Posters
Welcome to the AHS 2020 ePoster Session. Please scroll down to view all of the submitted posters or press Control-F to search. To view the poster and its abstract, click on the poster image. Many posters also have a brief audio introduction which can be played by going to the bottom of the poster screen.
P023: THE MULTIDISCIPLINARY MANAGEMENT OF A LOSS OF DOMAIN INGUINOSCROTAL HERNIA WITH CONCURRENT INFECTED SCROTAL WOUND
Colin G DeLong, MD; Matthew G Kaag, MD; John D Potochny, MD; Verghese T Cherian, MBBS; Melissa M Boltz, DO, MBA; Nimalan A Jeganathan, MD; Eric M Pauli, MD; Penn State Milton S. Hershey Medical Center
Introduction: The complexity of planned elective surgical procedures is greatly increased when patients present with unexpected, urgent complications. For patients awaiting hernia repair, such complications can delay and even prohibit future, definitive operative techniques. In these scenarios, a lack of published data is available to guide management and clinical decisions are best made using multidisciplinary expertise.
Methods: We describe the case report of an adult patient with a massive inguinoscrotal hernia complicated by a large scrotal wound and discuss the multidisciplinary, stepwise approach used in its successful management.
Results: The patient is a 41 y/o male with a large type 3 hiatal hernia and a massive inguinoscrotal hernia with loss of domain. Elective repair had initially been delayed due to the patient’s significant ongoing smoking, deconditioning, and malnutrition. The patient subsequently presented to the hospital with a scrotal wound draining purulent material which was managed with antibiotics and surgical debridement of the 15 x 6 cm wound. During this admission, the patient also underwent ultrasound guided botulinum toxin injection to the lateral abdominal musculature and was discharged home with assistance for smoking cessation and nutritional optimization. Significant risks of definitive inguinal hernia repair were discussed, including abdominal compartment syndrome, prolonged intubation, worsened hiatal hernia symptoms, and need for orchiectomy, colectomy, or tracheostomy. A multidisciplinary surgical team was assembled including colorectal, plastics, urology, and abdominal wall reconstruction surgeons. The hernia contents were reduced utilizing abdominal and scrotal access, obtained through a midline incision extended across the groin and onto the scrotum. The patient then underwent a preperitoneal Stoppa type abdominal wall reconstruction, with bilateral transversus abdominis release and retromuscular permanent synthetic mesh repair. Finally, orchiectomy, resection of hemiscrotum and scrotal abscess, and scrotoplasty were performed. Following an extensive, yet anticipated, postoperative recovery that included tracheostomy placement, the patient surpassed his preoperative functional status and quality of life. No recurrences have been noted with 10 months follow-up.
Conclusion: Thoughtful stepwise management was used to achieve definitive hernia repair in a patient with a Class 4 infected wound. Careful operative sequencing allowed for isolation of the contaminated wound, permitting the safe use of synthetic mesh for definitive closure. Several maneuvers including preoperative botulinum toxin injection, scrotal counter-incision, extensive retromuscular dissection, and skin flap creation allowed for full reduction of the hernia with complete fascial closure. Finally, extensive preoperative risk discussions prepared the providers and patient for efficient, proactive postoperative management.
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