40 Severe scrotal soft-tissue infection: a rare case of complicated inguinal hernia with colonic perforation

Abstract Background Inguinal hernias are a common surgical condition, typically presenting with reducible abdominal contents. The incarceration or strangulation of bowel segments within the hernia sac can lead to serious complications, including bowel perforation. Caecal perforation in an inguinal hernia is an exceptionally rare presentation, often associated with delayed diagnosis and high morbidity. This clinical case highlights the diagnostic and surgical challenges of a perforated cecum and ascending colon in an inguinal hernia, emphasizing the importance of early recognition, the different clinical presentation compared to intra-abdominal perforations and prompt intervention in preventing life-threatening complications. Case Report 57-year-old man, with a medical history of Ebstein anomaly with atrial septal defect corrected in childhood. Multiple admissions for decompensated heart failure, the last 3 with cardiogenic shock. He required a heart transplant in 2021, and since then is treated with Tacrolimus. He attended the Emergency Department presenting with increasing pain in the last 10 days of a previously asymptomatic right inguinoscrotal hernia, associated with foul-smelling exudate from the scrotal skin. The physical examination showed an incarcerated large right inguinoscrotal hernia complicated with a skin fistula pouring faecal content and a severe scrotal soft-tissue infection. Upon examination there was no abdominal tenderness. Blood tests showed leucocytosis and elevated C-reactive Protein. A CT-scan showed an indirect inguinoscrotal hernia complicated with ischemic and perforated intestinal content and exteriorized through a large skin defect. Emergency laparotomy was performed, revealing cecum and ascending colon herniation that presented 2 perforations within the hernia sac, which had faecal content that had fistulized to the scrotal skin. There was also localized fasciitis and right testicular necrosis, but no peritonitis or other intra-abdominal alterations were found. Right hemicolectomy with ileocolic anastomosis, hernia repair with intraperitoneal mesh, scrotal debridement and right orchiectomy was performed. The first 4 postoperative days required management in the ICU due to renal impairment and a single episode of haematochezia, treated with transfusion of 2 units of RBC, but no vasopressors were required and he did not present other complications. The patient was discharged on the 10th postoperative day and did not require new hospital admissions. Educational Highlights Cecal and ascending colon perforation within an inguinal hernia is an extremely rare. An extrabdominal and fistulised perforation, can present a subacute and less severe clinical course. Early recognition, as well as prompt surgical intervention are essential to prevent life-threatening complications such as sepsis, shock, and organ failure. In patients with preexisting comorbidities, particularly those on immunosuppressive therapy, timely intervention is crucial to improving outcomes. This case demonstrates the rare occurrence of cecal perforation within an inguinal hernia, which present unique diagnostic and treatment challenges. It highlights the importance of early recognition and intervention, especially in patients with complex medical histories. Additionally, it underscores the value of a multidisciplinary approach in managing complicated cases that involve abdominal and extra-abdominal infections, hernia and scrotal complications.