Surgical Science, 2011, 2, 322-325
doi:10.4236/ss.2011.26068 Published Online August 2011 (
Copyright © 2011 SciRes. SS
Unusual Contents of Inguinal
Hernia Sac. An Approach
to Management
Norman Oneil Machado, Nikita Neha Machado
Department of Surgery, Sultan Qaboos University Hospital,
Muscat, Oman
Received February 18 , 20 11; revised May 31, 2011; accepted June 10, 2011
Background: unusual contents of hernia sac are uncommon, but are likely to be encountered by a surgeon in
his career due to the frequency of hernia repair. The aim of this study, is to present our experience of unusual
contents in inguinal hernia sac, discuss its management and review the relevant literature with regards to
others experience. Patients and methods: retrospective study of 662 patients who underwent inguinal hernia
repair over an 8 year period from 2000 to 2008 was carried out. Results: seven patients presented with un-
usual contents in inguinal hernia sac; an incidence of 1.05%. Three of them had vermiform appendix, with
acute appendicitis (Amyand’s Hernia) noted in one of them. All patients underwent appendicectomy with
repair of hernia, with mesh being employed only in patients with normal appendix. In 2 cases urinary bladder
had herniated and there was one case each of ovarian cyst and fallopian tube with ovary as its content. In all
these patients hernia repair was carried out after carefully reducing the contents. Conclusion: unusual con-
tents of hernia may pose a surgical dilemma during hernia repair even to an experienced surgeon. Although
rare, a hernia may contain vermiform appendix and exceptionally it may be acutely inflamed. Tubal and
ovarian herniation in an inguinal hernia may be found in adult and perimenopausal women, though the inci-
dence is reported to be more common in children. Urinary bladder herniation occurs with similar incidence
as tubo ovarian hernia; however it requires special attention because of the risk of iatrogenic bladder injury
during inguinal dissection. Though appendix as a content is dealt with by appendicectomy followed by her-
nioplasty, every effort should be made to preserve other organs found in the hernia sac to achieve an un-
eventful postoperative period.
Keywords: Inguinal Hernia, Amyand’s Hernia, Appendix, Ovarian Cyst, Hernia Repair
1. Introduction
Inguinal hernia repair is one of the commonest opera-
tions in surgical practice. However, when a surgeon en-
counters unusual content it could pose a difficulty in its
management [1,2]. The often encountered unusual con-
tents are appendix, ovary, fallopian tubes and urinary
bladder [1,2].The presence of unusual contents of ingui-
nal hernia has been reported exceptionally in the litera-
ture and most studies are low volume case reports. In this
study we aim to present our experience of unusual con-
tents and the approach to its management and review the
relevant literature.
1.1. Materials and Methods
This is a retrospective study of 662 patients who under-
went inguinal hernia repair at our institution between
January 2000 to December 2008. The patient’s hospital
records were analyzed for the unusual content of hernia
sac, including vermiform appendix, ovary and fallopian
tubes, and urinary bladder. The demographic details, the
type of hernia, surgical procedure and intraoperative
findings an d operative complications were recorded
1.2. Results
Of the 662 patients, 438 were indirect hernias and 224
were direct hernias. There were 654 male patients and 8
female patients. The organs found in the hernia sac were
vermiform appendix, urinary bladder, ovaries and fallo-
pian tubes and ovarian cyst.
2. Vermiform Appendix and Acute
The inguinal sac was found to contain a normal appendix
in 2 cases and an inflamed appendix (Amyand’s Hernia)
in one patient. The mean age of patients was 28 years (4 -
48 years). All patients were males. In 2 patients with
normal appendix the hernia was on the right sid e (Figure
1) and in the patient with inflamed appendix it was on
the left side. All patients underwent appendicectomy. In
patients with normal appendix this was followed by ten-
sion free hernia repair using a vicrylprolene mesh. In the
patient with acute appendicitis, following appendicec-
tomy a thorough wash of the sac was carried out and it
was then ligated and a repair without a mesh was carried
3. Vescio Inguinal Hernia
Urinary bladder was found in the hernia sac of 2 patients
with direct hernias. Both the patients were males and
their mean age was 60 years (52 & 68). One of these
patients had benign prostatic hypertrophy which was
treated 8 weeks prior to hernia repair with transurethral
resection of prostate. Both patients underwent tension
free repair of the hernia using vicrylprolene mesh after
careful reduction of the urinary bladder from the sac.
