repair depending on the surgical expertise and local factors.[6] There have been no specific recommendations for pantaloon hernia repair. Whereas in this case, we selected the method of modified Bassini's repair with reinforcement of the posterior wall with a sheet of prolene mesh.

The International EndoHernia Society has developed a set of recommendations based on meta-analysis and expert opinions for both transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) repairs, but even those do not specify any for pantaloon hernia. This may be due to the uncommon nature of pantaloon hernia and similar treatment as other inguinal hernias.[6],[7] In this case, as it was an emergency, we had performed an open herniorrhaphy, but laparoscopically TAPP under general anesthesia is preferred as the defect is larger and nonreducible, whereas TEP under general anesthesia is technically more demanding with longer duration of general anesthesia, which may cause anesthesia complications in such elderly persons. However, the practice for the repair of pantaloon hernia is the same as for repair of other inguinal hernias in adults. Both open and laparoscopic techniques are used. Nonmesh repairs are not recommended due to lesser evidence is more chances of recurrence. Open repairs are preferred where the surgical expertise for laparoscopy and cost constraints are present.[8] Open herniorrhaphy can also be carried on through preperitoneal approach, with modified Stoppa's operation, applying a prosthetic mesh over the Fruchaud's myopectineal orifice of the affected side after reduction of all hernia contents.[9]


  Conclusion Top


Our case is a pantaloon-type inguinal hernia, which consisted of an indirect sac laterally containing the appendix and ascending colon, and a direct sac medially containing urinary bladder in the same inguinal area. Both of ascending colon and urinary bladder formed the sliding component of the hernia sac. A sliding hernia is uncommon, and Pantaloon's hernia is even very rare. A hernia of long duration in old patients should raise a suspicion of a sliding hernia. One should be very careful to identify the contents of the hernia to avoid inadvertent injury to the vital structures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Acknowledgment

I would like to thank my parents, department, and teachers for their constant support in drafting this unusual case report.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ofili OP. Possibilities of the strong posterior wall of inguinal canal in women. Cent Afr J Med 1990;36:300-4.  Back to cited text no. 1
    
2.
Rutkow IM, Robbins AW. Classification systems and groin hernias. Surg Clin North Am 1998;78:1117-27.  Back to cited text no. 2
    
3.
Jones RG, Livaditis I, Almond PS. An unexpected finding during an inguinal herniorrhaphy: Report of an indirect hernia with two hernia sacs. J Pediatr Surg Case Rep 2013;1:331-2.  Back to cited text no. 3
    
4.
Sakorafas GH, Halikias I, Nissotakis C, Kotsifopoulos N, Stavrou A, Antonopoulos C, et al. Open tension free repair of inguinal hernias; the Lichtenstein technique. BMC Surg 2001;1:3.  Back to cited text no. 4
    
5.
Kulacoglu H. Current options in inguinal hernia repair in adult patients. Hippokratia 2011;15:223-31.  Back to cited text no. 5
    
6.
Hernia Surge Group. International guidelines for groin hernia management. Hernia 2018;22:1-65.  Back to cited text no. 6
    
7.
Bittner R, Arregui ME, Bisgaard T, Dudai M, Ferzli GS, Fitzgibbons RJ, et al. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia International Endohernia Society (IEHS). Surg Endosc 2011;25:2773-843.  Back to cited text no. 7
    
8.
Pahwa HS, Kumar A, Agarwal P, Agarwal AA. Current trends in laparoscopic groin hernia repair: A review. World J Clin Cases 2015;3:789-92.  Back to cited text no. 8
    
9.
Ates M, Dirican A, Ozgor D, Gonultas F, Isik B. Conversion to stoppa procedure in laparoscopic totally extraperitoneal inguinal hernia repair. JSLS 2012;16:250-4.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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