"Uncommon Contents of Inguinal Hernial Sac": A Surgical Dilemma

A Case Report of Inguinal Hernia Sac Lithiasis

We report a case of a stone in inguinal hernia sac. A 41-year-old male patient presented to Hakim Hospital in Neyshabur city, Iran, with complaints of pain and swelling in the right abdominal region. After initial evaluations, a diagnosis of right inguinal hernia was made, and the patient was scheduled for hernioplasty. He had no history of previous surgeries, hospital admissions, underlying diseases, or kidney and gallbladder stones. The surgery was performed. The hernia sac was exposed. Inside the hernia sac, a stone measuring approximately 2 cm in diameter, with a hard consistency and yellow color, was found. The stone was not adherent to the sac and was mobile. The hernia sac was opened, the stone was removed, and sent to the pathology lab. The patient was discharged 24 h later in good general condition. According to the pathology report, the components of the stone were identified as calcium oxalate.

Cord structure within an inguinal hernia: could the ureter be involved?

Inguinal hernias are commonly encountered and are primarily managed by surgeons; however, it is unusual for retroperitoneal structures, such as the ureter, to herniate into it. More importantly, hernias containing ureters are not usually identified preoperatively unless specific imaging was ordered prior, as they are generally asymptomatic. This poses a risk to the patient as unidentified structures can be mistakenly injured during the surgery. We describe a case of a man in his 60s, who presented with a large left-sided indirect inguinoscrotal hernia. Intraoperatively, a large amount of irreducible retroperitoneal fat was encountered in addition to a cord-like structure, which was discovered to be the left ureter after reviewing imaging intraoperatively. Initially, the hernia repair was done robotically, but it was converted to open repair due to its irreducibility and the potential risk imposed on the ureter. Additionally, we discuss the aetiology and common presentations of this kind of hernia.

A Rare Case of Complete Inguinoscrotal Bladder Herniation With Ureteric Involvement: Assessing Diagnostic Challenges and Complex Surgical Management

Inguinoscrotal hernias involving the urinary bladder are exceedingly rare, constituting a small subset of inguinal hernias. We present a case of a 47-year-old male with long-standing scrotal enlargement and obstructive uropathy due to complete herniation of the bladder with ureteric involvement. Diagnostic imaging confirmed the condition. Following an open laparotomy, the bladder was reduced, and a modified Bassini technique with orchiopexy was used for repair. Recurrence of the inguinoscrotal hernia with evidence of the bladder in the scrotal sac required additional surgery. This case underscores the rarity, diagnostic complexity, and potential complications of inguinoscrotal bladder hernias. Specialized surgical techniques and a multidisciplinary approach are crucial for successful management, especially in cases of complete bladder herniation. Future considerations should include innovative approaches to enhance primary repair outcomes for extensive hernias involving the bladder.

Gastric Outlet Obstruction from Stomach-Containing Groin Hernias: Case Report and a Systematic Review

Most abdominopelvic structures can find their way to a groin hernia. However, location, and relative fixation are important for migration. Gastric outlet obstruction (GOO) from a stomach-containing groin hernia (SCOGH) is exceedingly rare. In the current report, we present a 77-year-old man who presented with GOO from SCOGH to our facility. We performed a review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) of patients presenting with SCOGH since it was first reported in 1802. Ninety-one cases of SCOGH were identified (85 inguinal and six femoral) over the last two centuries (1802-2023). GOO from SCOGH occurred in 48% of patients in one review and 18% in our systematic analysis. Initial presentation ranged from a completely asymptomatic patient to peritonitis. Management varied from entirely conservative treatment to elective hernia repair to emergent laparotomy. Only one case of laparoscopic management was documented. Twenty-one deaths from SCOGH were reported, with most occurring in early manuscripts (1802-1896 [n = 9] and 1910-1997 [n = 10]). In the recent medical era, outcomes for patients with this rare clinical presentation are satisfactory and treatment ranging from conservative, non-operative management to surgical repair should be tailored towards patients' clinical presentation.

Controversies Regarding Mesh Utilisation and the Attitude towards the Appendix in Amyand's Hernia-A Systematic Review

Inguinal hernia containing the vermiform appendix is a rare entity. It is more common in children than in adults. It can be discovered incidentally during the surgical intervention performed for the cure of the inguinal hernia or when the appendix shows inflammatory changes, a situation that can lead to diagnostic confusion with a number of other diseases. Imaging can guide the diagnosis, which often comes as an intraoperative surprise. The therapeutic approach is controversial both in terms of whether or not to perform an appendectomy in the case of an appendix without inflammatory changes and especially in terms of using a mesh during the hernia repair process. Since the pathology is not very frequent, there are no standardized stages in terms of surgical ethics that can guarantee good surgical practice. The study aimed to carry out a review of the specialized literature to obtain some conclusions or trends regarding the management of this pathology. The low frequency of this type of hernia did not allow the consultation of large-scale studies or extensive reviews focusing on case reports or case series communications. The obtained results were statistically analyzed and integrated in relation to the surgical attitude depending on the particularities of the condition.

