A 78-year-old Caucasian male (175 cm, 85 kg, BMI 27.7 kg/m2) being treated chronically for arterial hypertension and neuropathy, with a past surgical history of bilateral hip arthroplasty, reported to the emergency department with acute abdominal pain. The pain began the previous day and worsened gradually over 32 hours, starting as diffuse abdominal pain that migrated to the right lower quadrant with radiation to the lumbar region. Other than anorexia, no gastrointestinal symptoms were present. The patient also reported the presence of a right inguinal hernia, which he had been aware of for 5 years; however, he had not considered surgery due to inconvenience. Additionally, the abdominal pain was not associated with any local changes to the hernia or pain related to the hernia.
Physical examination showed localized pain in the right lower quadrant with local tenderness. Both Bloomberg and Pleniés signs were positive, while the Rovsing sign and rectal examination were negative. There was a right sided inguinal hernia with a large irreducible sac reaching deep into scrotum (approximately 15x7cm). The sac was slightly painful; however, typical signs of incarceration were absent.
Laboratory findings showed significant inflammatory activity: CRP 293 mg/l, leucocyte count 21500/µl. Our first line diagnosis, considering typical current complaints and clinical findings, was acute appendicitis. Nevertheless, we considered complications related to the large inguinal hernia, as well. As a result, we requested abdominal ultrasonography. Surprisingly, it showed a medially located cecum with no signs of appendicitis and an ectopic right kidney located in the right hypogastrium with slight dilation of the pelvis, calices, and proximal ureter. The point of maximal pain was clearly located at the kidney. Following this unexpected finding, we performed a CT scan, which showed the right ptotic kidney located in the right iliac fossa, with grade 2 to 3 renal stasis. (Fig. 1) The renal artery and vein were stretched from their normal anatomic origin caudally towards the descended kidney hilum. Renal perfusion in both arterial and venous phases of the scan was normal. The right renal capsule was almost completely dislocated in the inguinal hernia. The ureter was proximally dilated to 15mm and was headed towards the inguinal hernia with apparent constriction in the hernia neck. Considering these findings, we concluded the final diagnosis of a sliding right inguinal hernia containing the capsule of the right kidney with acute obstruction (incarceration) of the right ureter. Painful palpation of the right kidney along with elevated inflammatory markers strongly indicated acute obstructive pyelonephritis, although urinalysis showed completely negative results. Due to the risk of ischemic damage to the right kidney and the ureter, as well as risk of urosepsis, we initiated empiric antibiotic therapy with ceftizoxime and recommended urgent surgery.
Surgery was performed under general anesthesia. A foley urinary catheter was inserted, and the urinary bladder was filled with 50ml normal saline. Through a standard inguinal incision, the external ring was visualized, and the hernia content was extracted from the right hemiscrotum revealing well bordered fatty tissue with a fibrous capsule. After the incision of the anterior wall of the inguinal channel, we identified an epigastric artery located medial to the hernia neck, confirming an anatomically indirect hernia. The spermatic cord was identified dorso-medially to the neck and isolated. Throughout the preparation of the hernia content, no peritoneal structures were involved. The ureter was located in the medial proximal part of the hernia and was pulled to the external orifice with significant dilatation of the proximal half. There were no signs of ischemia, and shortly after liberation, typical ureteral peristalsis was present. After the incision of the frontal wall of the fibroadipose tissue in the external inguinal ring, the inferior pole of the right kidney was revealed as part of the content of the hernia neck heading towards the hernia. Despite this, there were no signs of mechanical damage to the visible part of the kidney. After the complete separation of the ureter and manual repositioning of the kidney cranially, no other anatomical structures were found in the hernia neck. Almost the whole perirenal fat capsule, which was contained in the hernia, was completely resected at the level of inferior renal pole. (Fig. 2, Fig. 3) The whole formation measured 23x10x6cm and weighed 850g.
The right ureter was approximately 30cm long, and, as the kidney was dislocated in the right iliac fossa, the direct distance from the inferior pole to the urinary bladder was reduced to approximately 5cm. The ureter was, therefore, extremely crooked and prone to future kinking. As a result, we resected a 10 cm segment, ligated the distal part, and implanted the proximal segment to the bladder wall with a JJ stent. A sample for microbiology was taken from the ureter. A Redon drain was placed in the space of Retzi to control possible urinary leak. Finally, we performed a Liechtenstein hernioplasty using polypropylene mesh 10x15cm for definitive treatment of the inguinal hernia.
Perioperative microbiology showed sterile findings from the ureteral sample. The postoperative period was uneventful consisting of slight hematuria and satisfactory reduction of inflammatory parameters. Renal parameters showed no significant pathology. The urinary catheter was removed after 4 days, and the patient was discharged for outpatient treatment. The JJ stent was removed 6 weeks after the procedure.