Ramiro Gálvez-Valdovinos1*, Juan Francisco Funes-Rodríguez1, Gustavo López-Ambriz1, Luis L Tinoco Téllez1 and Luis Gerardo Domínguez Carrillo2
1Surgery Division, Hospital Angeles Leon, Guanajuato, México
2Medicine School from Leon, Guanajuato University, Mexico
Received: 13 May, 2017; Accepted: 05 July, 2017; Published: 06 July, 2017
*Corresponding author:
Ramiro Galvez Valdovinos, Surgery Division, Hospital Angeles Leon, Guanajuato, México, Tel: (52) 477 78-78-623; E-mail: @; @
Valdovinos RG, Rodríguez JFF, Ambriz GL, LLT Téllez, Carrillo LGD (2017) Laparoscopic surgery without peritoneal space contamination in perforated acute abscedated diverticulitis of incarcerated inguinoscrotal hernia. Arch Clin Gastroenterol 3(3): 063-065. 10.17352/2455-2283.000040
© 2017 Valdovinos RG, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Perforated diverticulitis; Incarcerated inguinoscrotal hernia; Acute scrotum

Sixty seven year old male patient with hypotension, tachycardia, 38.5°C fever, tensioning left inguinoscrotal hernia and hyperemia (acute scrotum). By abdominal computed tomography, recto-sigmoid perforation in diverticulitis area with collection and free air in hernial sac, was observed. This clinical finding of perforated abscedated diverticuitis with an inguinoscrotal hernia is uncommon. Usefulness of minimally invasive surgery for Hartmann’s procedure without peritoneal contamination as well as surgical piece removal via scrotum is discussed, including a literature review.


Relation of perforated abscedated diverticuitis with an inguinoscrotal hernia (ISH) is uncommon. There are no cases report published in literature in patient’s clinical context. One of most serious complication of an inguinal hernia is to become incarcerated, the inguinal hernia sac most frequently contains the intestine and the omentum and more uncommonly the appendix, like the sigmoid colon is extraordinary found in an inguinal hernia, especially on the right side. We present a case of this class in which for to extract the contaminated specimen, a minimally invasive surgery to remove sigmoid was combined with trans-scrotal via, achieving resolution of the problem.

Case Report

Sixty seven year old male patient who refers a 10 years’ evolution of an inguinoscrotal hernia, with no other relevant background, came to emergency room at Hospital Ángeles León, due to a sudden hernia growth, pain, 38.5°C fever, changes in intestinal habits and general bad condition. When clinically explored, he presented hypotension (AT 90/60), tachycardia (113 beats/minute), fever (38.5°C). Abdominal exploration showed inguinoscrotal hernia with hyperemia (Figure 1), pain palpation and tensioning scrotum. Blood cytometry revealed leukocytosis of 15,000/mm3 with 12 bands. Abdominal CT scan (Figure 2) showed inguinoscrotal hernia incarcerated by sigmoid rectum which demonstrated perforated diverticulitis. Patient was admitted in intermediate care unit for shock recovery and broad spectrum antibiotic. Twelve hours later, patient undergone exploratory laparoscopy. During surgery, sigmoid rectum was observed trapped in the hernia, there was no free fluid in peritoneal cavity, end descending colon resection was performed, starting with meso-colon release with harmonic scalpel followed by linear cutting staples, colon reduction was not attempted in order to avoid peritoneal cavity contamination. Simultaneously, other surgeons approached the scrotum (Figure 3) for in bloc extraction preserving the hernia sac with sigmoid rectum and testicle with its elements (Figure 4). Hernia zone was directly closed with continuous non absorbable suture without mesh placement. Penrose drainage was left in scrotum and surgery was concluded with terminal colostomy opening on right iliac fossa. Ertapenem sensibility to Escherichia coli was found in exudate culture. Patient overcome was successful and with no complications, he was discharged 5 days post-surgery with intramuscular ertapenem for home application. Histopathologic study revealed acute perforated diverticulitis with ischaemia in the resected colon segment, ischaemia free resection margins and diverticular disease. Laparoscopic Hartmann’s reversal was performed three months later, repairing hernia by inguinal via and placing mesh. In one year of follow-up the patient is normal and carries out its usual activities.

  1. Figure 1:
    Scrotal pouch with erythema and volume increased due to incarcerated hernia.

  1. Figure 2:
    CT scan in a coronal section; incarcerated inguinoscrotal hernia by sigmoid perforated by divertitulitis, with free air in scrotum.

