One-stage surgical management of pyostercoral phlegmon complicating strangulated inguinoscrotal hernia with scrotal fistulization: a case report and narrative literature review
Mouhamadou Laye Diop, Yacine Seye, Mohamadou Lamine Gueye, Ahmed Omar Diagne, Chipier Kaissoiria, Mamadou Seck, Alpha Oumar Touré, Madieng Dieng, Ibou DiengIntroduction/rationale:
Pyostercoral phlegmon – a mixed purulent-fecal collection arising from transmural bowel perforation within the hernial sac – is a rare, life-threatening complication of strangulated inguinal hernia, with an incidence <5%, for which optimal management in resource-limited settings remains debated. We report a case successfully treated by one-stage surgery.
Patient concerns:
A 56-year-old male laborer presented with a 7-day history of painful, irreducible right inguinoscrotal swelling and a febrile obstructive syndrome, on a background of a 10-year history of an untreated hernia. Examination revealed septic shock (BP 90/60 mmHg, HR 120/min, T 38.3°C) and a scrotal fistulous opening draining foul-smelling pus.
Diagnostic assessment:
Laboratory findings confirmed severe sepsis (WBC, 23 000/mm 3 ; CRP, 126 mg/L; prothrombin time, 66%). The diagnosis was established clinically; no preoperative imaging was performed, given the unambiguous presentation and hemodynamic urgency.
Therapeutic interventions:
After hemodynamic stabilization with fluid resuscitation and norepinephrine, a one-stage procedure was performed: (1) a midline laparotomy with end-to-side ileocolic resection and anastomosis for cecal and terminal ileal necrosis; (2) a mesh-free Bassini hernia repair via an inguinal approach; and (3) wide scrotal debridement with partial vaginectomy and drainage. Total operative time was 3 hours and 20 minutes.
Outcomes:
Recovery was uneventful. The patient was discharged on postoperative day 7 (CRP, 62 mg/L; WBC, 11 000/mm 3 ). Complete wound healing and no recurrence were documented at 12 months.
Lessons:
One-stage surgery combining bowel resection-anastomosis, mesh-free parietal repair, and wide scrotal debridement is safe and reproducible in adequately resuscitated patients. A structured narrative literature review identified 78 published cases worldwide (2000–2025); reported mortality reached 15–20% in the setting of established septic shock. Early diagnosis, aggressive resuscitation, and multidisciplinary collaboration are the critical determinants of outcome.