4. Ovary and Fallopian Tube/Ovarian Cyst
Ovary with fallopian tube was the content in one patient
Figure 1. Normal appendix as a content of right inguinal
hernia in a 4 year old boy.
who was a 5 year old girl. The contents were healthy and
had no torsion and no associated genital malformation.
The patient underwent redu ction of the con tents followed
by ligation of the sac. The ovarian cyst was seen in a 48
year old lady who presented with left iliac fossa pain of 6
months duration associated with inguinolabial swelling
(Figure 2(a)). Following the confirmation on MRI scan
(Figure 2(b)) the patient underwent laparoscopic exci-
sion of the ovarian cyst and transabdominal preperitoneal
mesh repair.
There were no complications noted in any of these pa-
tients, nor recurrence.
5. Discussion
Inguinal hernia is a common surgical problem which
Figure 2. (a) Prominent inguinal labial swelling due to her-
niation of ovarian cyst into left hernia sac; (b) MRI- Sagit-
tal view revealing ovarian cyst in the pelvis and its exten-
sion into the inguinal region.
Copyright © 2011 SciRes. SS
may sometime surprise the surg eon with its unusual con-
tent [1,2]. This may pose problems in management due
to its surprise element. Almost all intra abdominal con-
tents including stomach and their pathologies have been
reported to have been found in the hernia sac [3,4].
Moreover, acute conditions including perforated diver-
ticular abscess have also been reported to track into the
inguinal canal mimicking a strangulated inguinal hernia
[5]. Patients with no evidence of bowel obstruction
clinically and radiologically, presenting with painful in-
guinal swelling have a risk of significant extra-abdomi-
nal or intra-abdominal disease processes [5]. An infected
hip prosthesis abscess, a subcutaneous fungal abscess,
pancreatic psuedocyst [5], leaking abdominal aortic an-
eurysms [6] and peritonitis have presented as an atyp ical
inguinal hernia [7].
Although definite diagnosis of ingu inal hernia is often
established by the cough impulse and the ability to re-
duce the swelling into the abdominal cavity, clinician
may face difficulties in the diagnosis of non reducible
masses. The differential diagnosis could include inguinal
lymphadenopathy, spermatic cord cysts, undescended
testis, lipoma. While sonographic examination of this
region is usually sufficient to confirm the diagnosis, CT
scan or MRI could be better in anatomical delineation of
its content.
The presence of a normal vermiform appendix in an
inguinal hernia sac is uncommon with a reported inci-
dence of 0.6% [8] to 1% [9] of inguinal hernias. They are
usually on the right side and often seen in males. It has
generally been associated with large indirect inguino-
scrotal hernias but occasionally direct hernias may also
contain them [1,8]. Acute append icitis within an inguinal
hernia accounts for 0.1% of all cases [1]. They are in-
variably on the right side and exceptionally on left side
as in one of our cases [10]. Inflammation of the appendix
is attributed to the external compression of the appendix
at the neck of the hernia. The inflammatory state of the
appendix determines the surgical approach and the type
of hernia repair. In the case of acute appendicitis, fol-
lowing appendicectomy the hernia repair is performed
without a synthetic mesh, due to the ongoing infective
and inflammatory process [2] .While there are some who
carry out appendicectomy, in the case of normal appen-
dix incidentally found within the sac [1], there are others
who feel that the addition of prophylactic appendicec-
tomy to the hernia repair is not adv isable [2]. Those who
do not favour it, feel that appendicectomy adds to the
possibility of infection to an otherwise clean procedure
[2]. Superficial wound infection adds to the morbidity
while deep infection may contribute to recurrence. In
addition, the surg ical effort to visualize the entire appen-
dix by enlarging the hernia defect or distending the neck
of the sac may increase the possibility of recurrence by
weakening of the anatomic buttress around the hernia sac
[2,10]. Those in favour of appendicectomy however, feel
that the partly traumatized appendix, due to its handling
is better dealt with by an appendicectomy, with outmost
care taken to prevent contamination.
