Giant elephantiasis and inguino-scrotal hernia

A 65-year-old man presented in Beira Central Hospital, Mozambique, with a right scrotal mass (diameter 80 x 80 cm), evolved over 15 years. The patient could barely move, and his weight at admission was 142 kg (Fig 1A and 1B). History of previous diseases was unremarkable, his general condition was good, and he had normal vital parameters. Physical examination showed wrinkled and thickened scrotal skin and right leg and foot edema. Due to his physical condition, penile erection had been impossible for many years. The patient was hospitalized for surgery with a diagnosis of “giant elephantiasis of the scrotum with bilateral inguinal hernia”. The man was HIV negative, and preoperative tests showed only a moderate anemia (hemoglobin [Hb] = 7.7 g/dL). The patient was treated with folic acid and multivitamin tablets for 2 months. Finally, he was transfused (4 U), and his Hb increased to 10.2 g/dL before surgery. Although guidelines suggest hygiene treatment with soap and water for 6 months and antibiotics therapy before surgery, it was not possible to accomplish this protocol, and we proceeded directly with surgery. Anesthesia was induced intravenously by atropine, 0.5 mg, fentanyl, 150 μg, and thiopental, 500 mg, and it was maintained by fentanyl, 75 μg per hour. The first step of the surgical procedure was the hydrocele’s reduction, and 15 liters of a brown-colored liquid were aspirated from the mass. After this procedure, there remained a scrotal elephantiasis mass of 67 kg and a bilateral inguino-scrotal hernia. To proceed further with the procedure, it was necessary to do a Foley catheterization in order to get a careful dissection with cautery to delineate the penis circumferentially from the root of the scrotal lymphedema. A bilateral inguino-scrotal incision was performed. The right testis was stiff and impossible to isolate; the left one was atrophic, and it was not possible to find it. The only solution was to do a bilateral orchiectomy and leave the cords behind in an attempt to form an alternative pathway for lymphatic drainage. The right scrotum presented also a giant inguino-scrotal hernia containing the colon, ileum, and part of the jejunum. The hernia sac was well separated from the internal ring and was easily opened. A hyperemic, inflamed appendix was found; thus, an appendectomy was performed, and the bowels were reduced into the abdomen. The neck of the large hernia sac was transected at the midpoint of the inguinal canal, and the proximal part was sutured—ligated. A high ligation of the proximal sac was done, and the stump was reduced, deep underneath the internal ring. The distal sac was left in place. The hernia repair was finally performed with polypropylene mesh, according to the Lichtenstein tension-