Frequently observed in surgical consultations, inguinal hernias are the specialty of many surgeons, who have a growing understanding of this debilitating pathology. Thus had they described a variety of inguinal hernia said:”Hernia in pants”. Indeed, we have sometimes encountered this type of hernia in our practices. A brief anatomical reminder of the inguinal region, followed by the summary presentation of the inguinal hernias and the pantaloon hernia will precede the presentation of our pantaloon hernia clinical case.
THE SKELETON INVOLVED IN THE FORMATION OF HERNIAS
The skeleton of the bony pelvis is made up of 4 bones which form the pelvic girdle: the sacrum behind, the coccyx below and, laterally, the two iliac bones.
They are represented by the muscles of the anterolateral wall of the abdomen namely: The external oblique, the internal oblique and the transverse muscle.
The external oblique muscle
The origin of the external oblique muscle of the abdomen is on the bony part of the dimensions C5 TO C12. The fibers have a ventral, caudal and medial course.
The termination is done by an aponeurosis. The lateral pillar is inserted on the inguinal ligament and the pubis, the medial pillar is fixed on the pubic symphysis and the cross pillar will be inserted on the contralateral pubic symphysis.
The internal oblique muscle
It begins on the thoraco-lumbar fascia, the iliac crest, and lateral half of the inguinal ligament. Its fibers are oriented upwards. It has a cranial termination: C9-C12, a caudal termination which participates in the formation of the conjoined tendon and a medial termination which participates in the formation of the white line.
The transverse muscle of the abdomen
Origin: costal, thoraco-lumbar fascia, dimensions C7-C12.
It starts on:
- The dimensions C7-C12 and the thoraco-lumbar fascia.
- Lumbar vertebrae: Costiform process L1 to L4.
- Iliac : anterior 2/3 of the internal lip of the iliac crest and external 1/3 of the femoral arch, but also on the anterosuperior iliac spine.
It is inserted through an anterior aponeurosis over the entire height of the white line.The inferior fibers, coming from the femoral arch bend and insert themselves on the pubis in front of the rectus femoris, leaving a ring above the femorar arch.
The inguinal canal
is a small, descending canal, having a downward and inward direction, just above and parallel to the lower half of the inguinal ligament. It begins at the deep and continuous inguinal ring for a distance of about 4 cm, ending at the superficial inguinal ring. The contents of the inguinal canal are: the genital branch of the genito-femoral nerve, the spermatic cord in men and the round ligament of the uterus in women.
Deep inguinal ring
This is the beginning of the inguinal canal, it sits in the middle of the space between the anterosuperior iliac spine and the pubic symphysis. It is just above the inguinal ligament and lateral to the inferior epigastric vessels. It is the beginning of a tubular evagination of the fascia transversalis which forms one of the envelopes of the cord in men or the round ligament of the uterus in women.
Superficial inguinal ring
This is the end of the inguinal canal, it is above the pubic tubercle. It is a triangular opening in the aponeurosis of the greater oblique, with its apex supero-lateral and its base formed by the pubic ridge. The two remaining faces (the medial cross and the lateral cross) are attached to the symphysis and pubic tubercle respectively, at the apex of the triangle, the two crosses are held together by crossed fibers which prevent the enlargement of the superficial ring. The superficial annulus is the beginning of the tubular evagination of the external oblique fascia which covers structures crossing the canal and passes through the superficial annulus forming the external spermatic fascia.
THE WALLS OF THE INGUINAL CANAL
It is formed by the aponeurosis of the greater oblique. It is reinforced laterally by the inferior fibers of the internal oblique coming from the lateral 1/2 of the inguinal ligament. This gives additional coverage to the deep inguinal ring, which is a potential point of weakness in the anterior abdominal wall. In addition, as the internal oblique covers the deep inguinal ring, it provides an envelope (cremaster fascia, containing the cremaster muscle) for covering structures crossing the canal.
THE REAR WALL
It is formed by the fascia trasversalis which is reinforced in its medial 1/3 by the conjoined tendon (inguinal falx). This tendon is the combined insertion of the transverse and the internal oblique in the pubic crest and in the pectineal line. Like the internal oblique that reinforces the internal inguinal ring, the position of the conjoined tendon behind the superficial ring allows additional support to the anterior abdominal wall.
THE UPPER WALL
The upper wall is formed by the arched fibers of the transverse and the internal oblique. They pass from their lateral point of origin from the inguinal ligament to their medial point of attachment such as the conjoined tendon.
It is formed by the medial half of the inguinal ligament, it coils below the free edge of the lower part of the fascia of the greater oblique forming a groove through which the contents of the inguinal canal pass. The lacunar ligament strengthens most ofof the glutter.