Novel treatment of gastric outlet obstruction secondary to incarcerated inguinal hernia: percutaneous endoscopic gastrostomy tube

A 93-year-old man presented with gastric outlet obstruction (GOO) secondary to a massive left inguinal hernia with incarcerated antrum. He reported a desire to avoid operative intervention, and given his comorbidities, such an operation carried high risk for perioperative complications. As such, we offered percutaneous endoscopic gastrostomy (PEG) tube placement, as this would allow intermittent decompression of the stomach to reduce the risk of obstruction and strangulation. He tolerated the procedure well and was discharged after several days of observation. He continues to do well at regular outpatient appointments. Although rare, GOO secondary to an incarcerated inguinal hernia is most likely to occur in a patient such as ours: elderly, comorbid and at high risk for perioperative complications. To our knowledge, this is the first documented case to be treated with a PEG tube, which can be a desirable and effective option in this subset of patients.

Femoral Hernia Containing a Strangulated Appendix: A Hybrid Approach

We present an intriguing case of an incarcerated femoral hernia containing an inflamed appendix inside the sac, also known as a De Garengeot hernia. This type of hernia is a rare occurrence that was first described in 1731 by the French surgeon René-Jacque Croissant de Garengeot. A 64-year-old woman presented to the emergency department with a painful mass in the right groin region. Following a computed tomography (CT) scan of the abdomen and pelvis to evaluate the mass, the diagnosis of a femoral hernia containing a strangulated appendix was established. Subsequently, a hybrid surgical approach was utilized, consisting of an open hernia repair and a laparoscopic appendectomy.

Large intestine as content of congenital inguinal hernia: A case report of intestinal obstruction

Introduction and importance

Hernias containing appendix, caecum and transverse colon are uncommon in contrast with usual inguinal hernias containing small intestine. The patient usually presents with inguinoscrotal swelling.

Case presentation

We present a case of a 2 months old male child presented with inguinoscrotal swelling, vomiting with abdominal distention. On Ultrasonography (USG) of the scrotum, protrusion of the abdominal cavity contents through the right inguinal canal into the scrotum of approximately 3.4 cm × 0.7 cm was found which indicates right inguinal hernia. On the opening of the hernia sac during surgical management, the appendix, caecum and transverse colon were lying inside the hernia sac. Open Herniotomy was performed and the abdomen was closed in layers. Postoperative period of the patient was uneventful.

Discussion

Congenital inguinal hernia in the child occurs mostly due to persistent processus vaginalis. History and clinical examination reveals the appearance of lump in the inguinal region or scrotum. Preoperative Ultrasonography can be used to supplement the physical examination and increase the accuracy of its diagnosis. Although the laparoscopic approach is increasingly used nowadays, open hernia repair is preferred in young children.

Conclusion

Appendix, caecum and transverse colon are unusual contents of an inguinal hernia. Open herniotomy combined with relieving of the intestinal obstruction is the treatment of choice in young children.

Herniation of ureter: a rare cause of hydroureteronephrosis

Background

Omentum and bowel loops are commonly seen in inguinal hernia. An unusual case of extraperitoneal herniation of ureter was detected in hernial sac with other contents, on computed tomography (CT) urography.

Case presentation

A 54-year-old male presented with inguinal hernia, with no previous history of surgery or trauma. Pre-operative screening showed a unilateral hydroureteronephrosis involving the pelvicalyceal system and entire ureter. No calculus was visualized in the ureter on ultrasound. On non-contrast CT (NCCT) followed by CT urography, the ureter was seen descending into the hernia sac causing hydroureteronephrosis. The patient subsequently underwent mesh repair surgery of the inguinal hernia with meticulous reduction of the herniated contents including the ureter, resulting in complete resolution of the hydroureteronephrosis.

Conclusion

An isolated extraperitoneal inguinal herniation of the ureter without concomitant urinary bladder involvement is extremely rare, especially with no prior history of trauma or surgery, as seen in our case. The case also exemplifies the role of pre-operative imaging as a protocol in cases of inguinal hernia to prevent per-operative complications.

