Laparoscopic bilateral etep mesh repair of bilateral recurrent right giant inguinoscrotal hernia + resection anastomosis of small intestine

Asha Sagish 1*, Shalini HS 2, Vijayakumari.D 3

1OT In-Charge, Kauvery Hospital, Electronic City, Bangalore

2Nursing Superintendent, Kauvery Hospital, Electronic City, Bangalore

3Nurse Educator, Kauvery Hospital, Electronic City, Bangalore

*Correspondence

Introduction

Giant inguinoscrotal hernias (GIH) are rare and can be complicated by loss of domain (LOD), which limits standard surgical repair options due to increased intra-abdominal pressure (IAP) and the risk of post-operative respiratory compromise. No prior reports describe GIH with LOD in patients with severe spinal deformity. While most cases can be managed electively, delayed presentation increases the risk of incarceration, strangulation, and loss of domain (LOD). Without prompt intervention, these complications can lead to obstruction, ischemia, and perforation, necessitating emergent intervention. Surgical repair remains the definitive treatment for inguinal hernias, with a variety of approaches available based on surgeon preference and patient anatomy. However, in patients with LOD, standard reduction and closure techniques pose risks of increased intra-abdominal pressure (IAP) and postoperative pulmonary dysfunction. Proposed techniques to mitigate increased IAP include the creation of a pneumoperitoneum , debulking of abdominal contents through resection, Stoppa’s technique, and the use of scrotal skin flaps, but no standardized method exists . Additionally, no case reports document GIH in patients with LOD and severe spinal deformity.

Case Presentation

A 55-year-old male patient was admitted to Kauvery Hospital on 18 January 2026 under Dr. Ganesh Shenoy, with complaints of swelling right inguinoscrotal region associated with dragging pain sensation for 6 months with a history of hypertension for 10 years on treatment (Tab. Telma-40 mg- BD) and Polycythemia. No history of constipation LUTS or chronic cough. He had CT abdomen and pelvis done elsewhere on 18/01/2026 suggestive of a large non obstructed, complete inguinal scrotal hernia with omento enterocele and cystocele. Small incomplete left inguinal hernia with omentocele. Mildly enlarged prostate. Patient was admitted for further surgical management.

History

  • Right herniorrhaphy in 1990.
  • Recurrent right Lichtenstein repair 2000.
  • Recurrent bilateral Lichtenstein repair 2010.

Clinical Examination

On arrival:

  • 55 years/Male, average built.
  • Pulse: 80/min. BP:110/70mmHg, Resp. Rate 12/min. Temp-98. SPO2-98% on RA.
  • Respiratory System: Bilateral air entry present.
  • Cardiovascular System: S1 S2+.
  • Abdomen: Soft.
  • Central Nervous System: Conscious and Oriented.
  • Local examination:
  • Type II Giant Right Sided Inguinoscrotal Hernia.

Investigations

Pre-operative investigations included CBC, RFT, RP-1, ABG, Hb, K+ , Electrolytes- Chest X-ray, Serology- LFT.

CT abdomen and pelvis confirmed the presence of:

  • Right inguinoscrotal hernia with small bowel, mesentery, omentum, bladder, and caecum.
  • Left direct recurrent hernia.
  • Mildly enlarged prostate.

Pre-operative Nursing Care

Pre-operative care included:

  • Monitoring vitals and hydration.
  • Foley’s catheterization.
  • NPO status.
  • Psychological support and consent verification.
  • Prophylactic antibiotics and infection control.

Surgical Management

On 19 January 2026, the patient underwent Laparoscopic Bilateral ETEP Mesh Repair of B/L Recurrent Right Giant Hernia + Inguinal scrotal Resection Anastomosis of Small Intestine.

Intraoperative findings

  • Massive bilateral hernia with bladder involvement.
  • Iatrogenic bladder injury (repaired).
  • Omentectomy and right orchiectomy.

Ports used:

  • 10mm infraumbilical.
  • 5mm right hypochondrium.

Specimen retrieval was via Pfannenstiel incision. Mesh placement and closure were completed laparoscopically. Foley’s catheter retained for 14 days.

