Serendipitous stomach in scrotal sac: an unusual cause of recurrent gastric outlet obstruction

Kimberly Ramsingh¹, Shirvanie Persaud¹, Jagathi Gora¹, Vishan Ramnarine¹

¹Department of General Surgery, Eric Williams Medical Sciences Complex, Champ Fleurs, Trinidad and Tobago

Corresponding Author:
Kimberly Ramsingh
Email: [email protected]

DOAJ: f3eee6c9fbd44d7fb52f2931c6ad7436
DOI: https://doi.org/10.48107/CMJ.2025.06.002
Published Online: June 30, 2025

Copyright: This is an open-access article under the terms of the Creative Commons Attribution License which permits use, distribution, and reproduction in any medium, provided the original work is properly cited.

©2025 The Authors. Caribbean Medical Journal published by Trinidad & Tobago Medical Association

ABSTRACT
Inguinoscrotal hernias commonly contain the bowel and omentum and very rarely contain the stomach – a distant, fixed organ. Diagnosis can be challenging as presentation ranges from asymptomatic, to gastric outlet obstruction and in extremis. Management can vary from conservative to surgical. We report the case of a large bilateral inguinoscrotal hernia containing the stomach and presenting with recurrent gastric outlet obstruction during the COVID-19 pandemic in a Caribbean island. We precluded perioperative morbidity by doing an initial combined conservative approach for the underlying reactive gastropathy followed by a single-stage, elective, bilateral inguinal hernia repair.

INTRODUCTION
Inguinoscrotal hernias are the most common abdominal wall hernia.¹ These hernias rarely contain stomach, with 70 cases reported before the year 1980 and up to 91 cases as of 2023.^2,3 Presentation ranges from asymptomatic to gastric outlet obstruction and in extremis with ischemia, strangulation, volvulus and perforation.^3,4 These cases are diagnostically challenging and evaluation has evolved from X-ray and upper gastrointestinal series that show the tip of the nasogastric tube (NGT) in the scrotum to combined computed tomography (CT) of the abdomen and pelvis and endoscopy.^5,6

Increased peri-operative morbidity and mortality associated with large inguinoscrotal hernias are due to loss of domain and risk of abdominal compartment syndrome.⁷ This may require visceral reduction surgical techniques or increasing abdominal wall length with mesh or transposition of viable tissue.^4,7

We present our approach to the management of a patient with large bilateral inguinoscrotal hernias with recurrent gastric outlet obstruction at a tertiary care hospital using a combined conservative and surgical approach. Highlighting its rarity, this case is the second reported case from Trinidad and Tobago, an English speaking Caribbean island, with the first case reported in 1987.⁵

PRESENTATION OF CASE
A 61-year-old male was referred to the Emergency Department for a 5-day history of epigastric pain, upper abdominal swelling, nausea and bloating. He had controlled hypertension for 15 years and was compliant with nifedipine. He had a 15-year history of large bilateral inguinoscrotal hernias that was asymptomatic and for which he did not seek medical attention. He had no prior surgeries and was a non-smoker with good social support.

During his first admission, his abdomen was tender at the epigastrium and mildly distended but not peritonitic or tense. He had large bilateral inguinoscrotal hernias extending proximal to mid-thigh that were soft, partially reducible on the left and irreducible on the right.

Lab investigations were normal; these included a complete blood count, kidney and liver function tests and an arterial blood gas to assess for acid base abnormalities and lactate levels which can guide resuscitation. Computed tomography of the abdomen and pelvis showed a grossly distended stomach with predominantly fluid contents. The stomach was seen to be herniated into a large 8.1 cm by 9 cm left inguinal hernia with no focal pyloric masses, suggesting a benign type gastric outlet obstruction. A large 13.6 cm by 10.4 cm right-sided inguinal hernia containing both large and small bowel and some mesentery was noted (Figure 1). There were no signs of ischemia, strangulation, or perforation. Endoscopy showed areas of reactive gastropathy with no ulceration, the pylorus was not visualized.

