Advantages of minimally invasive approach for inguinal bladder hernia repair: case report and literature review
Case Report

Advantages of minimally invasive approach for inguinal bladder hernia repair: case report and literature review

Lalida Rachiwong^, Nan-ak Wiboonkhwan^, Siripong Cheewatanakornkul^

Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand

^ORCID: Lalida Rachiwong, 0000-0003-2434-8039; Nan-ak Wiboonkhwan, 0000-0001-7855-3295; Siripong Cheewatanakornkul, 0000-0001-8230-8946.

Correspondence to: Nan-ak Wiboonkhwan, MD. Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand. Email: boatpsusurgery@gmail.com.

Abstract: Inguinal bladder hernia (IBH) is a rare disease, with only 73 adult cases being reported in Medline over the past decade, 75 cases including the present report. Its preoperative diagnosis is difficult without typical presentation; however, the three most common signs/symptoms are urinary frequency, two-stage urination and acute kidney injury (AKI). Prompt diagnosis should be made in patients presenting with an inguinoscrotal mass along with the aforementioned symptoms. According to a review of the literature of the last decade, 93.3% of IBH diagnoses were made prior to surgery, compared to fewer than 10% in the past century. However, documented cases show that IBH is associated with significant complications if diagnosis is delayed. In addition, there were no reports on the laparoscopic extended-totally extraperitoneal (eTEP) in such cases. Herein, we report 2 cases of IBH along with the literature review. The first patient was diagnosed with IBH during open hernioplasty using saline insufflation via a Foley’s catheter. The second patient presented as an early recurrence, with incarceration after ipsilateral open hernioplasty. This case was diagnosed and successfully treated by eTEP repair. All patients recovered without complications. We aimed to report the diagnosis and surgical approach in IBH along with evidence-based discussion from published studies. The eTEP approach was feasible and safe for the treatment of an incarcerated extraperitoneal type of IBH. The advantages of a minimally invasive approach for IBH are discussed in this report.

Keywords: Case report; hernioplasty; inguinal bladder hernia (IBH); inguinal hernia; laparoscopy

Received: 12 September 2021; Accepted: 22 October 2021; Published: 25 January 2022.

doi: 10.21037/ls-21-19

Video S1 Demonstration of laparoscopic extended-totally extraperitoneal hernia repair in the inguinal bladder hernia.

Introduction

Inguinal bladder hernia (IBH) is a rare disease, accounting for 0.5% of all inguinal hernias (1). Given to the rarity of the disease, patients with IBH are at risk for misdiagnosis during preoperative evaluation. Indeed, acute kidney injury (AKI), or even multiorgan failure (MOF) might be a result of delayed diagnosis (2,3). Upon diagnosis being made, open hernioplasty has been the treatment of choice; however, literature reviews have demonstrated that some patients with IBH have been treated with ipsilateral open hernioplasty (4,5). There are some advantages of a laparoscopic approach in such cases, specifically to the laparoscopic extended-totally extraperitoneal (eTEP) to be discussed. We present the following case in accordance with the CARE reporting checklist (available at https://ls.amegroups.com/article/view/10.21037/ls-21-19/rc).

Case presentation

We report on two cases of IBH and the literature review, using the following method: we conducted the literature search on Ovid (Medline), using the MeSH term: inguinal hernia, bladder hernia or “inguinal bladder hernia”, herniorrhaphy, and hernioplasty. The results were limited to an adult population, in the English language and between 2011 and 2021; last search date was on August 4, 2021.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (approval No. REC.64-406-10-3) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Clinical case 1

The first case was a 60-year-old, male presenting with a right groin mass for 1 year, without urinary symptoms. He was diagnosed with indirect inguinal hernia (IIH) and underwent an open hernioplasty. During the operation, we found 4 cm × 3 cm sized, sac-like structures with complete separation from the spermatic cord, protruding medially to the inferior epigastric vessels; suspected for urinary bladder. To confirm that the sac-like structures were from the urinary bladder, saline insufflation via a Foley’s catheter was used (Figure 1). Once confirmation was made, the urinary bladder was reduced, unopened to the extraperitoneal space. Light-weighted, polypropylene mesh, 15 cm × 10 cm in size, was used and completion of hernioplasty via the Lichtenstein technique was performed. The postoperative period was uneventful, the patient was discharged on postoperative day 2 and there was no clinical evidence of recurrence on follow-up at 6 months.

Figure 1 Insufflation of bladder to confirm inguinal bladder hernia: (A) distended bladder (arrow) after insufflation; (B) insufflation of saline via Foley’s catheter.

