Inguinal Sac Abscess Masquerading as a Strangulated Inguinal Hernia after Antrectomy and Proximal Duodenectomy for Perforated Peptic Duodenal Ulcer

Case Presentation

A 66-year-old male with a history of peptic ulcer disease presented with acute onset abdominal pain. Notably, he had undergone a Graham patch omentopexy for a perforated proximal duodenal ulcer four years prior to presentation. On admission, the patient had peritonitis, and a computed tomographic (CT) scan of the abdomen demonstrated a perforation of the right wall of the proximal duodenum with extravasation of contrast (Fig. 1). At laparotomy, the perforation of the proximal duodenum was identified (Fig. 2) along with purulent peritonitis. Because the patient had a history of non-compliance with proton pump inhibitors since the prior Graham patch omentopexy, the patient underwent an antrectomy, proximal duodenectomy, truncal vagotomy, Billroth II gastrojejunostomy, and a Witzel tube jejunostomy.

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FIG. 1.

Abdominal computed tomographic scan demonstrating perforation of the proximal duodenum with extravasation of contrast.

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FIG. 2.

(A) Antrum and proximal duodenum, resected, with perforated duodenal ulcer. (B) Surgical specimen, opened.

On post-operative day seven, the patient developed an acute onset of pain and swelling of his left groin that was concerning for a strangulated left inguinal hernia. His initial leukocytosis had resolved and abdominal examination did not reveal peritoneal signs. At operation, however, the left inguinal canal was explored and an indirect hernia sac abscess was identified (Fig. 3). The abscess was drained, the hernia sac was excised, and a McVay herniorrhaphy was performed. Cultures from the abscess grew Candida glabrata. The patient was treated with antifungal therapy and recovered without event.

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FIG. 3.

Skeletonization of the inguinal hernia sac abscess during left groin exploration. (Orientation: Patient's legs are beyond the top of the picture, the upper body is beyond the bottom of the picture, left is patient's left, right is patient's right, and the Penrose drain is around spermatic cord structures.) The hernia sac is held by forceps, and a cord lipoma is present.

Discussion

When considered separately, peritonitis (caused by perforation of the alimentary tract) and inguinal hernias are diagnoses that are neither rare nor infrequent in their incidence. However, the formation of an inguinal sac abscess resulting from peritonitis caused by perforation of the alimentary tract is a rare clinical entity. We report the case of a patient who developed a left inguinal hernia sac abscess after surgical management of a recurrent perforated peptic duodenal ulcer.

Perforated peptic ulcers with purulent peritonitis can predispose patients to the development of an intra-abdominal abscess. In this patient, who previously underwent a Graham patch omentopexy for a perforated duodenal peptic ulcer, it is believed that the patient's non-compliance with proton pump inhibitors caused a recurrence of the duodenal ulcer because he had no evidence of H. pylori infection on laboratory testing or other pathology. Because the patient had reported no symptoms or history of inguinal hernias, the development of left inguinal pain and swelling in the post-operative period was unexpected, especially with features that were concerning for a strangulated hernia. However, once the inguinal sac abscess was identified, drained, and excised, the microbiologic analysis confirmed that the perforated duodenal ulcer was the cause of the abscess. Ultimately, effluent from the perforated ulcer accumulated in dependent areas of the peritoneal cavity, which in this case included an unknown, sub-clinical indirect hernia sac that allowed for abscess formation.

After the initial reports of inguinal hernia sac abscesses following management of peritonitis by Cronin and Ellis in 1959 [1] and by Chary in 1977 [2], few additional cases have been reported. Other cases of hernia sac abscesses have been related to appendicitis, especially in the setting of Amyand or De Gargenot hernias [3–7], diverticular abscesses [8–10], Littre hernia [11], cancer [12], other colonic pathology [13], and even colorectal surgery [14]. Also, in an earlier era, several reports described cases in which a hernia sac abscess was identified before a diagnosis of generalized peritonitis was made [15–18], but this phenomenon may have been a result of the limitations of the diagnostic imaging modalities that were available at the time, and is not expected to persist in the modern era in which CT imaging enables surgeons to diagnose specific causes of peritonitis promptly.

Percutaneous drainage of a hernia sac abscess has been reported previously [13]. Yet, in the case presented here, surgical exploration was performed in part because a strangulated inguinal hernia was suspected. This approach would allow for effective treatment of both the abscess and inguinal hernia. Hernia sac drainage and excision with McVay herniorrhaphy was deemed to be safe in a contaminated environment and, after more than two years of clinical follow up, there has been no evidence of a hernia recurrence or other complications. It seems self-evident that herniorrhaphy with prosthetic mesh should be avoided in situations involving peritonitis and deep space infection. Furthermore, even if the existence of the inguinal hernia had been known at the time of laparotomy, surgical intervention for the hernia would have been deferred until the patient had recovered fully from the laparotomy for peritonitis to limit the risk of a surgical site infection in the inguinal wound and allow for a more durable mesh herniorrhaphy in the future.

Conclusion

An inguinal hernia sac abscess can develop after the operative management of a recurrent perforated peptic duodenal ulcer and may masquerade as a strangulated inguinal hernia. Surgeons should consider this entity in any patient who recently underwent a laparotomy for generalized peritonitis caused by a perforated hollow viscus and has acute onset groin pain. Although inguinal hernia sac abscesses can be managed percutaneously, any plan for sac excision and herniorrhaphy should avoid the use of a prosthetic mesh to limit the risk of a prolonged surgical site infection.