Uncommon content in congenial inguinal hernia.

Although sliding indirect inguinal hernias containing the ipsilateral ovary and fallopian tube are not uncommon in infant girls, sliding hernias containing uterus with both ovaries and fallopian tubes are extremely rare. At surgery, a 5-month-old infant girl was found to have an indirect hernia in which the uterus and fallopian tubes were sliding components with a wide deep inguinal ring.

INTRODUCTION

Inguinal hernia is one of the most common surgical pathologies in childhood. Any of the abdominal organs can slide into the hernial sac and become incarcerated there. In girls, the fallopian tubes, ovaries, rarely uterus can form the sliding component of an inguinal hernia.[1] We present a rare case of indirect inguinal hernia containing uterus and bilateral fallopian tubes in a 5-month-old female infant, discussing the embryological basis of this disorder.

CASE REPORT

A 5-month-old infant girl was brought with the complaints of visible swelling in the left groin while crying noticed since birth. There was no other associated history of bowel or bladder complaint. Clinical examination revealed reducible left groin swelling extending to the upper part of labium majora. No signs of obstruction or strangulation were noted. A clinical diagnosis of left congenital inguinal hernia was made and planned for open herniotomy. The exploration of the inguinal canal revealed a large hernial sac with a firm mass as its contents. After mobilization, the hernial sac was opened and to our surprise it contained uterus and fallopian tubes as sliding indirect inguinal hernia [Figure 1] with wide deep ring admitting tip of little finger. The hernial sac was dissected and ligated. The uterus along with its adnexa was pushed back into the peritoneal cavity and wide deep ring was plicated.

Figure 1

Operative photograph showing the uterus and fallopian tube as sliding components of left indirect inguinal hernia

DISCUSSION

In the pediatric age group inguinal hernia results from an incomplete closure of processus vaginalis developed at around the 6th month of fetal growth. During this time, the processus vaginalis is accompanied by the round ligament of the uterus and passes through the inguinal canal up to labium majora. If the duct remains patent, it is termed as canal of Nuck.[1] The patent canal of Nuck may allow the ovary and fallopian tube to enter the inguinal region but, the presence of the entire uterus as its content in inguinal hernial sac is very unusual in infant girls with a normal karyotype and phenotype. The presence of the uterus may be found in association with other several disorders of sexual development.[2] Diagnosis is usually clinical and rarely requires any evaluation. The imaging modality of investigation is not a routine in our set up for congenital inguinal hernia, but many authors recommend it in cases of palpable movable mass in the groin of infants.[3] However, in certain cases even the sonographic pre-operative diagnosis may be misleading.[4] A sliding inguinal hernia is usually diagnosed during the surgical procedure rather than pre-operatively. Operative findings in our case showed that the uterus, fallopian tubes and ovaries were in the wall of the left hernia sac, forming a sliding hernia. Rarely, the presence of the uterus as a sliding component of the hernia may present as vaginal bleeding.[5] On an extensive search, four cases of indirect hernia and one case of direct hernia containing whole or part of the uterus and both ovaries and fallopian tubes have been reported in the literature, all located on the left side similar to our case.[6] The anatomical abnormality of this entity is unknown and due to the small number of cases reported in the literature, there is no specific surgical treatment for an indirect inguinal hernia containing the uterus and the adnexa. However, in our case after reduction of hernial contents we plicated the wide deep inguinal ring to prevent any recurrence. The infant will require close follow-up and gynecological consultation during her reproductive age group.

CONCLUSION

Sliding hernias of the tube and ovaries occur occasionally in newborn female infants, but congenital inguinal hernia containing uterus is extremely rare especially in an asymptomatic baby. The case is presented due to its rarity of presentation.