THE SPERMATIC CORD
The spermatic cord begins at the deep inguinal ring and is formed by the structures that pass between the abdominopelvic cavity and the testes and the 3 fascias that surround these structures.
A hernia is the protrusion of an organ outside of its natural cavity through neoformed orifice.
Inguinal hernias develop in the inguinal area and include:
- Indirect inguinal hernias,
- Direct inguinal hernias,
- Femoral hernias
A pantaloon hernia, otherwise known as a saddlebag hernia, is a combination of direct and indirect hernia. The hernial sac pushes through both sides of the inferior epigastric vessels.
Evidence suggests a multifactorial cause.The indirect variety is congenital, but occurs when the abdominal pressure remains constantly positive causing dilation of the deep orifice of the inguinal canal leading to weakness of the posterior wall which causes the bulging of the hernial sac on both sides of the epigastric artery. The direct variety is acquired and results from the stretching and weakening of the abdominal wall medial the epigastric artery. Hereditary, hormonal, and environmental factors are cited.
This type of hernia can be seen during recurrences if the indirect sac is incompletely ligated and also associated with a small direct hernia.
In Gilbert's classification, pantal hernia is classified as type VI, while in the nyhus classification it is classified as type III b.
It May present itself as a large inguino scrotal or direct hernia and as two hernias.
At the level of an inguinal region, two hernial sacs are present on each side of the inferior epigastric vessels, and separated by the posterior walls of the inguinal canal which is collapsed. The two hernias can be contained in one bag or in both bags. (Oxford texbook of fundamentals of surgery).
Intestinal obstruction by strangulation /incarceration.
Open or laparoscopic methods can be used depending on the case and the expertise of the surgeon. Perhaps best addressed by ligation of the inferior epigastric vessels to convert the indirect and direct components into a single sac (Hiccup maneuver).
The clinical case
Our patient is 47 years old. He presented with a huge enlargement of the inguinal region and the right scrotal sac. The pathology has existed since childhood and has become more pronounced over time and with manual activities in the fields, until it takes on a disabling volume.
On examination, the inguino-scrotal mass increases when standing and coughing, but only decreases slightly when lying down. It is associated with intermittent pain.
The patient has no history suggestive of chronic cough, urinary tract infection, constipation, or diabetes mellitus. The mass is single with an inguinal portion that appears to continue into the scrotal region. The diagnosis of right inguino scrotal hernia with reduced reducibility (slippage?) is made. The patient is proposed for Lichtenstein hernioplasty.
During the operation, we come across two distinc bags containing the intestines on the outside and the bladder on the side, separated by the epigastric vessels.(Pict.1) The posterior inguinal wall is non-existent.
The intervention consisted of resection of the outer sac, preservation of the inferior epigastric artery and Lichtenstein hernioplasty, considering the whole as a single entity. The postoperative is uncomplicated at three months.
It is common to meet in Haiti some adults with large unilateral or bilateral inguino scrotal hernias, associated with direct hernias.
This situation is only possible by a combination of genetic, socio-cultural,nutritional and occupational factors. The long latency period to finally access treatment can be explained by the forced tolerance of the situation, the financial unavailability to access surgical care in the absence of other therapeutic methods. The worsening of the general condition is due to the size of the lump and episodes of vomiting. Accessibility to elective or emergency operative ease puts an end to the patient’s endless suffering. The herniorrhaphy with modified Bassini and Mc Vay with pelvis tension, difficult to perform in these exceptional situations and burdened with a high rate of recurrence, are replaced by Lichtenstein hernioplasties or other techniques without tension.
The pantaloon hernia is a pathological entity in Haitian adults that deserves to be prevented by better accessibility to health care. Its intraoperative recognition requires technical expertise in the repair of "large” inguinal hernias and the systematic use of a hernioplasty.
1. Awgesh Kumar Verma and Mumtaz Ahmad Ansari - Correspondence to Professor Vivek Srivastava; firstname.lastname@example.org -http://dx.doi.org/10.1136/bcr-2020-238619
2. Wani I, hernia D direct - Double direct hernia, triple indirect hernia, double pantaloon hernia (Jammu, Kashmir and Ladakh hernia) with anomalous inferior epigastric artey: case report. Int J
3. SurgCaseRep 2019;60:42doi:10.1016/j.ijscr.2019.05.035pmid:http://www.ncbi.nlm.nih.go v/pubmed/31200214 – Pub Med Google Scholar
4. Qvist G. Saddlebaghernia. BrJSurg 1977;64:442doi:10.1002/bjs.1800640619pmid:http:// www.ncbi.nlm.nih.gov/pubmed/871622 – Pub Med Google Schola
Date de dernière mise à jour : 11/07/2021