An unusual case of a strangulated right inguinal hernia containing the sigmoid colon

Abstract

The strangulated inguinal hernia is one of the most common emergencies in surgery. Although the diagnosis is usually made by physical examination, the content of the hernia sac and the extent of the following operation may vary. We present an extremely rare case of a strangulated right inguinal hernia containing the sigmoid colon and review the relevant literature.

1. Introduction

It is estimated that 75% of all hernias occur in the inguinal region. The most serious complication of a hernia is strangulation, which occurs in approximately 1–3% of groin hernias.¹ The sac of an inguinal hernia most frequently contains the intestine and the omentum and uncommonly the appendix, the Meckel diverticulum, the ovary or the urinary bladder.² Except in sliding hernia, the sigmoid colon is uncommonly found in an inguinal hernia, especially on the right side.

We present a case of strangulated right inguinal hernia containing the sigmoid colon and we review the literature on this rare condition.

2. Case report

A 69 year old male was admitted to our Emergency Department with vague abdominal pain, vomiting and obstipation that had started 48 h before. The patient had previous history of Parkinson's disease, which affected his ambulatory status, and he was receiving the relevant medication. He was a nursing home resident and his initial symptoms were attributed to the Parkinson's disease.

On physical examination the abdomen was moderately distended, the bowel sounds were diminished and there was a mild diffuse tenderness without peritoneal signs. In the right inguinal region there was a large, tender, irreducible hernia. His body temperature was 37.8 °C. The laboratory tests showed mild leukocytosis. The plain abdominal X-ray showed marked dilatation of the large bowel with a cut-off sign at the sigmoid colon (Fig. 1). This finding was inconsistent with the typical irreducible right inguinal hernia, where the small intestine is expected to be contained and affected in the hernia sac. For that reason and in order to exclude concomitant colon pathology, a CT scan was ordered. The abdominal CT revealed that the content of the right inguinal hernia was the strangulated sigmoid colon (Fig. 2).

Fig. 1.

Plain abdominal film showing dilatation of large bowel with a cut off at sigmoid colon.

Fig. 2.

CT scan showing the strangulated sigmoid colon.

At operation, through a right inguinal incision, the sac of an indirect hernia and surrounding tissues were necrotic and the contained sigmoid was severely ischemic. Through a midline laparotomy, the affected sigmoid was resected and an end-colostomy of the descending colon was created (Fig. 3).

Fig. 3.

Intraoperative image of gangrenous sigmoid colon prior to resection.

The patient had an uneventful recovery and was discharged from the hospital 7 days later. The histology report showed severe ischemic necrosis of the sigmoid colon. Following complete colonoscopy, the patient had his stoma successfully closed 3 months later.

3. Discussion

Inguinal hernias are relatively common in the elderly with an estimated prevalence 6%.³ Incarceration of inguinal hernia occurs in approximately 10% of cases which in turn can lead to intestinal obstruction, strangulation and infarction.⁴ Among these complications, strangulation is the most serious with potentially lethal sequelae.⁵

The content of inguinal hernias varies widely. In most cases small intestine and omentum are usually contained in the hernia sac, but urinary bladder, fallopian tube with the ovary, Meckel's diverticulum, appendix and inflamed colonic diverticulum have also been reported.^6–11 Inguinal hernia sacs in 0.5% of cases contain malignancies, either of saccular origin or generating from the herniated organ, usually sigmoid, cecum and other parts of colon.^12–14

In our case the content of hernia sac was the strangulated loop of an otherwise normal sigmoid colon. Due to anatomical considerations the sigmoid colon is commonly found to herniate through abdominal defects at the left inguinal region, especially as a sliding hernia. The sigmoid colon as a content of a right side inguinal hernia is extremely rare. To date, only three such cases of strangulated right inguinal hernia have been reported.^14–16 In two of them the clinical presentation was related to complicated sigmoid pathology, volvulus and carcinoma respectively.^14,16 In the third case a strangulated hernia was misdiagnosed in a patient suffered from a fecal peritonitis due to perforated sigmoid cancer.¹⁵ In most cases the clinical examination is sufficient to diagnose a complicated inguinal hernia.¹⁴ In our case, though the clinical findings were consistent with strangulated inguinal hernia, the gas pattern on plain abdominal films raised the suspicion of concomitant colon pathology. An abdominal CT scan was ordered to exclude sigmoid obstruction and secondary hernia incarceration due to increased intra-abdominal pressure.

Intraoperatively, the presence of the ischemic sigmoid colon warranted its excision through a midline incision. A Hartmann's procedure was followed by a Bassini repair to avoid septic complications. In agreement with other authors, we believe that a mesh hernia repair in such heavily contaminated cases is inappropriate.^2,15 However, there are few reports that support the use of mesh techniques in cases with minimal contamination along with the use of broad spectrum antibiotics for several days.^17,18

4. Conclusion

Inguinal hernia is a common clinical condition which usually has limited differential diagnostic spectrum. Its repair is also simple for the experienced surgeon. In rare cases though, hernias may pose a great surprise, not only due to their content, but also for their complexity in management. Even in the urgency of a strangulated hernia, a thorough preoperative evaluation utilizing imaging methods accordingly is required in order to make the right diagnosis and to exclude concomitant intra-abdominal pathology.

Conflict of interest statement

None declared.

Funding

None.

Ethical approval statement

A written consent has been obtained for this publication.