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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 28-30

Inguinal hernia containing hemorrhagic ovarian cyst in an adolescent: A rare case report


Department of General Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. RML Hospital, New Delhi, India

Date of Submission31-Jul-2020
Date of Decision14-Aug-2020
Date of Acceptance09-Sep-2020
Date of Web Publication22-Feb-2021

Correspondence Address:
Dr. Rohit Chauhan
Department of General Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. RML Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijawhs.ijawhs_34_20

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  Abstract 


Inguinal hernia repair is one of the most common procedures done in the surgical discipline. The hernia sac commonly contains the omentum and small bowel as contents, but structures such as cecum, appendix, urinary bladder, Fallopian tubes, and ovary have been reported. We report an extremely rare presentation in our emergency of a right indirect irreducible inguinal hernia containing hemorrhagic ovarian cyst in an adolescent female. The inguinal region was explored, the cyst was excised, the contents were reduced, and a polypropylene mesh was laid. The preservation of reproductive organs and fertility with prompt surgical intervention is extremely important in such cases of inguinal hernia.

Keywords: Fertility, inguinal hernia, ovarian cyst


How to cite this article:
Chauhan R, Saurabh A, Yadav V. Inguinal hernia containing hemorrhagic ovarian cyst in an adolescent: A rare case report. Int J Abdom Wall Hernia Surg 2021;4:28-30

How to cite this URL:
Chauhan R, Saurabh A, Yadav V. Inguinal hernia containing hemorrhagic ovarian cyst in an adolescent: A rare case report. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2021 Sep 17];4:28-30. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/1/28/309978




  Introduction Top


Inguinal hernia repair is one of the most common procedures done in the surgical discipline. An inguinal hernia is predominantly seen in the male population. The incidence of females operated for inguinal hernia is <10%.[1],[2] The omentum and small bowel are one of the most common contents of inguinal hernia,[3] but contents such as cecum, appendix, urinary bladder,  Fallopian tube More Detailss, and ovary have been reported.[4] Reproductive organs as the content of hernia sac are mostly seen in the infant population[3],[5],[6],[7] and rarely in the adult population.[8]

We report an extremely rare presentation in our emergency of a right indirect irreducible inguinal hernia containing hemorrhagic ovarian cyst in an adolescent female. In consultation with the obstetrics and gynecology department, an emergency inguinal exploration was done. The cyst was excised, the contents were reduced, and a polypropylene mesh was laid. The preservation of fertility is of utmost importance in such cases. The laparoscopic approach can be safely used if diagnosed early.[9],[10]


  Case Report Top


An 18-year-old nulliparous female presented to our emergency department with pain and a diffuse bulge in the right inguinal region for the past 5 days. The pain was gradual in onset, constant, dull-aching pain, and nonradiating. The patient noticed the bulge after the onset of pain. There was no history of nausea, vomiting, or any other urinary complaint. Her menstrual cycle was regular, with a normal flow and duration. The last menstrual period was 24 days before the onset of symptoms. The patient had no history of abdominal surgery or intervention. There was no medical comorbidity. On examination, the patient was afebrile and had a blood pressure of 116/72 mmHg and a pulse rate of 108 beats/min. Local examination revealed a tender diffuse swelling above and lateral to the pubic tubercle [Figure 1]. The surface of the swelling was smooth, with no defined margins and erythema of the skin overlying it. It was irreducible with no cough impulse. The abdomen was soft and nontender. Routine blood investigations were within normal limits. The urine pregnancy test was negative. On ultrasonography, a thin-walled, anechoic, oval cystic structure of size approximately 2.5 cm × 2 cm with no internal septations was noticed. An edematous, thick, tubular structure was noted along with it. The findings were suggestive of an ovary along with the Fallopian tube. On limited color flow Doppler, vascularity was found intact, ruling out ovarian torsion. The left ovary and the rest of the adnexa were normal. The patient was taken up for emergency inguinal exploration to ensure that fertility was preserved. Consultation from the obstetrics and gynecology department was taken. An indirect hernia sac was found intraoperatively, and on opening the sac, 20 ml serous fluid was drained. A hemorrhagic ovarian cyst of size approximately 4 cm × 3 cm × 3 cm along with an edematous Fallopian tube was found in the sac [Figure 2]. The hemorrhagic fluid in the cyst was aspirated, and cystectomy was performed. The healthy ovary and Fallopian tube were reduced [Figure 3]. Meshplasty was done using a polypropylene mesh of size 7.6 cm × 15 cm. The patient was given intravenous ceftriaxone in the postoperative period. There was no evidence of endometrioma or malignancy in the histopathological examination of the cyst. Postoperative recovery was uneventful, and the patient was discharged on the fourth postoperative day. There was no recurrence of hernia at a 3-month follow-up.
Figure 1: Diffuse bulge in the right inguinal region

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Figure 2: Hemorrhagic ovarian cyst as a content in the sac

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Figure 3: Healthy ovary after cyst excision

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  Discussion Top


An inguinal hernia is one of the most common clinical conditions encountered by the general surgeon. Similarly, the ovarian cyst is a common clinical condition encountered by the gynecologists. The incidence of an ovarian cyst ranges from 8% to 18% in various studies.[11],[12] However, an inguinal hernia containing a hemorrhagic ovarian cyst is extremely rare. One of the most detailed studies done on rare presentations of groin hernia on 1,950 patients is by A Gurer in 2006 in which the author reported a mere 2.9% incidence of the ovary and Fallopian tube in the inguinal hernia sac.[7] Some of the risk factors predisposing to such a condition include elongation of the suspensory ligaments of the ovary following multiple childbirth, raised intra-abdominal pressure due to excessive coughing or straining during defecation, and frequent heavy weight lifting.[13] In our case, none of these risk factors were present.