Entrapment of adnexae in an indirect inguinal hernia is
rare in adult women. Most reported cases concern the
paediatric population in whom ovaries and tubal herni-
ation have long been associated as unusual contents [11].
The reported incidence of its occurrence is 71% in chil-
dren under 5 years [12] and 30% in adolescents or
women in reproductive age group [12] and 2.9% exclu-
sively in adults [1]. Embryogenic derangements are as-
sociated with this condition. During embryogenesis the
gubernaculums and broad ligaments suspend the ovary
and prevent its descent through the canal of Nuck (proc-
ess vaginalis peritonei) to the base of the labium major
[2]. The canal of Nuck is obliterated by the 8th week of
fetal life and the ovary is then suspended between the
cornu of the uterus and the internal ring. If it remains
patent the ovary and the fallopian tube may be forced
through the can al to a congenital he rnia sac. When ovary
and fallopian tube form the contents of the inguinal her-
nia sac, they are often associated with anomalies in the
development of the genital tract such as vaginal atresia,
bicornuate uterus and renal anomalies [1,2,11,12]. These
patients are treated with reduction of the content pro-
vided there is no ovarian or tubal abnormality, the blood
supply is not impaired and there is no evidence of
salpingitis [1,2]. Reduction of the content is followed by
high ligation of the hernia sac, closure of internal ring
and re-enforcement of the posterior wall with a mesh in
patients older than 20 years of age [1,2,12]. The presen-
tation of the ovarian cyst as an inguinolabial swelling
however is extremely rare and has been reported only
once before in English literature [13] .The ovarian cyst
rarely herniates into the canal of Nuck as it is usually
obliterated by birth. Moreover even if the canal were to
be patent, the ovarian cyst would find it easier to expand
within the pelvis rather th an enter into a narrow inguinal
The incidence of inguinal hernia containing urinary
bladder is 0.36% [1]. Herniation of bladder is often as-
ymptomatic and only a small percentage of them are di-
agnosed preoperatively [14,15]. Even though most of
them are associated with direct hernias [15] there are
reports of its occurrence in indirect hernias [1,14]. Male
sex, obstructive urinary symptoms, older age group and
obesity are some of the risk factors [1]. There is a poten-
tial risk of injury to the bladder (28.6%), particularly
when it is incarcerated in an indirect inguinal hernia [1].
The injury, if not detected on table, should be suspected
Copyright © 2011 SciRes. SS
Copyright © 2011 SciRes. SS
to have occurred if there is unexplained haematuria in the
postoperative period.
6. Conclusions
Unusual contents of inguinal hernia sac are rare, but are
likely to be encountered in one’s surgical career during
hernia repair, as it is one of the most commonly per-
formed surgeries. The commonest unusual contents in-
clude appendix, fallopian tubes and urinary bladder
which are usually dealt with by reduction of the content
and hernioplasty using a mesh. However, when appendix
is the content, appendicectomy is often carried out with
mesh placement being avoided only in the presence of
acute appendicitis. In most other instances, every effort
should be made to preserve the organ found in the hernia
sac to ensure an uneventful postoperative period. Un-
usual contents may pose special challenges even to an
experienced surgeon because of its surprise element.
Being aware of this possibility, along with the appropri-
ate management would ensure better outcome in these
7. References
[1] A. Gurer, M. Ozdogan, N. Ozlem, A. Yildirim, H. Kula-
coglu and R. Aydin, “Uncommon Content in Groin her-
nia Sac,” Hernia, Vol. 10, No. 2, 2006, pp. 152-155.