Figure 1: Computed Tomography Abdomen Pelvis – coronal slice – showing gastric distension into the left inguinoscrotal hernia

The patient had clinical resolution after nasogastric decompression, bowel rest and proton pump inhibitors. The patient was booked for an elective hernia repair but was delayed by two years due to the COVID-19 pandemic restrictions on non-emergent cases and he was lost to follow-up. Thereafter, he presented to the Emergency Department acutely with signs and symptoms of gastric outlet obstruction similar to his first presentation. On examination, he had an increase in the size of the hernia with no overlying skin changes and he was hemodynamically stable. The hernia was soft and irreducible bilaterally. His abdomen was not peritonitic and mildly distended with epigastric tenderness.

An upper gastrointestinal series showed a grossly distended stomach extending into the left inguinoscrotal hernia with no contrast extravasation to suggest perforation. CT abdomen and pelvis showed an interval increase in the size of bilateral inguinal hernias with similar findings to his initial CT of benign gastric outlet obstruction and no acute complications of perforation, strangulation or ischemia.

The patient was treated with nasogastric decompression, draining 4 litres of non-bilious output. His gastric outlet obstruction clinically resolved and he was discharged on proton pump inhibitors with a planned elective bilateral inguinal hernia repair in two weeks.

On the day of the operation, the patient fasted six hours prior to general anaesthesia. He had bilateral inguinal hernia repair via bilateral inguinal incisions and midline laparotomy. The hernia sacs were divided and its contents were eviscerated. The left inguinal hernia contained omentum (Figure 2) and the right inguinal hernia contained small intestines, appendix and cecum (Figure 3). Direct visualization of a shrunken stomach with no areas of ischemia, perforation, masses or lax ligaments was facilitated by a midline laparotomy (Figure 2). This precluded the need for gastric resection or gastropexy. The hernia contents were successfully reduced with no need for visceral volume reduction techniques such as omentectomy or colectomy. The abdominal wall was lax, avoiding the need for component separation techniques and a mass closure of the abdominal wall was done using nylon. The inguinal hernia was repaired using the Lichtenstein approach with polypropylene mesh reinforcing the posterior wall. The patient’s testes and spermatic cord were preserved.

Figure 2: Left hernia sac containing omentum and midline laparotomy showing shrunken intact stomach

Figure 3: Right hernia sac containing small intestines, cecum, and appendix

The patient had an uneventful postoperative stay with no complications of respiratory compromise or abdominal compartment syndrome. The patient was graduated to a hypertensive diet and passed a bowel movement by day 2 post operation. He was discharged and had follow-up in the outpatient clinic. He had no surgical site infection, scrotal swelling, hematoma, chronic pain or signs of recurrence up to the 2-year follow up and repeat X-rays showed no gastric distension. The patient was able to resume normal activities and was satisfied with the outcomes.

DISCUSSION
Inguinal hernias are defined as a protrusion of the contents of the abdominal cavity through the inguinal canal. Inguinal hernias account for 75% of abdominal wall hernias and occur in 27-43% of men.¹ Contents are usually small bowel, large bowel and omentum. Inguinal hernias rarely contain the stomach with 70 cases reported before 1980 and 21 more cases reported as of 2023.^2,3 This comparative difference in the frequency of cases between these two time periods is reflective of the trend for earlier surgical intervention of small, asymptomatic hernias.³

Inguinal hernias rarely contain the stomach due to its anatomical location and relatively fixed position due to tethering gastrohepatic, gastrocolic, gastrosplenic and gastrophrenic ligaments. It is thought that laxity in these ligaments from traction and gradual descent of the omentum in chronic hernias result in the stomach descending into the hernia.³

Presentation of patients with an inguinal hernia containing the stomach ranges from asymptomatic (5%), gastric outlet obstruction (48%) (epigastric pain, abdominal distension, nausea, vomiting, dyspepsia) or in extremis (48%) with ischemia, strangulation and perforation (hematemesis, peritonitis, overlying scrotal skin changes, tenderness and hemodynamic instability).^4,9,10

