A 68-years-old man who at the age of 53 years underwent transurethral resection of the prostate (TURP) for adenomyomatosis, presented in our Department of Surgical Sciences, “Umberto I” Hospital, in Rome. He had been suffering for about 10 years for an increasing left-sided inguinoscrotal hernia becoming in the last week not more reducible. Inguinal scrotal pain and septic fever appeared 30 days before the admission to our Department. Suspecting urinary infection, his clinician had prescribed antibiotic therapy which proved partially effective.
At the admission the patient was in fair general conditions without vomiting. The left emiscrotum, covered with normal skin, appeared fully occupied by hernia that extended over the middle third of the thigh. The penis was not visible. The hernia (20 × 20 cm in latero-lateral and antero-posterior diameters) was of increased consistence and not reducible. The testis was not palpable. The abdomen was treatable, without distention, but with minimal peristalsis and bowel constipated but open to gas.
The patient underwent elective surgical treatment with an oblique incision (about 15 cm) parallel to the inguinal ligament prolonged up to the scrotum. Opening the hernial sac, the fibro-necrotic omentum was evident. It covered a huge abscess with thick fibrotic pseudocapsule and wide necrotic areas (Fig. 1). Once drained the abscess, the phlegmonous perforated appendix (Fig. 2), the caecum, the ascending colon, the last ileal loops and the bladder were debrided. After accurate debridement of the herniated organs, we proceeded with the appendectomy and resection of necrotic omentum with handmade sutures. Then we isolated the funiculus spermaticus and the testis from the other herniated viscera. Once checked the vitality of the herniated organs, we reduced them into peritoneal cavity. We positioned a transabdominal drainage on the finger guide introduced through internal inguinal ring. Finally, we performed a hernioplasty according to Postempski technique without mesh, considering the risk of infection. Histological examination confirmed the appendiceal phlegmon (Fig. 3) and the necrosis of the omentum removed (20 × 20 × 5 cm).
The postoperative course was regular. On the third postoperative (p.o.) day the drainage was removed. On the seventh p.o. day, after doing an abdominal ultrasound that showed no postoperative complications, the patient was discharged with the advice of wearing a restraining underwear and of avoiding physical exercises for about 6 months.