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Paper text:
a giant inguino - scrotal hernia is defined as a hernia that extends below the midpoint of the inner thigh in the standing position ( 1 ) .
complications include impairment of mobility ( 2 , 3 , 4 ) , incarceration and intestinal obstruction ( 3 ) .
scrotal ulceration ( 5 ) is also common ; this is due to pressure necrosis or frictional rub .
this type of hernia poses a major surgical challenge and the operative approach requires careful planning .
a 52 year old history teacher presented as an emergency with a recurrent bleeding scrotal ulcer .
three months previously he had undergone a double cardiac valvular replacement for severe aortic and mitral valvular disease following an attack of rheumatic carditis as a child .
the patient had had a right inguinal hernia for 20 years but was deemed unfit for surgery because of his diseased cardiac valves ; he had to give up work as his hernia grew to a size where he could barely walk .
abdominal examination revealed a giant right inguino - scrotal hernia ; there was a large 15 by 15 cm ulcer on the base of the right hemiscrotum that was bleeding .
the giant inguinoscrotal hernia demonstrating the scrotal ulcer the scrotal wound was dressed and the patient was transfused .
his inr was reversed and under the cover of antibiotics he underwent a lichenstein repair of his right inguino - scrotal hernia through a right groin incision . at operation
the hernia sac contained the entire length of the small and large intestine , the appendix was stuck to the base of the scrotum and the stomach was in the pelvis .
the intestine was reduced out of the scrotum , an appendicectomy was performed and the contents replaced back into the abdomen .
the sac was closed with 2/0 vicryl , transveraslis fascia was plicated and a prolypropylene mesh was used to repair the posterior wall of the inguinal canal .
a vertical right hemiscrotal incision was made the right testis was delivered , the redundant skin and ulcer was excised .
the dartos muscle was closed with interrupted 0 vicryl and the skin with haemostatic 2/0 vicryl rapide mattress sutures .
post - operatively the patient was transferred to the intensive care unit , was extubated two hours after surgery and did not suffer any respiratory problems .
he was discharged home 6 days later with an inr of 3.2 . he was re - admitted with bleeding from his mini - circumcision wound on the 12 post - operative day , his inr was 5.9 , this was corrected and he was discharged 5 days later on warfarin .
he was reviewed in the clinic 12 weeks later , he was satisfied with the final outcome ( fig 2 ) and was about to return to work . image taken 3 months postoperatively
our patient had been suffering for many years and had given up his job due to resulting disability .
he presented with a bleeding scrotal wound that was compounded by the fact that he was on warfarin .
the surgical management of a patient with a giant inguino - scrotal hernia should be carefully planned . the key factors to consider are the operative approach , whether or not to use a mesh for the repair , how to deal with the sudden increase in intra abdominal pressure due to loss of domain , obtaining informed consent and dealing with the redundant scrotal skin or scrotal haematoma .
we had the added challenge of ensuring that our patient did not develop infective endocarditis as well as tightly controlling his clotting to prevent post - operative bleeding and thrombosis .
the operative approach could be through an inguinal incision , laparotomy or as a combined approach ( 3 ) .
we chose an inguinal approach in our patient for recovery from a laparotomy would have taken longer and he had to be re - anticoagulated immediately after surgery . if the patient is unstable or has a strangulated hernia the operation may have to be performed in stages ( 5 , 6 ) .
if the operation is going to be performed in one stage careful consideration should be paid to the type of implant used to repair the hernia defect , it is inadvisable to use a mesh if a bowel resection is performed .
there are tissue grafts that could be used instead , these are expensive and may not be readily available for emergency use .
giant inguinal herniae tend to be commoner in males hence the patient should be consented for an orchidectomy .
most patients with giant inguino - scrotal herniae tend to have most of their abdominal contents sitting in the scrotum ( 3 , 7 ) , as result , the abdominal cavity would have shrunk ; sudden replacement of these contents back into the abdominal cavity could lead to respiratory embarrassment .
where intensive care facilities are readily available the hernia contents could be reduced into the abdominal cavity and the patient could be ventilated until they are able to breath unaided , this was the approach taken in our patient .
such patients should be carefully monitored for signs of intra abdominal compartment syndrome . in developing countries where medical facilities are limited creating a pneumoperitoneum over a number of days to re expand the abdominal cavity is the desired option ( 2 , 8 , 9 )
creating a pneumoperitoneum does not always lead to re - expansion of the abdominal cavity especially if the air leaks into the hernia sac .
other surgeons have made relaxing incisions in the flanks to increase the abdominal girth ( 4 , 10 ) or placed an interposition mesh in the abdominal wound ( 4 , 6 , 10 ) .
mehendal et al performed a bowel resection in order to reduce the amount of viscera reduced back into the abdomen ; this approach is difficult to justify in a patient with viable bowel for creating an anastomosis adds to the post - operative risks .
once the hernia has been dealt with the redundant scrotal skin should be addressed as a primary or delayed procedure depending on the clinical status of the patient ( 1,4 ) . in our patient
the indication for surgery was haemorrhage from a scrotal ulcer so the redundant skin and the ulcer were excised .
one should exercise caution in excising the scrotal skin for the skin is usually oedematous and is likely to shrink post operatively ( 3 , 4 ) .
if the redundant scrotal skin is not excised there is a higher risk of haematoma formation , which could take several weeks to resolve .
our patient had to be anticoagulated 8 hours after surgery , haemostasis was ensured intra - operatively and he did not develop a haematoma .
giant inguinal herniae pose a surgical challenge , though not uncommon in the developing world they are a rare presentation in the uk . we present a patient with cardiac disease who presented with a giant inguino - scrotal hernia complicated by a bleeding scrotal ulcer . 
 we describe his medical management and the surgical repair of the hernia and refashioning of his scrotum .