CASE REPORT
Year : 2018 | Volume
: 7 | Issue : 2 | Page : 138--140
Sliding hernia uterus inguinale in a child
Rahul Gupta
Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
Correspondence Address:
Dr. Rahul Gupta
Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan
India
Abstract
Uterine adnexa may be the content of the inguinal hernial sac in up to one-fifth of the pediatric female patients. Inguinal hernia containing uterus is known as “hernia uterus inguinale” which is a very rare condition. We report sliding inguinal hernia containing uterus and uterine adnexa in a 2-year-old girl who presented with 3.5 cm × 2.5 cm, partially reducible swelling in the left inguinal region extending to the upper part of the left labia majora. Uterus and ipsilateral fallopian tube with ovary were meticulously dissected from the hernial sac till the margins were free for closure of the sac. The contents were reduced en mass, and high ligation of the hernial sac with plication of deep ring was performed. Close follow-up and gynecological evaluation during the childbearing age are recommended.
How to cite this article:
Gupta R. Sliding hernia uterus inguinale in a child.Saudi J Health Sci 2018;7:138-140
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How to cite this URL:
Gupta R. Sliding hernia uterus inguinale in a child. Saudi J Health Sci [serial online] 2018 [cited 2023 Jun 9 ];7:138-140
Available from: https://www.saudijhealthsci.org/text.asp?2018/7/2/138/242503 |
Full Text
Introduction
The uterine adnexa, chiefly fallopian tube and sometimes ovary, are found as a sliding component in 15% to 20% of inguinal hernias in pediatric female patients.[1] Inguinal hernia containing both uterus and its adnexa is an extremely rare condition.[2],[3],[4],[5],[6] It is known as “hernia uterus inguinale” and is seen in infants, especially in the newborn period.[2],[3] We present a rare case of sliding inguinal hernia containing uterus, ipsilateral fallopian tube, and ovary in the hernia sac of a 2-year-old girl and also briefly discuss the embryopathogenesis of this entity.
Case Report
A 2-year-old girl was brought with the complaints of visible swelling in the left groin that appeared larger while crying or straining. The swelling was present since birth. There was no history of pain, vomiting, abdominal distension, dysuria, or illness. Clinical examination revealed 3.5 cm × 2.5 cm, partially reducible swelling in the left inguinal region extending to the upper part of the left labia majora. No signs of obstruction or strangulation were noted; perineal examination was normal. A presumptive diagnosis of the left congenital inguinal hernia was made. Blood investigations were within normal limits. Exploration revealed a large hernial sac with a firm mass as its contents. On opening the sac, uterus and the left fallopian tube (ipsilateral) with left ovary were found to be components of indirect inguinal hernia [Figure 1]. In addition, part of the wall of the sac was formed by the uterus. The deep ring was wide admitting tip of index finger. The mesenteric attachment of the inner sac wall was divided in the bloodless plane within the sac; uterus and fallopian tube with ovary were meticulously dissected and freed from the hernial sac till the margins were free for closure of the sac. All the contents were reduced en masse into the peritoneal cavity, and high ligation of the hernial sac was performed. The deep ring was plicated (closed) using purse string suture to prevent any recurrence. Postoperative period was uneventful, and the baby was discharged on the 2nd day. The child is doing well after 6 months of follow-up.{Figure 1}
Discussion
Inguinal hernia is one of the most common surgical conditions in children.[3],[4] It may occasionally surprise the surgeon with its rare content. Female counterpart structure of processes vaginalis which extends into inguinal canal is known as the canal of Nuck. This is accompanied by the round ligament of the uterus and passes through the inguinal canal up to labia majora. This peritoneal sac is of small size and gets obliterated by 8th gestational month.[7] Failed obliteration leads to hernia. Inguinal hernia is relatively uncommon in females as compared to males with boys to girls ratio of 6:1.[3] Uterine adnexa may be content of the inguinal hernial sac, but hernia in females containing uterus is rare with <50 cases reported in the literature till date.[2],[3],[4],[5],[6] It has an estimated incidence of 0.23%.[2],[3],[4],[5],[6] The uterus may (a) lie freely within the hernial sac or (b) it may be adherent to the wall of the sac by adhesions or (c) walls of the sac is formed by the uterus itself which is a true sliding-type “hernia uterus inguinale.”[2] It has been postulated that “hernia uterus inguinale” may be due to the anatomic abnormality of the ligaments that suspend the uterus resulting in displacement of uterus in the hernial sac, failure of fusion of the Mullerian ducts (Persistent Mullerian duct syndrome) leading to excessive mobility of uterus and the uterine adnexa and nonfusion of the uterine cornua.[8],[9] In our case, round ligament of the contralateral side was comparatively lax. “hernia uterus inguinale” may be found in association with other genital tract abnormalities.[10]
The presentation of an asymptomatic palpable, movable mass in the inguinal region extending over the labia majora suggests sliding hernia with ovary; but in our case, it was uterus along with ovary.[5],[6] Preoperative sonography is a very helpful investigation to diagnose hernia uterus inguinale.[4] Sonography was diagnostic (uterus as the content of hernial sac) in many studies[2],[4],[6] while it was inconclusive in a recent study.[4] Magnetic resonance imaging was performed in one study to confirm the presence of uterus in the sac.[3] We did not suspect the diagnosis of “hernia uterus inguinale” preoperatively; hence, sonography was not performed. Sliding hernia is an intraoperative diagnosis and contents of the sac must be thoroughly evaluated at surgery. In our case, the ovary and fallopian tube were adhered to the wall of the sac and part of the wall of the sac was formed by the uterus itself. The surgical procedure involved freeing the attachment of ovary and the fallopian tube from the sac till the margins were free for sac closure. It was followed by the retraction of uterus and its adnexa (en mass) into the peritoneal cavity and high ligation of the hernial sac. Care is taken to avoid excessive dissection of uterine adnexa which may damage fallopian tube and ovary leading to stricture of the fallopian tube and devascularization of the ovary.
The procedure is slightly demanding in comparison to herniotomy in females (without uterine adnexa).[6] Timely intervention is important to prevent the occurrence of ovarian torsion (as performed in the index case). Close follow-up and gynecological evaluation during the childbearing age have been recommended.[6]
Conclusion
The presence of hernia uterus inguinale is rare in a female child. It presents as partially reducible inguinal hernia. Uterus and its adnexa should be meticulously dissected from the sac and carefully replaced into the abdomen. The deep ring which is usually wide should be plicated to prevent the recurrence.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the parent has given her consent for images and other clinical information to be reported in the journal. The parent understands that name and initial will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.
Acknowledgment
The author is sincerely thankful to the faculty and residents of the Department of Anesthesia and nursing staff of the Department of Pediatric Surgery, Government Medical College, Kota, for helping in this endeavor.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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