Reduction en-masse of inguinal hernia with strangulated obstruction
Teleradiology Solutions, Bangalore, India
�Reduction en masse of inguinal hernia� means
reduction/migration of a hernial sac into the properitoneal space. We report
the CT findings in a case of reduction en masse with strangulated obstruction.
CT scan demonstrated a hernial sac with fibrous constriction band at the neck,
situated in the properitoneal space superior to the inguinal region, causing
closed-loop obstruction. The hernial sac contained thickened bowel loop with
wall enhancement and fluid suggestive of incarceration/strangulation. We
propose to call this, �The properitoneal hernial sac sign�, defined as
�Presence of a hernial sac in the properitoneal space (and not in the
inguinal/femoral canal) containing an obstructed/incarcerated bowel loop and
causing small bowel obstruction� to identify �reduction en masse of inguinal
hernia�. � 2009 Biomedical Imaging and Intervention Journal. All rights
Keywords: Inguinal hernia, hernial sac, reduction en masse,
properitoneal space, closed-loop obstruction
�Reduction en-masse of inguinal hernia�, means
reduction/migration of a hernial sac along with the incarcerated bowel into the
properitoneal space  and is likely produced by forcible attempts at
reduction. Occasionally, it can also be spontaneous. There is usually a history
of difficult reductions, the last one being especially difficult, after which
the symptoms of intestinal obstruction occur. The hernia appears to have been
reduced but the signs of bowel obstruction persist.
A hernial sac containing incarcerated bowel loop is seen
between the parietal peritoneum and anterior abdominal wall, the properitoneal
sac (Figure 1).
A 62 year-old male had a bulge in the left groin for the
last two years. There was a history of repeated reductions. He presented with
severe abdominal pain and vomiting after an episode of forcible reduction, for
which a CT scan (5mm axial sections with intravenous contrast), was performed.
The CT scan demonstrated a hernial sac in the
properitoneal space, between the parietal peritoneum and anterior abdominal
wall (Figure 2). The neck of the hernial sac showed a fibrous constriction band
(Figure 2c) and there were features of closed loop small bowel obstruction. The
hernial sac contained thickened bowel loop with wall enhancement and fluid
suggestive of incarceration and strangulation (Figures 2c, 2d, and 2e). The
patient was operated on and the hernial sac was found to contain ischemic small
bowel loop, which was resected and end-to-end anastomosis was performed.
Reduction en-masse of inguinal/femoral hernia can be
defined as reduction of the hernial sac together with its intestinal contents
so that the bowel still remains incarcerated . It is a rare form of acute
intestinal obstruction that few surgeons get to see and with which many
radiologists are unfamiliar. It has been quoted by Pearse to occur in
approximately 1 of 13,000 hernias .
Reduction en-masse of hernia is quite rare as a result of
early repair of hernias and abandonment of forcible reduction .
Most unusual are the spontaneous reductions that have been documented.
Clinically, a tender mass can be palpated either high in
the inguinal canal, above the inguinal ring or in the lower abdomen, on the
side of reduction. Early surgical intervention is necessary as prognosis is not
always good due to the delay in time from onset of symptoms and surgery, more
so in spontaneous reductions.
Casten and Bodenheimer postulated that reduction en masse
can occur only if there is a relatively unyielding neck of the sac and a lax
internal ring . Fibrosis is probably produced by recurrent trauma from
difficult reductions. Pearse concluded that a preformed space between the
parietal peritoneum and anterior abdominal wall, the properitoneal sac, or
diverticulum was present in many cases, while Millard suggested that such a sac
was equally likely to be produced by forcible attempts at reduction . There
is usually a history of difficult reductions, the last being more difficult,
after which the symptoms of intestinal obstruction fail to subside or subside
only temporarily [7, 8].
In the above case, the bowel, along with hernial sac,
would appear to have been pushed back into the properitoneal space by repeated
reductions. We propose to call this, �The properitoneal hernial sac sign�,
defined as �Presence of a hernial sac in the properitoneal space (and not in
the inguinal/femoral canal) containing an obstructed/incarcerated bowel loop
and causing small bowel obstruction� to identify �Reduction en masse of
herniae�. The properitoneal space may have been pre-formed by similar past
incidents and later on, development of fibrosis at the neck of sac may have
caused small bowel obstruction.
We were unable to provide details of the MDCT or
intra-operative images as ours is a teleradiology service. Despite its numerous
advantages, the expansion of telemedicine may pose an increasing challenge to
collaboration, research and expansion of medical knowledge unless measures are
put in place to overcome them.
In summary, reduction en-masse of inguinal hernia is a
clinical diagnosis which can be confirmed by CT. Reduction en-masse of hernia
should be considered as a cause of acute intestinal obstruction in patients
with persistent bowel obstruction following reduction of inguinal/femoral
hernias. The proposed �properitoneal hernial sac sign� helps in identifying and
confirming �reduction en-masse of hernia�, likely to be produced by forcible
attempts at reduction. Rarely, it can also occur spontaneously, where the
prognosis is bad.
Figure 1 (a) Diagram of inguinal hernia at the site of inguinal ring. (b) Diagram of reduction en masse - A hernial sac is seen containing incarcerated bowel loop between the parietal peritoneum and anterior abdominal wall, the properitoneal sac.
Figure 2 (a) CT scan of the abdomen demonstrating dilated small bowel loops suggestive of bowel obstruction. (b) The hernial sac [arrow] containing thickened bowel loop and mesenteric fat [arrowhead] is seen in the properitoneal space, superior to the left inguinal region. (c) A fibrous constriction band is seen around the neck of the hernial sac [arrow] .Note enhancement of bowel wall [arrowhead]. (d) The inferior aspect of the hernial sac containing bowel [arrow]. (e) Fluid in the hernial sac [arrow]. Wall enhancement of the bowel loop and fluid in the hernial sac suggest incarceration and strangulation.
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|Received 4 December 2008; received in revised form 15 May
2009, accepted 8 June 2009
Correspondence: Teleradiology Solutions, Plot # 7G Opp. Graphite India, Whitefield, Bangalore 560078, India. Tel.: +91-80-4018 7500; E-mail: email@example.com (H. Ravikumar).
Please cite as: Ravikumar H, Babu S, Govindrajan MJ, Kalyanpur A,
Reduction en-masse of inguinal hernia with strangulated obstruction, Biomed Imaging Interv J 2009; 5(4):e14