Giant inguinoscrotal hernia in children: two rare cases

Inguinal hernia is one of the most common surgical diseases encountered in adults as well as in children. Though rare, giant inguinoscrotal hernias are reported in adults, however, are rarely reported in children. Here is a report of two rare cases of giant inguinoscrotal hernias in children managed successfully. Giant inguinoscrotal hernias in children are rare and should be referred early and managed in a tertiary care paediatric centre.


Background
The definition, the types as well as surgical management of giant inguinoscrotal hernias in adults have been well published in the literature; its presentation in children has rarely been reported.

Case 1
A four-year-old male child brought to us by parents with history of huge left inguinoscrotal swelling, noticed after a month of age and gradually started increasing in size to attain the present size of massive hernia around 25 cm × 12 cm reaching up to mid-thigh on standing (Type 1) (Fig. 1a). The swelling was partially reducible without any associated tenderness. The child never had any episodes of irreducibility, pain, bowel or bladder dysfunction or any associated chronic cough. His weight and height were appropriate for his age. Having normal biochemical and haematological parameters operative intervention was planned.
Giant inguinoscrotal hernia was reduced completely under general anaesthesia (Fig. 1b); thick and huge indirect inguinal hernia sac was felt; hence, the standard Fergusons herniotomy was performed by exposing the inguinal canal via inguinal skin crease 1.5 cm incision, giant; thick inguinoscrotal hernia sac was isolated meticulously from the spermatic cord structures and the proximal sac was ligated and transfixed at the normal looking deep inguinal ring (Fig. 2a, b), the excessive distal sac was trimmed and wound was closed in layers without any difficulty ( Fig. 2c, d). Child was started on feeds after 4 h and discharged after 12 h. The child is doing well on three year's follow-up.

Case 2
A five-year-old male child born by full-term vaginal delivery with a birth weight of 2.8 kg; brought to us with history of right inguinoscrotal swelling noticed 10 days after birth. The swelling has gradually progressed to attain the present size of 22 cm × 10 cm, partially reducible hernia on right inguino scrotal region reaching up to mid-thigh on standing posture (Type 1) (Fig. 1b). Child was clinically stable, without any history of irreducibility of the swelling or any other anomalies with normal bowel and bladder functions. Having routine laboratory investigations including cardiac evaluation normal, child was managed by right hernitomy through inguinal skin crease incision under general anaesthesia excising excessive distal sac, after ligation of proximal sac at the

Open Access
African Journal of Urology *Correspondence: jayalaxmisaihole@yahoo.com; jaihole4@gmail.com Department of Paediatric Surgery, IGICH, Bangalore, Karnataka, India level of normal looking deep inguinal ring with absorbable suture and wound was closed uneventfully. Child was discharged next day. Histopathological examination of distal sac revealed fibrous wall. The child is doing well on two year's follow-up (Fig. 2e, f ).
Both children withstood the surgical procedure well.

Discussion
The processus vaginalis a 'tongue or finger' of the peritoneum develops at around 12th week of gestation helps in testicular descent which usually regresses at around 36 to 40th week. In few neonates, this process is incomplete, hence, patent processus vaginalis (PPV) remains, 20% of which will close by first year of age [1,2].
The closure of the PV on the left side precedes the right; therefore, it is not surprising that 60% of congenital inguinal hernia noticed on the right side [1,2].
Isolated inguinal and inguinoscrotal hernias are common in infants as well as in children, which can be managed successfully with standard Fergusons technique. Though rare, Giant inguinoscrotal hernias in adults have been reported in the literature, but, however, their occurrence in children has rarely been reported as well as their definition.
Due to the massive size of giant inguinoscrotal hernias, child will have discomfort in walking, playing, sitting and lying down; hence, affecting the quality of life as well as having impact on psychological and social life. These patients might have bowel or bladder disturbances [3][4][5].