Abstract text (incl. references and figure legends)
Introduction
The incidence of inguinal hernia increases with age. This case study underlines the challenges of emergency management of an obstructed hernia in an elderly patient with co-morbidities:
89 year old male with prostate cancer and a saddle pulmonary embolus,on Rivaroxaban.
Clinical findings
The patient presented with bilateral painful irreducible inguinal hernias and vomiting.
Investigations
CT: right-sided inguinal hernia containing loops of small bowel with signs of obstruction and ischaemia,left-sided inguinal hernia contains sigmoid colon.
Therapy and progressions:
Due to bilateral painful hernias and signs of ischaemia emergency laparotomy was performed. Bowel was viable,reduction of both hernias required enlargement of internal inguinal rings. Bleeding from mesenteric sites required administration of prothromplex and tranexamic acid.
After commencement of enoxaparin on 3rd post-operative day, a decline in haemoglobin was noted, and CT showed potential haemorrhage from a branch of the inferior epigastric artery. The patient underwent embolization and had a good recovery post-procedure.
Comments
Laparotomy approach was chosen due to presentation with bilateral tenderness and a suspicion of bowel ischaemia.
With no specific reversal agent for Rivaroxaban, a combination of surgical haemostasis and procoagulation agents was utilized. Most likely, internal inguinal ring widening on the right side caused damage to a branch of the inferior epigastric artery. The patient was at high risk of postoperative bleeding - this was recognised early.
Conclusion:
This case illustrates complexity of an elderly surgical patient. With increasing number of elderly patients more cases will present similarly, but a good outcome can be achieved with appropriate decision making and cooperation of specialties.
References:
de Goede, B. et al. (2015) "Risk factors for inguinal hernia in middle-aged and elderly men: Results from the Rotterdam Study," Surgery, 157(3), pp. 540–546.
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