# Adaptive surgical approach to giant inguinoscrotal hernia with enterocutaneous fistula in an adult paraplegic male with severe lordoscoliosis causing loss of domain: A case report and review of literature

## TL;DR

A paraplegic man with severe spinal deformity and a rare hernia required a novel surgical approach using the scrotum as a new abdominal cavity.

## Contribution

First reported case of bilateral GIH with loss of domain in a paraplegic patient with severe scoliosis and a novel surgical solution.

## Key findings

- Standard abdominal reintegration was impossible due to anatomical constraints from scoliosis and loss of domain.
- The scrotum was repurposed as a functional neoperitoneal cavity to house the repaired bowel.
- The patient recovered well post-surgery with normal bowel function restored.

## Abstract

Giant inguinoscrotal hernias (GIH) are rare and can be complicated by loss of domain (LOD), which limits standard surgical repair options due to increased intra-abdominal pressure (IAP) and the risk of post-operative respiratory compromise. No prior reports describe GIH with LOD in patients with severe spinal deformity.

A 34-year-old paraplegic male with severe lordoscoliosis and bilateral strangulated GIH presented with small bowel strangulation and underwent emergent bowel resection. Due to LOD and anterior peritoneal displacement from scoliosis, standard abdominal reintegration was impossible, and the hernia was not reduced. His post-operative course was complicated by a scrotal enterocutaneous fistula. Two years later, bowel evisceration from the ECF site prompted elective reconstruction. Intraoperatively, a continuous chamber between the abdomen and scrotum was identified, containing most bowel loops, including the fistulized segment. The fistulized segment was resected, and remaining loops repositioned into the scrotum, which functioned as a permanent neoperitoneal cavity. Postoperative edema resolved conservatively, and the patient resumed normal bowel movements.

This case highlights the challenges posed by severe spinal deformities in GIH management. Traditional reduction strategies to mitigate IAP following full bowel reintegration were impractical due to anatomical constraints. Instead, the preserved scrotal sac served as a functional extension of the abdominal cavity.

This is the first reported case of bilateral GIH with LOD in a paraplegic patient with severe scoliosis. The novel approach of scrotal repositioning offers a viable alternative when standard abdominal reintegration is unfeasible.

•Giant inguinoscrotal hernias (GIH) are hernias that extend below the midpoint of the thigh.•Loss of domain can occur in patients with decades-long hernia chronicity or anatomical abnormalities•Elevated intraabdominal pressure may result following attempted hernia reduction into the abdominal cavity•A paraplegic male with severe lordoscoliosis presented with GIH and subsequent scrotal enterocutaneous fistula formation•Intraoperatively, the scrotum was utilized as a neo-peritoneal cavity to permanently house repaired bowel.

Giant inguinoscrotal hernias (GIH) are hernias that extend below the midpoint of the thigh.

Loss of domain can occur in patients with decades-long hernia chronicity or anatomical abnormalities

Elevated intraabdominal pressure may result following attempted hernia reduction into the abdominal cavity

A paraplegic male with severe lordoscoliosis presented with GIH and subsequent scrotal enterocutaneous fistula formation

Intraoperatively, the scrotum was utilized as a neo-peritoneal cavity to permanently house repaired bowel.