Generally, inguinal hernias are diagnosed clinically with history and physical examination.⁸ From the review of the literature, stomach-containing groin hernias should be suspected in the patient who presents with gastric outlet obstruction and a chronic inguinal hernia.³

Further evaluation is necessary for diagnosis of stomach contents in inguinoscrotal hernias. Investigations have progressed from plain X ray that shows the tip of the nasogastric tube in the scrotum and upper gastrointestinal series (5) to endoscopy and CT abdomen and pelvis (diagnostic).⁶

Giant inguinoscrotal hernias are associated with increased perioperative morbidity and mortality.⁷ They are associated with loss of domain and the risk of abdominal compartment syndrome as well as respiratory compromise which may require visceral reduction surgery such as gastric resection, colectomy or omentectomy.^4,7 Alternatively, surgical techniques described to increase intra-abdominal volume and lengthen the abdominal wall include preoperative progressive pneumoperitoneum, use of mesh (avoided in cases of gross contamination), transposition of viable tissue and component separation technique.

Gastric outlet obstruction (GOO) is a result of any disease process that causes a mechanical impediment to gastric emptying.⁹ Investigating the underlying cause of gastric outlet obstruction is necessary for guiding management. Patients with recurrent gastric outlet obstruction may have underlying benign pathology of peptic ulcer disease, most commonly or an incarcerated pylorus.^9,10 While GOO can be successfully managed conservatively, surgical intervention is still recommended due to the risk of recurrence and impending complications of perforation.^2,4,11,12

There are no established guidelines on management of inguinal hernias containing stomach.⁸ The approach to inguinal hernia repair in these cases is usually open with only one case done laparoscopically.³ The advantages of an open approach include a staged repair allowing for lavage and gastric resection in the event of gastric perforation followed by second stage mesh hernia repairs.⁴ The incidence of single stage midline laparotomy with groin hernia repair was higher in gastric perforation than GOO.⁴

In our case, evaluation led to the diagnosis of benign gastric outlet obstruction secondary to reactive gastropathy. This was successfully treated conservatively with nasogastric decompression and proton pump inhibitors. The patient benefitted from an elective planned single stage bilateral inguinal hernia repair due to the risk of further complications, including recurrence of the GOO and possible gastric perforation. The patient agreed and had a single-stage midline laparotomy and bilateral groin hernia repair with mesh that was uncomplicated and had no recurrence at the 2-year follow up.

Cases of stomach-containing groin hernias, although uncommon, are well documented. Alexandre described a large inguinal hernia with gastric contents successfully treated with open repair.¹⁴ We were able to successfully manage this case of large bilateral inguinoscrotal hernias containing stomach, small intestines, appendix and omentum as well as avoid major perioperative morbidity and mortality by adopting an initial conservative approach followed by an elective hernia repair. 

CONCLUSION
Inguinoscrotal hernias rarely contain the stomach. This diagnosis is suggested in a patient with large inguinoscrotal hernias that present with gastric outlet obstruction and can be confirmed on CT abdomen and pelvis. Avoiding major perioperative morbidity and mortality in this case of large bilateral inguinoscrotal hernias containing stomach, small intestines, appendix and omentum was achieved by adopting an initial conservative approach followed by an elective single stage bilateral hernia repair.

Ethical approval statement: Not applicable.
Financial disclosure or funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest: The authors declare no conflicts of interest.
Informed consent: Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Author contributions: Kimberly Ramsingh – Conception of the study, acquisition of data, drafting the original article.
Shirvanie Persaud – Revising it critically for important intellectual content, and final approval of the version to be submitted.
Jagathi Gora – Performed the surgery, Drafting the article, revising it critically for important intellectual content, final approval of the version to be submitted.
Vishan Ramnarine – Performed the surgery, Drafting the article, revising it critically for important intellectual content, final approval of the version to be submitted

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