[2] K. Ballas, T. H. Kontoulis, C. H. Skouras, A. Triantafyl-
lou, N. Symeonidis, T. H. Pavlidis, et al., “Unusual Find-
ings in Inguinal Hernia Surgery. Report of 6 Rare Cases,”
Hippokratia, Vol. 13, No. 3, 2009, pp. 169-171.
[3] C. E. R. Gibbons, A. K. Malhotra and M. H. Harvey,
“Inguinal Hernia an Unusual Case of Gastric Outlet Ob-
struction,” British Journal of Hospital Medicine, Vol. 52,
1994, pp. 360-361.
[4] M. T. Oruc, B. Kulah, B. Saylam, M. Moran, I. Albayrak
and F. Coskun, “An Unusual Presentation of Metastatic
Gastric Cancer Found during Inguinal Hernia Repair:
Case Report and Review of Literature. Hernia, Vol. 6, No.
2, 2002, pp. 88-90. doi:10.1007/s10029-002-0063-3
[5] S. I. H. Andrabi, A. Pitale and A. A.S. El-Hakeem, “Di-
verticular Abscess Presenting as a Strangulated Inguinal
Hernia: Case Report and Review of the Literature,” Ul-
ster Medical Journal, Vol. 76, No. 2, 2007, pp. 107-108.
[6] A. M. Abulafi, W. M. Mee and B. J. Pardy, “Leaking
Abdominal Aortic Aneurysm Presenting as an Inguinal
Mass,” European Journal of Vascular Surgery, Vol. 5,
No. 6, 1991, pp. 695-696.
[7] D. P. Sellu, “Pus in Groin Hernia Sacs: A Complication
of Non-Generalised Peritonitis,” British Journal of Hos-
pital Medicine, Vol. 41, No. 5, 1987, pp. 759-760.
[8] C. D’Alia, M. G. Lo Schiavo, A. Tonante, F. Taranto, E.
Gagliano, L. Bonanno, et al., “Amyand’s Hernia: Case
Report and Review of the Literature,” Hernia, Vol. 7, No.
2, 2003, pp. 89-91.
[9] W. E. G. Thomas, K. D. J. Vowles and R. C. N. Wil-
liamson, “Appendicitis in External Herniae,” Annals of
The Royal College of Surgeons of England, Vol. 64, 1982,
pp. 121-122.
[10] R. Solecki, A. Matyja and W. Milanowski, “Amyand’s
Hernia: A Report of 2 Cases,” Hernia, Vol. 7, 2003, pp.
[11] V. Mayer and F. G. Templeton, “Inguinal Ectopia of the
Ovary and Fallopian Tube. Review of the Literature and
Report of the Case of an Infant,” Archives of Surgery,
Vol. 43, No. 3, 1941, pp. 397-408.
[12] H. P. van Heesewijk, F. W. Smith, M. A. Heitbrink and F.
P. Kok, “Herniation of an Ovarian Cyst Through the In-
guinal Canal: Diagnosis with CT,” American Journal of
Roentgenology, Vol. 154, No. 1, 1990, pp. 202-203.
[13] K. D. Bradshaw and B. R. Carr, “Ovarian and tubal in-
guinal hernia,” Obstetrics & Gynecology, Vol. 68, Sup-
plement 3, 1986, pp. 50-52.
[14] M. T. Oruc, Z. Akbulut, O. Ozozan and F. Coskun,
“Urological Findings in Inguinal Hernia: A Case Report
and Review of the Literature,” Hernia, Vol. 8, No. 1,
2004, pp. 76-79. doi:10.1007/s10029-003-0157-6
[15] L. G. Gomella, S. M. Spires, J. M. Burton, M. D. Ram
and R. C. Flanigan, “The Surgical Implications of Herni-
ation of the Urinary Bladder,” Archives of Surgery, Vol.
120, No. 8, 1985, pp. 964-968.