This is about a sliding hernia

1. ZAGS - MORNING CLINICAL
PRESENTATION
YELLOW FIRM – UTH (01/06/2022)
Presenter : Dr. KUMARAN.V.S
Supervisor : Dr. F. PIKITI

2. Patient details
• 42-year-old male
• Referral from Mumbwa for further management.
• Admitted to surgical department in UTH on the 25/05/2022 at 22:00hrs

3. History
• Pt states that he had c/o straining when passing stool 3/7 when he
noticed the swelling at his scrotum which then disappeared but
reappeared a day later with severe pain
• Pt had c/o vomiting and had not opened bowels for the past 2 days
• He was apparently normal before this

4. History
Past medical history:
• DM –
• HTN –
• RVD – R (on A since 2010, last CD4 unknown)
• No h/o PTB
Surgical history :
• Pt had no significant surgical history

5. History
Drug history :
• ART since 2010
Allergic history :
• Nil significant
Social history :
• Married
• Smoking – stopped 1 year ago
• Alcohol – stopped 1 year ago

6. Examination
GC :
• Conscious, oriented, afebrile, nil pallor, no jaundice
• Well built stature
• No respiratory distress
Vitals :
BP – 141/85 mmhg PR – 103/min
Temp – 36.1 ° C SpO2 – 99% @ RA
Chest :
- Clear breath sounds, equal bilateral air entry

7. Examination
CVS :
• S1 S2 heard, slightly tachycardic
P/A :
• Not distended but tense
• Guarding present
• Dull tenderness present in Rt iliac region
• Rebound tenderness present

8. Examination
L/E : Inguinal + Scrotal
• Scrotum appeared distended severely
• Highly tender
• Slight discoloration
• irreducible
DRE :
• Anal opening appeared normal
• Normal tone
• No pain/mass/induration/bleed
• Feces seen on glove

9. Investigations

10. Investigations

11. Investigations
X-ray Chest :
• Normal findings

12. Impression
• Strangulated right inguinal hernia

13. Plan
• To do Baseline blood tests (FBC/DC, LFT, RFT)
• group and save blood
• To achieve IV access and start IVF + Abx
• Prepare consent and counsel for hernia repair ± laparatomy
• Anesthetist consult
• Foley’s catheter and Ryle’s tube insertion

14. Procedure
• Under GA + aseptic conditions, pt positioned supine, skin prepared with savlon,
povidone and Methylated spirit
• Incision made along Rt inguinal region and deepened
• Cord visualized and herniated bowel loop seen in thin sac.
• Closer inspection revealed that the caecum as well as distal 30cms of terminal
ileum was present in the herniated sac and appeared strangulated.
• Midline incision made and deepened for easier inspection and manipulation
• About 800-1000mls of bloody peritoneal fluid suctioned
• On freeing the herniated loop of ileum and caecum into the abdominal cavity,
they appeared gangrenous and nonviable.
• Other abdominal organs appeared normal

15. Procedure
• The mesentery was cut, clamped and ligated and all nonviable bowel
loops including caecum was removed.
• Rt hemicolectomy done, and stump closed and fixed to abdominal
wall
• Cut end of ileum refashioned and ileostomy placed at left side of ant
abd wall in view of incision at the rt side
• Lavage given and abdomen closed in layers
• Sterile dressing and ileostomy bag placed

16. Final diagnosis
• Strangulated rt inguinal hernia with gangrenous bowels

17. Plan for Post-op
• Care for GA
• IV antibiotics
• Analgesics (IM PETHIDINE)
• IVF to be continued
• Counselling regarding stoma care and management
• Keep NPO until full recovery from anesthesia followed by
commencing feeds
• Strict input/output monitoring
• Shift back to surgical ward

18. Post-op care
• Post-op period was uneventful
• Surgical wound healing with no evidence of any infection and pt feels
comfortable

19. Discussion points
Management of strangulated hernias in an emergency setup in low-income vs high
income countries

21. References
1) https://www.ncbi.nlm.nih.gov/books/NBK555972/
2) https://bmcresnotes.biomedcentral.com/articles/10.1186/1756-
0500-5-585
3) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719730/
4) https://wjes.biomedcentral.com/articles/10.1186/s13017-017-
0149-y