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Indian Journal of Surgery, Vol. 68, No. 3, May-June, 2006, pp. 174 Case Report Primary presentation of abdominal tuberculosis in an inguinal hernia BGurudutt B. Basrur, Ram Prasanna Naik*, Nilesh H. Doctor** S. K. Patil Municipal General Hospital, Malad (East), Mumbai - 400 097, *Shirdi, Maharashatra, **Jaslok and Bhatia Hospitals, Mumbai, India Code Number: is06055 Abstract Though abdominal tuberculosis is common, it is rare to primarily diagnose it through the contents of an inguinal hernia. A patient was found to have multiple tubercles in the omentum at inguinal exploration for an incarcerated hernia. Modified Bassini repair of the hernia was performed without placement of a mesh. Antituberculous drug therapy was started, and the recovery was uneventful. At a year of follow-up, there is no recurrence. When abdominal tuberculosis is diagnosed in a hernial sac, it may be better to avoid a hernioplasty. Keywords: Abdominal tuberculosis, inguinal hernia Though abdominal tuberculosis and inguinal hernia are both common in India, primary diagnosis of the former condition at the time of hernia repair, is extremely rare and might have therapeutic implications. CASE REPORT A 32-year old male presented with a partially reducible inguinoscrotal swelling on the right side, of 15 days duration. He had no history of cough, fever, loss of weight, or appetite. On examination, he had a right incarcerated inguinal hernia. His chest X-ray was normal. At inguinal exploration, an indirect hernia was seen, with the omentum as the irreducible contents. The omentum was diseased, studded with miliary tubercles, and adherent to the hernial sac. It was carefully dissected, ligated at the internal ring, and excised. Modified Bassini-type herniorrhaphy was completed by suturing the conjoint tendon to the inguinal ligament by no. ′0′. Polypropylene interrupted stitches, starting medially, carrying the union laterally behind the cord as far as the internal ring, where the emerging cord is enclosed snugly. In view of the suspicion of tuberculosis, no mesh was placed. The post-operative recovery was uneventful. Histologically, sections through the omentum revealed areas of caseation necrosis, surrounded by epithelioid cells, lymphocytes, and Langhan′s type giant cells, all typical features of tuberculosis [Figure - 1]. The patient was put on antitubercular drug therapy. In view of the miliary-type tuberculosis, patient consent and counseling was obtained to rule out HIV infection. Tests for both type 1 and 2 HIV viruses were negative. DISCUSSION It is surprising, that with the wide prevalence of tuberculosis, [1] and the common involvement of the omentum in patients with abdominal tuberculosis, this finding is not common in patients with inguinal hernia in our country[2],[3] even though the omentum is a common content of the sac, and inguinal hernia is amongst the most common surgical problems. Also, many patients with pulmonary tuberculosis have a chronic cough, which by itself is a risk factor for inguinal hernia. Perhaps, the omentum tends to remain adherent in the abdominal cavity, and does not migrate into the hernial sac. With the wider prevalence of HIV and the subsequent increase in tuberculosis, this problem is likely to be more frequently encountered. Hence, testing for HIV may be appropriate after adequate counseling, if the need arises. The presence of an omentum studded with tubercles in a hernial sac, may have several implications. Inflammatory adhesions between the omentum and the sac may form, causing the hernia to become irreducible. The infection could spread to the local tissues, which might jeopardize the strength of the repair, or lead to the formation of multiple sinuses and delayed wound healing. The presence of wound infection after conventional hernia repair is known to increase the incidence of recurrence. The placement of a mesh in this area might delay or inhibit the effect of the anti-tuberculous chemotherapy and form a source of chronic sepsis. Hence we believe, that the repair should use local tissues to strengthen the posterior abdominal wall, and should avoid the use of a prosthetic material in suspected cases. Although Shouldice repair is proven to be superior, best results are achieved by using a single, well tried procedure. The common factor that produces good results is the perfection with which it is accomplished. For these reasons, we carried out a modified Bassini′s repair, the technique with which the author is familiar. To ensure prompt healing of the local tissues and avoid the formation of sinuses, multidrug full-dose anti-tuberculous drug therapy should be rapidly initiated to allow for local healing. References
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