EGS SO22 - When What Is Left Is Not Right

Abstract Background Aims We present a case of small bowel obstruction in a massive inguinoscrotal hernia, with loss of abdominal domain, treated successfully by emergency surgery. The chronicity of the condition resulted in a large pendulous pelvic stomach, with the Duodeno jejunal flexure within the hernia and constricted by the hernial ring. Method The first contact with surgical team was as emergency, since initial referral to surgical outpatients was deferred by the patient, due to his embarrassment. After initial attempts to decompress the stomach through nasogastric tube and with nutritional support with parenteral nutrition, the patient was counselled for surgery. Informed consent was taken for right orchidectomy, possibility of open abdomen with delayed reconstruction, stoma, respiratory compromise, multiorgan failure and death.Prior to intervention, Intensive Therapy unit was consulted for admission following surgery, with plans to use Botox in the abdominal wall, to improve compliance, in case of abdominal compartment syndrome or respiratory failure. Results Through an inguinoscrotal incision, the inguinal canal was opened and the cord structures were transfixed and divided. The internal ring was divided laterally to allow gradual compression and replacement of the hernia intraabdominally. Over 8 litres of fluid was removed from Nasogastric aspirate. Lymphoedema in the scrotum made the laterality of the testis seen in the operative field ambiguous. The hernia was repaired with Bassini repair of the muscles, followed by polypropelene mesh. Following surgery, patient was discharged home with no immediate complications. Histology of the sac and Tunica Vaginalis revealed an atrophic right testis. Conclusion Distorted anatomy from chronicity of common surgical pathology may present challenge to even experienced surgeons. Unusual presentation of common pathology requires thinking outside the box. Since the lymphoedema in the scrotal hernial sac made the laterality of the testis unclear, an informed decision was taken not to remove the single testis seen in the operative field. The histology confirmed that this was the right decision, since the atrophic right testis was included in the operative specimen. Post operative imaging confirmed what was left, was the left testis.