The granulosa layer of the ovary remains avascular except immediately after ovulation when it becomes vascularized by thin-walled vessels. The rupture of these vessels gives rise to hemorrhagic ovarian cyst.[14] Such an appearance in an inguinal hernia can mimic a strangulated ovary. As in our case, expert opinion from a gynecologist is a must before further intervention as the preservation of fertility is of utmost importance.

The inguinal hernia can be repaired with or without a mesh. If the contents are gangrenous or contamination is present, a tension-free tissue repair is preferred to avoid mesh infection. In our case, as there was no evidence of gangrene or strangulation, a polypropylene mesh was laid. The laparoscopic approach for an inguinal hernia containing the ovary has been described in the literature.[9],[10] However, we would prefer the open approach in an emergency situation as the adnexa is highly vulnerable to incarceration and damage when entrapped, leading to loss of reproductive function.[8]


  Conclusion Top


Hemorrhagic ovarian cyst in an inguinal hernia is an extremely rare presentation in an adolescent female. The presence of the ovary in the sac should be kept in mind when a female presents with an inguinal hernia. Prompt surgical intervention should be done with a goal of reproductive organ and fertility preservation in mind.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kark AE, Kurzer M. Groin hernias in women. Hernia 2008;12:267-70.  Back to cited text no. 1
    
2.
Köckerling F, Hoffmann H, Adolf D, D Weyhe, Reinpold W, Koch A, et al. Female sex as independent risk factor for chronic pain following elective incisional hernia repair: Registry-based, propensity score-matched comparison. Hernia 2020;24:567-76.  Back to cited text no. 2
    
3.
Goyal S, Shrivastva M, Verma RK, Goyal S. “Uncommon contents of inguinal hernial sac”: A surgical dilemma. Indian J Surg 2015;77 (suppl 2):305-9.  Back to cited text no. 3
    
4.
Saurabh A, Chauhan R, Yadav V. An obstructed sliding hernia containing ileum, caecum and ascending colon as contents: A rare case report. AJCRS 2020;4:16-20.  Back to cited text no. 4
    
5.
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. 5
    
6.
Kaya O, Esen K, Gulek B, Yilmaz C, Soker G, Onem O. The inguinal herniation of the ovary in the newborn: Ultrasound and color Doppler ultrasound findings. Case Rep Radiol 2014;2014:281280.  Back to cited text no. 6
    
7.
Gurer A, Ozdogan M, Ozlem N, Yildirim A, Kulacoglu H, Aydin R. Uncommon content in groin hernia sac. Hernia 2006;10:152-5.  Back to cited text no. 7
    
8.
Graul A, Ko E. Indirect Inguinal Hernia Containing a Fallopian Tube and Ovary in a Reproductive Aged Woman. Case Reports in Obstetrics and Gynecology, vol. 2014, Article ID 437340, 3 pages, 2014. https://doi.org/10.1155/2014/437340.  Back to cited text no. 8
    
9.
Patle NM, Tantia O, Prasad P, Khanna S, Sen B. Sliding inguinal hernias: Scope of laparoscopic repair. J Laparoendosc Adv Surg Tech A 2011;21:227-31.  Back to cited text no. 9
    
10.
Machado NO, Machado LS, Al Ghafri W. “Laparoscopic excision of a large ovarian cyst herniating into the inguinal canal: A rare presentation”. Surg Laparosc Endosc Percutan Tech 2011;21:e215-8.  Back to cited text no. 10
    
11.
Greenlee RT, Kessel B, Williams CR, Riley TL, Ragard LR, Hartge P, et al. Prevalence, incidence, and natural history of simple ovarian cysts among women >55 years old in a large cancer screening trial. Am J Obstet Gynecol 2010;202:373.e1-9.  Back to cited text no. 11
    
12.
Modesitt SC, Pavlik EJ, Ueland FR, DePriest PD, Kryscio RJ, van Nagell JR Jr. Risk of malignancy in unilocular ovarian cystic tumors less than 10 centimeters in diameter. Obstet Gynecol 2003;102:594-9.  Back to cited text no. 12
    
13.
Okada T, Sasaki S, Honda S, Miyagi H, Minato M, Todo S. Irreducible indirect inguinal hernia containing uterus, ovaries, and Fallopian tubes. Hernia 2012;16:471-3.  Back to cited text no. 13
    
14.
Jain KA. Sonographic spectrum of hemorrhagic ovarian cysts. J Ultrasound Med 2002;21:879-86.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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