Clinical case 2

For the second case, a 67-year-old, male presented with a right groin mass, with difficult urination for 1 year. He was diagnosed as having a direct inguinal hernia with benign prostatic hypertrophy (BPH), and underwent open hernioplasty via the Lichtenstein technique. On postoperative day 4, he had a recurrent, irreducible tendered right scrotal mass, 5 cm × 5 cm in size, that extended from the most medial part of the inguinal area (Figure 2); this was accompanied with marked abdominal distension. His preoperative diagnosis was recurrent hernia with small bowel obstruction (SBO). Our decision was to undertake a posterior approach, using the eTEP technique (Video S1). The eTEP was selected instead of TEP because of two reasons: first, a short distance between an umbilicus and pubic tubercle, second, an incarceration of hernia which might causing a narrow view in TEP. Under general anesthesia, the patient was placed in the supine position. Ports placement are shown in Figure 3A. The retro-rectus space was created using a Hegar’s dilator and balloon spacer. We performed dissection of the retropubic as well as the lateral space, until reaching the anterior-superior iliac of the spine. Identification of spermatic contents confirmed no IIH component. The hernia defect (Figure 3B) was located through the anterosuperior to the pubic tubercle area, corresponding to the superficial inguinal ring externally (Figure 2). The content was reduced back; thus, clearly confirming the urinary bladder (Figure 3C), and was then reduced to its anatomical position. The pseudosac (transversalis fascia) was then fixed with the abdominal wall. Three-dimension mesh, 10 cm × 15 cm in size, was placed over the defect and the myopectineal orifices (Figure 3D).

Figure 2 Right scrotal mass (white arrows), 5 cm × 5 cm in size extended from the most medial part of inguinal area corresponding to the superficial inguinal ring (dot circle).
Figure 3 Laparoscopic preperitoneal repair findings: (A) ports placement; (B) hernia defect (arrow) located at just anterolateral to pubic tubercle (P), close to the origin of rectum muscle (R) and medial to inferior epigastric vessels (IEV); (C) the peritoneoscopy shows redundant viable bladder (*); (D) mesh placement cover all potential defects including pubic tubercle (P) and midline (M).

The postoperative period was uneventful, the patient was discharged on postoperative day 5. The patient was free of urinary symptoms, and there was no clinical evidence of recurrence on follow-up at 7 months.

Literature review

Thirty-four original articles, with 73 cases of IBH have been reported over the past decade; 75 cases including this present report, with most IBHs being diagnosed preoperatively (2-4,6-27); accounting for 93.3% (70 of 75 patients). Computed tomography (CT) scanning is the imaging of choice in 26 of 34 articles (2-4,6,7,9-11). Of the total, 4.0% (3 of 75 patients) were diagnosed during operation (5,23). Surprisingly, 10.7% (8 of 75 patients) had surgical repair of their ipsilateral inguinal hernias (4-6,22,23), with only two patient undergoing transabdominal preperitoneal (TAPP) repair (15,22). The most common three presentations were: urinary frequency (14-16,18,21,22,24,27-29), two-stage urination (3,8,12,15,19,23,24,26,28,30,31) and AKI (2,3,9-11,21,27,32-34) accounting for 17.3%, 16.0% and 12.0%, respectively. It was also noticed that one-third of the patient are asymptomatic and five patients presenting with only an inguinal mass without urinary symptoms (5,20). Summary of reported cases are presented in Table 1. The possible presenting symptoms and signs are summarized in Table 2.

