Introduction
Strangulated inguinal hernia surgery is a common surgical emergency worldwide [
1]. No sex or age is exempt. The content of the hernia sac may be any intra-peritoneal or retro-peritoneal viscus. The small intestine and omentum are the commonest viscera encountered in the hernia sac [
1]. Intra-abdominal structures rarely encountered in the inguinal canal include the vermiform appendix, ovary, fallopian tube and urinary bladder [
2,
3]. More rarely, uterine fibroid have been encountered as a content of inguinal hernia sac in pregnant women [
4,
5]. Delta State University Teaching Hospital, DELSUTH is one of the tertiary health facilities in the South –South Geo–Political zones of Nigeria and wish to highlight and share our experience on a rare case of uterine fibroid as a content of a strangulated inguinal hernia sac in a non-pregnant woman.
Case Report
Mrs O.F is a 46 year old woman from Warri, Delta State who had myomectomy four years previously and thereafter noticed a reducible swelling in her left groin for one year. For the last 3 months the swelling had become irreducible, however it became painful with associated vomiting and constipation 24 hours before presenting to a private hospital from where she was referred to our specialist services.
She was in painful distress, afebrile, not dehydrated or pale. She had a well healed Pfannenstiel scar, a non-gravid uterus of about 20 weeks size, and a tender irreducible left groin swelling with no skin changes. Her bowel sounds were normal. A pre-operative diagnosis of strangulated left inguinal hernia was made. Her complete blood count, urinalysis, electrolytes, urea and creatinine levels were within normal. A plain abdominal X-ray was not contributory. She was prepared for emergency hernia relief and repair. The findings at surgery were a strangulated indirect left inguinal hernia; the content was torsion of a pedunculated fibroid measuring 10x12 cm [Fig.1]. The fibroid and its pedicle were excised. A modified Bassini repair was effected with nylon 1. She was placed on intravenous co-amoxiclav, pentazocine and intravenous fluids.
She had an uneventful post-operative period, and she was discharged home on the third post-operative day. Histopathology report of the excised specimen confirmed uterine myoma. She has been seen twice in the surgical follow-up clinic and she has remained well.
Discussion
The finding of a strangulated uterine fibroid in the inguinal hernia sac is very rare. In our search of the literature we were able to locate only six cases, with five of these cases occurred during pregnancy and one of them outside of pregnancy [
4,
6-
10]. Therefore this index case is probably the second case presenting outside of pregnancy. In the earlier reported case occurring outside of pregnancy, the surgeons did extensive investigations to make an exact diagnosis [
8]. This investigations included magnetic resonance imaging which was able to clearly demonstrate a pedunculated uterine fibroid in the inguinal canal. In the index case, the “fear” of a strangulated viscus in the inguinal hernia sac and the limited diagnostic armamentarium in a low resource country, were limiting factors to elaborate diagnostic investigations. The patient’s past surgical history of previous myomectomy associated with a physical finding of a bulky non-gravid uterus could have drawn attention to the possibility of this rare condition.
It is the author’s opinion that the herniated pedunculated fibroid occurred secondary to pulsion of a recurrent fibroid on the bulky non gravid uterus into the inguinal canal and subsequently underwent growth within the inguinal canal. The increased size of the mass beyond the size of the internal ring prevented reduction of the inguinal hernia which the patient noticed 3 months before presentation, and torsion of the pedicle of the pedunculated fibroid in the inguinal canal lead to the pain that simulated a strangulated inguinal hernia. In the pregnant state, the increasing size of the uterus pushed the pedunculated fibroid into the inguinal canal.
The treatment of the reported cases has all been surgery. The surgical intervention of these reported literature cases vary, from, simple reduction of the mass and herniorrhaphy to excision of the mass and herniorrhaphy. In the only previous case seen outside of pregnancy, abdominal hysterectomy and hernioplasty [
8] was the mode of treatment, no reason was given for this extensive surgery. The rarity of these cases means that there is no standardized protocol for treatment. It is our opinion that the recommendations for routine hernia treatment should be followed. In our index case, the strangulated fibroid with its pedicle were excised and the hernia repaired.
Conclusion
It is the author’s opinion/advice to clinicians practicing in low resource countries that though strangulated inguinal hernia fibroid in a non-gravid uterus is rare; it should be considered in the diagnosis of groin swellings even in myomectomised patients with bulky non-gravid uterus as another recurrent fibroid.
Acknowledgement
I wish to appreciate Prof. V. Odigie for reading through the manuscript and the invaluable corrections he made to it.
References
- Foster NM, McGory ML, Zingmond OS, Ko CY. Small bowel obstruction: a population-based appraisal. J Am Coll Surg. 2006;203:170-176
- Nicolo E. Unexpected Findings in Inguinal Hernia Surgery. In: Bendavid R, Abrahamsom J, Arregui M, Phillips EH (eds). Abdominal Wall Hernia: Principles and Management. 2001: Springer Verlag; New York. pp.184-191.
- Machado NO, Machado NN. Unusual Contents of Inguinal Hernia Sac. An Approach to Management. Surgical Science. 2011;2:322-325.
- Sherer DM, Edgar DM, Pulli GJ, Scibetta JJ. Pendunculated uterine fibroid simulating an incarcerated inguinal hernia in pregnancy. Am J Obstet Gynecol. 1994;170:724-725.
- Ehigiegba AE, Selo-Ojeme DO. Myomectomy in pregnancy: incarcerated pendunculated fibroid in an umbilical hernia sac. Int J Clin Prac. 1999;53(1):80.
- Obstetric case reports. J Obstet Gyneacol. 2001;21:306-310.
- Sciannameo F, Madami G, Madami C, et al. Torsion of uterine fibroma associated with incarcerated inguinal hernia in pregnancy. Case report. Minerva Ginecol 1996;48:501-504.
- Kawakami S, Nishimura K, Tanaka A, Eguchi M, Obata T, Mukaihara S, et al. Uterine leiomyoma appearing as an inguinal mass. Am J Roentgenol. 1997;69:547-548.
- Meen E, Vergis A. A rare cause of inguinal mass in pregnancy. Can J Surg. 2008;51:E124
- Kelly EG, Babiker M, Meshkat B, Beggan C, Leen E, Keeling P. An unusual finding in the inguinal canal of a 26-week pregnant patient. Hernia. 2013;17:537-540.