Amyand's hernia- outcome of nylon darn repairs after complicated appendix surgeries in a district hospital: case series

INTRODUCTION

Complicated appendix is a least expected sac content of inguinal hernias that always require appendix surgery and hernia repair. The current recommendations for posterior wall repairs however, continue to attract conflicting views as to which modality gives the best outcome in infected surgical wounds. New posterior wall repair methods with properties to withstand surgical site infections, minimise hernia recurrence, affordable and easy skill to acquire with a potential to be widely adopted are continuosly sort.

AIM

To determine the surgical outcomes of complicated Amyand Hernias repaired using the open tissue base Nylon Darn posterior wall re-enforcement method.

METHOD

A retrospective review of medical records of patients who had surgery for emergency inguinal hernia with intra-operative confirmation of complicated appendix in the hernia sac from January 2015 to December 2020 at the Margaret Marquart Catholic Hospital, Kpando were included. Data on age, sex, clinical presentation, surgical procedure, intra-operative findings, post operative complications were captured and presented as descriptive statistics.

RESULTS

Twelve out of 286(4.6%) repairs were complicated Amyand Hernias in patients aged 6weeks to 76-years{median age 54.5-years}. Most of them were adults, long-standing hernias. All diagnosis were made on-table. Surgical site infections was the most frequent complication in types III and IV AHs which resolved with antibiotic treatment.

CONCLUSION

The incidence of complicated AHs is higher and should be anticipated in surgeries for long-standing complicated inguinal hernias. Even though complications were significantly associated with longer hospital stay, no second procedure or mortality was recorded.

Inguinoscrotal hernias containing stomach: risk of emergency presentation

INTRODUCTION

Inguinoscrotal hernias are the commonest form of abdominal wall hernia, but for them to contain stomach is extremely rare. The management of these hernias can be very challenging owing to their acute nature of presentation and distortion of anatomy. Our aim was to systematically review the literature for all reported cases of inguinoscrotal hernias containing stomach. In turn we analysed patient demographics, site of hernia, presentation and treatment. Outcomes were reviewed where available.

METHOD

We conducted a systematic search of the PUBMED, Embase and Medline databases with a combination of keywords: Hernia AND (inguin* OR scrot*) AND (gastric OR gastro*). An author's own case has also been included.

RESULTS

There were 20 case reports included in the review, plus the author's own case. They ranged in publication date from 1942 to 2020. Mean age at presentation was 71 years (range 49 to 87). All cases were male. In total, 62% (n = 13) of cases presented with combined symptoms of abdominal pain and vomiting, 48% (n = 10) presented with gastric outlet obstruction (GOO) and 48% (n = 10) presented with gastric perforation. All successfully treated cases with gastric perforation required a midline laparotomy approach, whereas 56% (n = 5) of patients in the GOO group were successfully treated conservatively. There were three deaths reported in this review, all in the gastric perforation group.

CONCLUSION

Stomach as a content of inguinoscrotal hernias is extremely rare. These hernias predominantly present acutely in the form of GOO or gastric perforation. All patients with gastric perforation will require a midline laparotomy. Patients with GOO can be successfully managed either surgically or in selective cases with conservative management.

Persistent scrotal swelling after laparoscopic inguinal hernia repair: "Omentaloma of the scrotum"

Complete removal of all the contents of a hernial sac is crucial in laparoscopic inguinal hernia repair. We report a case who underwent transabdominal preperitoneal repair for a complete, irreducible inguinal hernia. He had persistent scrotal swelling and new onset scrotal pain post-surgery. Ultrasonography of the scrotum revealed a well-defined hypoechoic scrotal lesion. A magnetic resonance imaging revealed a fat-containing mass lesion, hypointense on T2 fat-saturated image. He underwent exploration of the scrotum and a well-encapsulated mass was excised. The histopathological evaluation revealed a well-encapsulated structure comprising of lobules of fibroadipose tissue with foci of chronic inflammation and foamy histiocytes likely retained omentum from previous surgery. His scrotal pain disappeared post-excision. A missed retained omentum in the hernial sac causes considerable anxiety to patients and diagnostic and therapeutic dilemmas for the treating surgeon. We coined the term "omentaloma of the scrotum" for such a lesion.

Amyand's hernia associated with mesenteric chylous cyst in infant: a rare case report

Background

Amyand’s hernia is a rare condition approximately 0.4–0.6% of all inguinal hernias. Although rare, the Amyand’s hernia is worthy of discussion since the variable presentation that make clinical challenge to diagnose especially in infant. A mesenteric chylous cyst is rare disease and has not been reported in Amyand’s hernia.

