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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 3  |  Issue : 3  |  Page : 218-222

Mysterious inguinal swellings disguised as hernia: Series of four cases


Department of General Surgery, Dr. D. Y. Patil Hospital and Research Centre, Pune, Maharashtra, India

Date of Web Publication9-Jun-2016

Correspondence Address:
Vishal Tomar
Prabhu Apartments, Opposite Union Bank, Near Bus Stop, Ulhasnagar, Thane, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-3334.183747

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  Abstract 

A hernia surgeon may encounter unexpected intraoperative findings. It is important to be prepared to detect them and apply the appropriate treatment. We retrospectively studied twenty patients with inguinal swellings who were admitted to our surgical department over a 2-year period including patients without a definitive diagnosis of inguinal hernia upon admission. Our aim was to present our experience with the unexpected findings during inguinal hernia surgery, either unusual hernial contents or pathologic entities, such as neoplastic masses, masquerading as a hernia.

Keywords: Amyand′s hernia, Litter′s hernia, Meckel′s diverticulum, mysterious inguinal swelling, seminoma, uterus in hernial sac


How to cite this article:
Nirhale D S, Athavale V S, Bhatia M, Tomar V. Mysterious inguinal swellings disguised as hernia: Series of four cases. CHRISMED J Health Res 2016;3:218-22

How to cite this URL:
Nirhale D S, Athavale V S, Bhatia M, Tomar V. Mysterious inguinal swellings disguised as hernia: Series of four cases. CHRISMED J Health Res [serial online] 2016 [cited 2019 Sep 22];3:218-22. Available from: http://www.cjhr.org/text.asp?2016/3/3/218/183747


  Introduction Top


We present our experience in dealing with unexpected findings during hernia surgery by a series of cases in which inguinal swelling turned out to be other than routine inguinal hernia on further investigation and thereby treated accordingly. The usual contents of inguinal hernia are as follows: Omentum, small bowel, lipoma of spermatic cord, hydrocoele of spermatic cord, and varicocele. The unusual contents of inguinal hernia are vermiform appendix (Amyand's hernia), Meckel's diverticulum (Litter's hernia), transverse colon, undescended testis, ovaries,  Fallopian tube More Detailss, and urinary bladder. Two hundred and fifty nine cases of inguinal hernia operated at Dr. D. Y. Patil Medical College, Hospital and Research Centre, over the past 2 years were studied retrospectively. Experience in dealing with unusual cases is outlined in this study.


  Case reports Top


Case report 1

A 42-year-old male presented with swelling in the right inguinal region for 6 years [Figure 1]. The swelling was nonreducible and noncompressible. No cough impulse was observed. The patient did not present with any symptoms or signs of bowel obstruction. The swelling was nontender and firm in consistency. The right hemiscrotum was empty. Ultrasonography (USG) and computed tomography scan findings were suggestive of nonvisualization of the right testis and spermatic cord with visualization of the right inguinal mass, probably of neoplastic origin suggestive of undescended testis [Figure 2]. Serum alpha feto protein was found to be 1.36 IU/ml (normal range: 0.5-5.5 IU/ml, in males).
Figure 1: Right inguinal swelling with the right undescended testis

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Figure 2: Computed tomography scan of inguinal swelling

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Intraoperative findings

Incision parallel to the swelling revealed a mass present within the inguinal canal with thinned out external oblique aponeurosis. It was removed in toto and repair of associated hernia was done. Hemostasis was achieved and the specimen was sent for histopathological examination [Figure 3] and [Figure 4].

Histopathology report was suggestive of seminoma.
Figure 3: Dissection of the right inguinal region

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Figure 4: Specimen of seminoma

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Case report 2

A 60-year-old male patient came with a chief complaint of swelling in the right inguinal region for 2 years. Cough impulse was absent. Swelling was partially reducible and partially compressible.

No signs and symptoms of bowel obstruction were noted. CT scan of the abdomen and pelvis was suggestive of bowel as contents with dense adhesions [Figure 5].
Figure 5: Computed tomography scan of the right inguinal swelling

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Intraoperative findings

There was an extremely thinned out external oblique aponeurosis with evidence of bowel and omentum seen. On further dissection, it was realized that transverse colon was the content of hernia along with complete omentum [Figure 6] and [Figure 7]. Extensive adhesiolysis with omentectomy was required before the contents could be reduced into the peritoneal cavity. Posterior wall repair was done. No bowel resection was required. No prolene mesh was placed. Hemostasis was achieved and closure was done in layers.
Figure 6: Right inguinal hernia with bowel as content

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Figure 7: Transverse colon along with omentum as content of the right inguinal hernia

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Case report 3

A 25-year-old male patient came with a chief complaint of swelling in the right inguinal region for 2 months. Pain radiated to the right lumbar region and the patient complained of colicky pain more on the right side of the abdomen. No symptoms or signs of bowel obstruction were found. Operative procedure was undertaken based on clinical judgment. The content of the hernia presented as vermiform appendix.