  1. Figure 3:
    Surgical pathology specimens. Sectioned sigmoid rectum. Incarceration view.

  1. Figure 4:
    Surgical specimen’s extraction via scrotum.


Combination of inguinoscrotal hernia and diverticulitis is a rare couple [1-3]. In acute scrotum, patient presents acute pain in scrotal bag or its content and could be followed by inflammation, blush, oedema and size increase [3,4]. Cause of acute abdomen in this patient was a perforated diverticula with a previous inguinoscrotal hernia. Patient’s clinical evaluation was relevant to obtain a correct diagnosis over decisions in surgical approach. Computed tomography lead us correctly. In this case, laparoscopic strategy let us to examine the peritoneal cavity looking for purulent collections, discarding colon chronic constrictions, and other possible perforations near or far of the hernia neck (avoiding future stenosis), acute ischaemia or colon necrosis and moreover, to perform the Hartmann´s intervention easier without contamination of peritoneal cavity when extracting perforated abscedated colon through scrotum. Due to a high pollution degree of scrotal bag, it was impossible to save the testicle, the inguinal plasty was reserved for a second chirurgical time, giving preference to resection and controlling damage for septic shock, fortunately no other constriction was presented during postoperative period. Laparoscopic Hartmann’s reversal was performed three months later, repairing hernia by inguinal via with a polypropylene mesh.

PubMed’s review (Table 1) of similar cases showed rarity of this clinical presentation, laparoscopic Hartmann’s intervention is the most common [1-9].

  1. avatar

    Table 1:

    Similar cases in literature.

There are two [10,11] reports of draining abscess via scrotum or by laparotomy, resecting sigmoid with primary anastomosis afterwards. Just in one case, sigmoid anastomosis resection was done laparoscopically [10]. Only two reports make mention of the technique for hernia repair [5,8], reporting no contraindication to use light mesh, however with this procedure, patients could be infected or to present a fistula rejection. Is important to mention that in 11 clinical cases reviewed from 1980 to 2015, two patients died (18%).


Combination of laparoscopic sigmoid resection and perforated diverticulum excision in case of hernia, the via scrotum without peritoneal contamination could be a surgical alternative in these cases.

  1. Andrabi SI, Pitale A, El-Hakeem AA (2007) Diverticular abscess presenting as a strangulated inguinal hernia: case report and review of the literature. Ulster Med J 76: 107-108. Link:  
  2. Hwang EJ, Karas JR, Zawin M, Bergamaschi R (2011) Acute scrotum caused by sigmoid diverticulitis. Surg Infect 12: 507-508. Link:  
  3. Klutke CG, Miles BJ, Obeid F (1988) Unusual presentation of sigmoid diverticulitis as an acute scrotum. J Urol 139: 380-381. Link:  
  4. Ota S, Noguchi T, Takao T, Sakamoto T, Kanie Y, et al.  (2015) An Incarcerated Colon Inguinal Hernia That Perforated into the Scrotum and Exhibited an Air-Fluid Level. Case Rep Med 2015: 105-183. Link:  
  5. Tufnell ML, Abraham-Igwe C (2008) A perforated diverticulum of the sigmoid colon found within a strangulated inguinal hernia. Hernia 12: 421-423. Link:  
  6. Kouraklis G, Glinavou A, Andromanakos N, Karatzas G (2004) Perforation of a solitary diverticulum of sigmoid colon in an incarcerated scrotal hernia. Dig Dis Sci 49: 883-884. Link:  
  7. Raimondi P, Aceto L, Caldaralo F, Cichella AD, d'Alessandro V, et al. (2016) Localized peritonitis from perforated sigmoid diverticulum in a non-reducible inguinal hernia. Case report. Int J Colorectal Dis 3: 935-936. Link:
  8. Badowski A, Symonowicz P, Zaremba Z, Zaraś T (1980) Strangulated inguinal hernia with sigmoid perforation by a foreign body and scrotal phlegmon. Wiad Lek 33: 575-577. Link:  
  9. Georgiev-Hristov T, Álvarez-Gallego M, Juliá JB, Redondo MG, Verón A, et al. (2011) Necrotising fasciitis of the lower limb due to perforated inguinal hernia. Hernia 15: 571-573. Link:  
  10. Greenberg J, Arnell TD (2005) Diverticular abscess presenting as an incarcerated inguinal hernia. Am Surg 71: 208-209. Link:  
  11. Bunting D, Harshen R, Ravichandra M, Ridings P (2006) Unusual diagnoses presenting as incarcerated inguinal hernia: a case report and review of the literature. Int J Clin Pract 60: 1681-1682. Link:

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