Case presentation

We report an unusual case of Type II Amyand’s hernia with an enlarging chylous mesenteric cyst on the retrocaecal in the anulus into canalis inguinalis. A-2-months old infant presented with enlarging mass in the right scrotal. During laparotomy exploration, we found inguinal sac with intestinal and appendix content in the sac. In the edge site of the sac we found enlarging of mesenteric cyst on the retrocaecal in the anulus into canalis inguinalis. Based on the histopathology examination, the morphological feature is suitable for mesenteric chylous cyst appearance.

Conclusion

Presentation of mesenteric chylous cyst is rare, and there was no report about it in Amyand’s hernia. This unusual presentation should be considered by the surgeon, especially pediatric surgeon, in Amyand’s hernia cases.

First sliding Amyand hernia harbouring appendicular schistosomiasis: Case report

INTRODUCTION

Amyand's hernia (AH) is rare, schistosomiasis of the appendix is very uncommon, and both conditions coexisting together is an extremely rare event. Pre-operative diagnosis of each of the two conditions is usually difficult. To the best of our knowledge, the current paper is first to report both these two conditions in coexistence.

PRESENTATION OF CASE

A 31-year old man who had no comorbidities was admitted electively as a day case of non-complicated right indirect inguinal hernia. Further history and physical examination were unremarkable. Intraoperatively the patient was found to have right sliding AH with appendicular schistosomiasis (AS). The patient underwent Lichtenstein repair of the hernia with appendectomy. On follow up he was referred to infectious disease clinic, and the post-operative course was uneventful.

CONCLUSIONS

Intraoperative identification of non-typical hernia sac before its opening should alert the surgeon to the possibility of sliding hernia and the presence of an organ as a part of the sac. Rare causes of appendicular masses like schistosomiasis granuloma should be considered in endemic areas or immigrants from these areas, despite the difficulty of preoperative diagnosis. Management should follow general guidelines of appendectomy, hernia repair and dealing with the associated pathology if present.

Diagnosis and treatment of inguinal hernia of the bladder: a systematic review of the past 10 years

OBJECTIVE

Inguinoscrotal hernia (ISH) of the bladder is a rare condition involved in less than 4% of inguinal hernias. In most cases, it occurs to men older than 50 years who are overweight. Little is known about the subject and mainly based on case reports. When undiagnosed, it may be associated with bladder injuries during hernia repair. There is also no consensus on the ideal repair technique to use. The aim of the study is to evaluate the particularity of the management of the inguinal herniation of the bladder in term of diagnosis, choice and results of treatments.

METHODS

A Prisma systematic review of the literature was performed over the last 10 years using a database. We selected 51 articles including 64 patients with ISH of the bladder.

RESULTS

ISH of the bladder mainly occurred in overweight men aged over 50 years (Body Mass Index >30). Symptoms were reported for 76% of the patients (n=49), including inguinal swelling 60% of cases (n=38), lower urinary tract symptoms (48%), pain (40%) and a reduction of an inguinal mass after voiding (12.7%). Diagnosis was incidental on imaging for 7 patients, during inguinal repair surgery for 8, or on imaging performed following symptoms for the remaining 49 patients. Surgical repair was reported for 46 patients (71%) including various procedures as open surgery (80%) and laparoscopic approaches (20%). Excellent short term results were reported.

CONCLUSION

ISH of the bladder seams more likely to occur with patients suffering from lower urinary tract obstruction and best diagnosed with a computerized tomography scan. Various surgical techniques are reported.

Acute appendicitis presenting as an abdominal wall abscess: A case report

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Amyand’s hernia is uncommon in females.

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The initial presentation as an abdominal wall abscess is very rare in the contemporary literature.

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An index of suspicious, early diagnosing and surgical intervention lead to favorable recovery.

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The management should follow general guidelines of appendectomy, hernia repair and dealing with the associated pathology if present.

Introduction

Amyand hernia (AH) is a rare type of hernia characterized by the presence of appendix vermiformis in the inguinal hernial sac. It is rarely reported in women.

Presentation of case

We presented a case of a 60- year old woman who was admitted initially with an abdominal wall abscess and found to have perforated appendix in the right inguinal hernia. The patient underwent standard open appendectomy and the post-operative course was uneventful.

Discussion

The initial presentation of our case as an abdominal wall abscess is rare in the contemporary literature.

Conclusions

A high index of suspicious, early diagnosis and timely surgical intervention are the keys to have favorable outcome in amyand hernia. The management should follow general guidelines of appendectomy, hernia repair and dealing with the associated pathology if present.