Large Pantaloon Hernia in a Five-months-old Infant: Case rep
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Inguinal hernia occurs more commonly in premature infants than in the general population with incidence being up to 30%. They are almost always indirect type. Direct inguinal hernia is rare in infants.

An extremely rare case of ipsilateral, concurrent direct and indirect hernias in an infant, also known as a pantaloon or dual hernia reported. A five-months-old male infant attended with huge unilateral (right) scrotal swelling since birth. He had a history of prematurity, born at 30 wk gestation and Neonatal intensive care unit (NICU) stay after birth. There was a large, right inguinal hernia that was reduced back with difficulty. The patient was taken up for surgery.

Following inguinal exploration, the indirect hernia sac was divided and high ligated. On careful evaluation, surprisingly, the deep ring was inappropriately wide and a gap could be identified in the floor of the inguinal canal through which herniatingbowel contents could be seen. The fascia transversalis was repaired with non-absorbable sutures to strengthen the floor of the inguinal canal. Postoperative period was uneventful.

Risk factors for inguinal hernias in infancy include prematurity, urogenital anomalies, connective tissue disorders like Ehlers-Danlos syndrome, Marfan syndrome, mucopolysaccharidosis, abdominal wall defects and Cystic fibrosis. For this patient, it appears that the large indirect sac with heavy contents caused widening of the deep ring and weakened the fascia transversalis causing the floor of the canal to give way and resulted in the direct hernia.

Therefore, in all babies with large hernia presentations and/or with predisposing factors, it is important to carefully visualize the floor of the inguinal canal to avoid missing a concurrent direct hernia. If present, repair of the inguinal floor must be done to reduce the risk of recurrence in later life.