Table 1

Summary of case reports on diagnosis and treatment of inguinal bladder hernia

Authors n Clinical presentations† Previous hernia repair Time of diagnosis Diagnostic test Surgical approach Complications Recurrence‡ (month)
Bernhardson et al. (4), 2021 1 Urinary retention Ipsilateral, open Pre-op CT scan Open Bladder injury No (N/A)
Tome et al. (6), 2021 1 Scrotal pain, hematuria, oliguria Bilateral, robotic Pre-op CT scan Open N/A N/A
Levi et al. (2), 2020 1 Urinary retention, hematuria, AKI No Pre-op CT scan Open ESRD No (N/A)
Gonzalez-Urquijo et al. (3), 2019 5 Two-stage urination [2], abdominal pain [2], MOF [1] No Pre-op CT scan [3], US and cystography [2]‡ Open None No (28)
Cimadamore et al. (7), 2019 1 Hematuria No Pre-op CT scan Open None N/A
Wang et al. (8),
2018		 1 Two-stage urination No Pre-op CT scan and cystography Open None No [24]
Safavy et al. (9), 2018 1 Flank and groin pain, hematuria, AKI No Pre-op CT scan, cystoscopy Open Hydronephrosis No [4]
Ghielmini et al. (10), 2017 1 Oliguria, AKI No Pre-op CT scan Open None No [6]
François et al. (11), 2017 1 Urosepsis, AKI No Pre-op CT scan Open§ None No [1]
Ugur et al. (12), 2016 1 Two-stage urination No Pre-op CT scan Open None N/A
Tokgöz et al. (13), 2016 1 Flank pain, scrotal mass No Pre-op CT scan Open None N/A
Kim et al. (5), 2011 1 Scrotal mass Ipsilateral, open Intra-op None Open None No [2]
Khan et al. (14), 2014 2 Urinary frequency [1] No Pre-op US and MRI TAPP Scrotal No [6]
Urinary incontinence [1] No Pre-op Cystogram TAPP hematoma No [5]
Umemura et al. (15), 2018 1 Urinary frequency, two-stage urination Bilateral, TAPP Pre-op CT scan TAPP None No (N/A)
Karanikas et al. (32), 2020 1 AKI, Inguinoscrotal mass No Pre-op US Open None No (N/A)
Hasegawa et al. (16), 2021 32 Urinary frequency [4], sensation of residual urine [1] No Pre-op CT scan (prone position) TEP None 1 of 32 patients [2]
Tazaki et al. (17), 2019 1 Abdominal pain, vomiting, diarrhea No Pre-op CT scan TAPP None No [24]
Namba et al. (18), 2020 1 Urinary frequency, inguinal mass No Pre-op CT scan TAPP None N/A
Lee et al. (19), 2013 1 Two-stage urination, inguinoscrotal mass No Pre-op US, CT scan, cystography TAPP None N/A
Kohga et al. (20), 2021 1 Inguinal mass No Pre-op CT scan TAPP None No [2]
Chang et al. (21), 2021 1 Urinary frequency, urosepsis, AKI, inguinoscrotal mass No Pre-op CT scan TEP None N/A
AlMohaya et al. (22), 2019 1 Urinary frequency, hesitancy Ipsilateral, TAPP Pre-op CT scan Open None No [1]
Moufid et al. (23), 2013 4 Inguinoscrotal mass [1] Ipsilateral, open Pre-op Cystography Open None N/A
Two-stage urination [1] No Pre-op Cystography Open None No [1]
Inguinal mass [1] No Intra-op Methylene blue bladder instillation Open Bladder injury N/A
Inguinal mass, urinary incontinence [1] Ipsilateral, open Post-op Exploratory laparotomy Open Bladder injury, intraabdominal bleeding No [12]
Omari et al. (24), 2013 1 Two-stage urination, urinary frequency, urgency No Pre-op US, cystography Open: femoral, inguinal None No [6]
Katsourakis et al. (25), 2014 1 Inguinal mass, bladder tumor Contralateral, open Pre-op CT scan Open None No [12]
Westera et al. (26), 2012 1 Two-stage urination, inguinoscrotal mass No Pre-op US, MRI Open None N/A
Ellimoottil et al. (27), 2012 1 AKI, Urinary frequency No Pre-op CT cystography Open None N/A
Tarchouli et al. (35), 2015 1 Giant inguinoscrotal mass, difficult urination No Pre-op CT scan Open None No [6]
McKay et al. (30), 2014 1 Two-stage urination, Inguinoscrotal mass No Pre-op CT scan Open, transperitoneal Bladder ischemia, UTI N/A
Coelho et al. (33), 2016 1 AKI No Pre-op Antegrade nephrostography, cystography Open None N/A
Karatzas et al. (28), 2013 1 Two-stage urination, CRF, urinary frequency, inguinoscrotal mass No Pre-op US, CT scan Open None No [6]
Frenkel et al. (31), 2015 1 Two-stage urination, urinary retention No Pre-op CT scan Open None No [24]
Uchio et al. (29), 2012 1 Urinary frequency, UTI, Inguinal mass No Pre-op Pyelogram, cystoscopy, cystography TAPP None No [24]
Ryan et al. (34), 2015 1 Urinary retention, AKI No Pre-op CT scan Trans-scrotal cystostomy None N/A
Present report 2 Inguinoscrotal mass [1] No Intra-op Bladder insufflation Open None No [7]
Recurrence hernia [1] Ipsilateral, open Post-op eTEP No [6]

†, parenthesis indicates number of patients; ‡, outcomes at the last follow-up; §, two-step approach: open repair after laparoscopic reduction. Pre-op, pre-operation; CT, computed tomography; N/A, not available; AKI, acute kidney injury; ESRD, end-stage kidney disease; MOF, multiorgan failure; US, ultrasonography; Intra-op, intra-operation; eTEP, extended-totally extraperitoneal; TAPP, transabdominal preperitoneal; MRI, magnetic resonance imaging; UTI, urinary tract infection; CRF, chronic renal failure.

