Spontaneous Entero-Scrotal Fistula: A Rare Complication of Inguinal Hernia in a Developed Country-A Case Report

Entero-scrotal fistula is an exceptionally rare and severe complication of inguinal hernias in adults. We present the first reported Australian case, highlighting the unique diagnostic challenges of Richter-type hernias, particularly in socially isolated patients, where presentation is often delayed.

A 71-year-old male with a history of hypertension and chronic alcohol disorder was transferred from a group home with sepsis and a necrotic scrotal ulcer. Computed tomography confirmed a right inguinal hernia with an enterocutaneous fistula originating from the terminal ileum. Intraoperative findings revealed a Richter's hernia with the antimesenteric wall of the terminal ileum incarcerated within the deep inguinal ring, leading to a spontaneous fistula through the scrotal wall. Management involved an ileocecal resection with side-to-side anastomosis and debridement of necrotic scrotal tissue. Due to gross fecal contamination, a primary tissue repair was performed rather than mesh placement.

Spontaneous fistulization typically results from prolonged incarceration. In this case, the Richter-type hernia allowed for intermittent bowel patency, which masked typical obstructive symptoms and delayed surgical intervention. In the setting of gross contamination (Type IV), primary suture repair-such as the "Nylon Darn" technique-is preferred over synthetic mesh to prevent prosthetic infection and chronic wound complications.

This case underscores the importance of considering socioeconomic factors and atypical hernia types in surgical delays. In contaminated fields, primary tissue repair remains the gold standard to ensure a safe recovery and optimal patient outcomes.