Intraoperative findings

Inflamed vermiform appendix was found as content [Figure 8] and [Figure 9]. Appendectomy was done followed by hernial repair. Prolene mesh was not used [Figure 10].
Figure 8: Appendix as hernia content

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Figure 9: Amyand's hernia

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Figure 10: Appendicectomy with hernia repair done

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Case report 4

A 1½-month-old female child presented with swelling in the left inguinal region since birth as informed by mother [Figure 11]. There was no history suggestive of bowel obstructive symptoms.
Figure 11: Left inguinal hernia in a 1½-month-old female child

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The patient was afebrile, pulse rate at 124/bpm. The left inguinal region had a swelling of 3 cm × 2 cm in size, reducible. Swelling became prominent on crying. Another swelling of 2 cm × 2 cm was also present over the umbilicus. Ultrasound of the abdomen revealed patent canal of Nuck with herniating ovary and part of uterus.

Intraoperative findings

Content of inguinal hernia was found to be uterus and ovary [Figure 12]. Contents were reduced into anatomical positions. Inguinal canal was closed in layers [Figure 13].
Figure 12: Postoperative healthy scar

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Figure 13: Uterus as a content of hernial sac

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  Discussion Top


Inguinal hernia repair is one of the most common operations in surgical practice. Yet in spite of its great incidence, hernias often pose a surgical dilemma, even for the skilled surgeon. [1]

The undescended testicles carry 20-48 times higher potential for malignant transformation than the normally descended testicle. Testicular ectopia is uncommon and the most frequent ectopic location of testis is the superficial inguinal pouch, in front and lateral to the external inguinal ring and very rarely in the abdomen. The position of the undescended testis is related to the likelihood of carcinogenesis with intra-abdominal testis having the highest malignant potential. [2] Approximately, 7-10% of the testicular tumors develop in patients who have a history of cryptorchidism; seminoma is the most common form of tumor these patients have. [3]

Inguinal hernias are relatively common in the elderly with an estimated prevalence of 6%. Incarceration of inguinal hernia occurs in approximately 10% of the cases which in turn can lead to intestinal obstruction, strangulation, and infarction. [4] The incidence of sliding inguinal hernia increases with the age of the patient. It is nearly zero before the age of 30 years and increases to as much as 20% after the age of 70 years. The presence of vermiform appendix, acute appendicitis, ovary, fallopian tube, and urinary bladder has been reported in sliding hernia, exceptionally, in literature. Infrequently, it might even contain transverse colon and stomach. [5]

The incidence of appendicitis within an inguinal hernia is rare, estimated at 0.07% to 0.13%. [6] It is very rare to find an inflamed appendix in the obstructed inguinal hernia on USG alone preoperatively, as diagnosed by Singal et al. in their study. Fernando and Leelaratna defined Amyand's hernia as an inguinal hernia containing (a) a noninflamed appendix, (b) an inflamed appendix, or (c) a perforated appendix. It is usually caused by extraluminal obstruction due to pressure on the hernial neck rather than intraluminal obstruction of the appendix. [7]

Hernia of the canal of Nuck is a rare condition, and around 15-20% contain ovary, sometimes fallopian tube. Uterus as a content of hernial sac is still rarer with thorough literature search, there were only few cases of hernia in female infants containing uterus. [8] Once diagnosis of inguinal hernia in a female is made, repair should be carried out promptly because incarceration occurs in the 1 st year of life. [9]

Hence, from the above series of case reports, we can comment that a hernia surgeon may encounter unexpected intraoperative findings. It is important to be prepared to detect them and apply the appropriate treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Rutkow IM, Robbins AW. Demographic, classificatory, and socioeconomic aspects of hernia repair in the United States. Surg Clin North Am 1993;73:413-26.  Back to cited text no. 1
    
2.
Woodward PJ. Case 70: Seminoma in an undescended testis. Radiology 2004;231:388-92.  Back to cited text no. 2
    
3.
Shah MS, Patel LN, Shah RR, Bhatt C, Modi J. Case report: Seminoma in abdominal ectopic testis. Indian J Radiol Imaging 2004;14:299-300.  Back to cited text no. 3
  Medknow Journal  
4.
Bali C, Tsironis A, Zikos N, Mouselimi M, Katsamakis N. An unusual case of a strangulated right inguinal hernia containing the sigmoid colon. Int J Surg Case Rep 2011;2:53-5.  Back to cited text no. 4
    
5.
Sahoo MR, Kumar TA. Sliding hernia with appendix, cecum, ascending colon forming sliding component and transverse colon and greater omentum forming contents of the sac: A case report. Int J Case Rep Images 2013;4:123-6.  Back to cited text no. 5
    
6.
Sharma H, Gupta A, Shekhawat NS, Memon B, Memon MA. Amyand′s hernia: A report of 18 consecutive patients over a 15-year period. Hernia 2007;11:31-5.  Back to cited text no. 6
    
7.
Singal R, Gupta S. "Amyand′s Hernia" - Pathophysiology, Role of Investigations and Treatment. Mædica. 2011;6:321-7.  Back to cited text no. 7
    
8.
Kamio M, Nagata T, Yamasaki H, Yoshinaga M, Douchi T. Inguinal hernia containing functioning, rudimentary uterine horn and endometriosis. Obstet Gynecol 2009;113 (2 Pt 2):563-6.  Back to cited text no. 8
    
9.
Ming YC, Luo CC, Chao HC, Chu SM. Inguinal hernia containing uterus and uterine adnexa in female infants: Report of two cases. Pediatr Neonatol 2011;52:103-5.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]



 

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