Table 2

Summary of presenting symptoms and signs of inguinal bladder hernia

Symptoms or signs of inguinal bladder hernia
   Urinary frequency
   Two-stage urination
   Acute kidney injury
   Abdominal or flank or scrotal pain
   Hematuria
   Urinary retention
   Inguinoscrotal mass
   Urinary tract infection
   Oliguria
   Urinary incontinence
   Hesitancy or difficult urination
   Sensation of residual urine

Discussion

This present study has added two new cases of IBH to the body of literature; moreover, this report includes the first case of a laparoscopic eTEP approach for treatment of IBH. Open hernioplasty may result in recurrence, if the hernia is extraperitoneal bladder type with herniated through the pubic tubercle area. Hence, a laparoscopic approach seems to be superior to an open repair; in terms of diagnosis and repair of extraperitoneal IBH.

Regarding diagnosis of IBH, when patients have one or more of the following signs/symptoms: urinary frequency, two-stage urination, AKI in combination with an inguinoscrotal mass, in this clinical setting it is highly suggestive of IBH (2,3,6-12,15,16). CT scanning is the imaging of choice in such cases (2-4,6-13,15,17-22,25,27,28,30,31,35). Although, our second patient had abnormal urinary symptoms, the diagnosis of IBH was still missed during pre-operative and intra-operative of open hernioplasty. We revealed that the missed diagnosis of IBH was attributed to the location of the herniated bladder through the pubic tubercle area corresponding to the superficial inguinal ring. During open hernioplasty, this area is usually not covered by mesh; thus, the IBHs could be missed during surgery. This is consistent with reported series with history of ipsilateral open hernioplasty (4-6,22,23). This patient had an incarcerated hernia with suspected SBO that necessitated emergency surgery, so, preoperative CT scan was not performed. The early diagnosis of IBH is of paramount importance, as AKI, MOF and end-stage renal disease are the results of delayed diagnosis (2,3). We found that, if IBH is suspected during an operation, insufflation of the bladder, via a Foley’s catheter, is both a simple and valid tool for diagnosis.

In cases of preoperatively diagnosed IBH, either an open or laparoscopic approach can be used. However, laparoscopy has a number of advantages over an open procedure; including, shorter hospital stay, an earlier resume to daily activities, better cosmetic results, and equally low or reduced complication rates, are indeed a few of the benefits (36). In addition, TEP approach had been the preferred approach in extraperitoneal type of IBH compared to intraperitoneal and paraperitoneal type. Regarding IBHs in whom preoperative diagnosis could not be made or were recurrent after an anterior approach, we found that a laparoscopic eTEP approach offers clearer visibility of the hernia defect and content, avoids surgery in distorted anatomy or dense fibrous scarring. Moreover, wider operative field attributed to eTEP might be more suitable in an incarcerated case than TEP. Hence, laparoscopic eTEP would contribute to increased diagnostic yield, and a decreased chance of bladder injury. Furthermore, evidence has shown that an anterior approach has more pubic tubercle recurrence than a posterior approach (37). The extraperitoneal posterior mesh placement ensures the covering of all potential defects (37); including, more medially, and the pubic tubercle or extraperitoneal type of IBH (16).

Conclusions

IBH is a rare disease, and prompt diagnosis should be made in patients presenting with an inguinoscrotal mass along with urinary frequency, two-stage urination, AKI. Bladder insufflation is a simply tool for intraoperative diagnosis. Additionally, Laparoscopic eTEP repair might offer advantages of diagnosis and repairing of incarcerated extraperitoneal type of IBH.

Acknowledgments

The authors would like to thank Mr. Andrew Jonathan Tait for his assistant in English language editing.

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://ls.amegroups.com/article/view/10.21037/ls-21-19/rc

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ls.amegroups.com/article/view/10.21037/ls-21-19/coif). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (approval No. REC.64-406-10-3) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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doi: 10.21037/ls-21-19
Cite this article as: Rachiwong L, Wiboonkhwan NA, Cheewatanakornkul S. Advantages of minimally invasive approach for inguinal bladder hernia repair: case report and literature review. Laparosc Surg 2022;6:8.

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