Routine labs and PAC were completed. Physician clearance was obtained considering hypertension and polycythaemia. Patient was suggested for surgery and hence admitted with above mentioned complaints and diagnosis. After admission all necessary preoperative investigations were done. PAC done. Physician opinion was taken in view of chronic systemic hypertension and polycythaemia, advice followed and clearance obtained for surgery. After informed and written consent, patient was taken up for procedure.

He underwent Laparoscopic Bilateral ETEP Mesh Repair of Bilateral Recurrent and Right Giant Inguinoscrotal Hernia + Resection Anastomosis of Small Intestine under General Anesthesia on 19.01.2026, Intraoperatively iatrogenic injury to bladder repaired, omentectomy and right orchidectomy done. Foley’s retained for 14 days. Postoperatively patient was shifted to ICU with ventilator support.

Before Surgery

After Surgery

Post-Operative Course

  • Strict NPO.
  • NG Tube.
  • Clexane 0.4cc s/c.
  • IV Fluid 100ml/hr.
  • Piptaz 4.5 gm TID.
  • Pan 40mg IV BD.
  • Emeset 4mg IV TID.
  • PCT 1gm IV TID.
  • Abdominal girth measurement 12th
  • Ryles tube aspiration 4th
  • Foley’s and drain care.

On POD-1 patient was extubated, post extubation patient remained hemodynamically stable. Patient was managed with IV fluid, antibiotics, PPI’s, analgesics, antihypertensive, drains care (ADK & Romovac). Foley’s care, RT aspiration and other supportive measures under the guidance of intensivist.

On POD-2 patient was mobilized with physiotherapist and shifted to ward.

On POD-3, Ryles tube removed, patient was started on clear liquids orally and increased gradually as tolerated, patient moved bowels. On POD-3 dressing changed, wound healthy, ADK drain cut and colostomy bag applied. Now he is being discharged in hemodynamically stable condition on liquid diet with Foley’s & drains in situ with following advice. Patient was discharged on 23 January 2026 in stable condition.

Post-operative Nursing Care

Post-operative nursing care was directed at supporting recovery, preventing complications, and facilitating early return to normal function. The nursing team monitored airway, breathing, and circulation closely in the immediate post-anaesthesia period, with regular checks of heart rate, respiratory rate, blood pressure, and oxygen saturation.

Pain Management

Pain was assessed using appropriate scale. Administer prescribed analgesics:

  • Support scrotum with scrotal sling or rolled towel under scrotum.
  • Teach patient to splint abdomen when coughing or moving.

The patient was observed for gastrointestinal recovery, including assessing bowel sounds, abdominal distension, nausea/vomiting and tolerance to oral feeds. Nurses encouraged early mobilization to reduce postoperative morbidity.

The nursing team also supported for wound, scrotal care and Catheter care.

  • Inspect Laparoscopic port sites for bleeding, redness, discharge.
  • Assess Scrotum for excessive swelling, hematoma and discolouration.

Infection Prevention:

  • Monitor Temperature.
  • Observe Wounds.
  • Maintain Aseptic technique during dressing changes.
  • Administer Antibiotics, if prescribed.

Outcome & Follow-Up

  • Normal diet can be consumed following discharge.
  • Routine physical activity like walking, climbing stairs etc can be resumed immediately following surgery.
  • Strenuous activity like lifting heavy weights and driving should be avoided one month following surgery.
  • Minor pain at the port sites is common following hernia repair.
  • Sutures and pressure dressing will be removed a week at the time of your first follow-up in the OPD.
  • Report immediately to the emergency in case discharge and develops any of the following problems following discharge.
  • Severe abdominal pain.
  • High grade fever.
  • Abdominal distention.

Discussion

This case illustrates the complexity of managing recurrent hernias with organ involvement. Laparoscopic ETEP mesh repair combined with specimen retrieval via Pfannenstiel incision minimized morbidity and improved recovery. Multidisciplinary coordination ensured safe anaesthesia and postoperative care.

Conclusion

Laparoscopic repair of bilateral recurrent inguinoscrotal hernia with complications is feasible and effective. Early mobilization, structured nursing care, and coordinated surgical planning are key to successful outcomes in complex hernia cases.

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