Fasciitis Necroticans after Elective Hernia Inguinal Surgery

Necrotising fasciitis is a rare but disastrous complication after elective surgery. We present two patients (both male, 58 and 18 years old) who developed necrotising fasciitis following elective inguinal hernia repair according to Lichtenstein. The importance of both recognition and time interval between symptom occurrence and surgical intervention is illustrated, emphasising the need for immediate action when necrotising fasciitis is suspected. A high index of suspicion of necrotising fasciitis should be maintained when a wound infection is accompanied by disproportional pain, lethargy, or sepsis. Epidermolysis and subcutaneous emphysema are often very late symptoms. Recognition and immediate intervention decrease mortality and morbidity. 1. Case Report A 58-year-old man undergoes an elective correction of an inguinal hernia according to Lichtenstein [1]. His medical history includes insulin dependent diabetes and hypertension. The procedure was straightforward and the patient was discharged the same day. Two days after the operation the patient visited our emergency room with severe pain and swelling at the operation site. On physical examination we saw a moderately ill man, with a temperature of 38.7 degrees Celsius and a pulse rate of 101 beats per minute. Blood examination showed leukocyte numbers of 9.9 × 109 and a CRP 179？mg/L. The surgical site showed a hematoma without redness or pus. The patient was admitted and reassessed after eight hours. Moreover an ill man was seen with blistering, livid discoloration of the scrotum. With the suspicion of a fasciitis necroticans (FN) the patient was brought to the operation theatre and antibiotics were started. Perioperatively a fulminant Fournier gangrene [2] was seen, for which an extensive necrosectomy was performed with the formation of a colostomy (Figure 1). Perioperative cultures showed group A beta-hemolytic streptococcus (GAS). The patient was admitted to the intensive care unit (ICU). After a total of nine reinterventions and two months in hospital, he was discharged to a rehabilitation centre. Figure 1 Secondly, an 18-year-old male underwent elective inguinal hernia surgery according to Lichtenstein. Medical history showed a through-the-hip amputation in its first weeks of life because of iatrogenic dissection of the femoral artery. The surgical procedure was straightforward, whereafter the patient was discharged the same day. That evening he felt unwell; after a few hours he visited the emergency room with groin pain and fever. The patient was severely ill with a temperature of 39.1 degrees