{"paper_id":"eb66ec2e-55d3-4f39-b0f6-b520485734f6","body_text":"Thiyagarajan et al. \nEgyptian Pediatric Association Gazette           (2025) 73:89  \nhttps://doi.org/10.1186/s43054-025-00438-8\nCASE REPORT Open Access\n© The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which \npermits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the \noriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or \nother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line \nto the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory \nregulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this \nlicence, visit http://creativecommons.org/licenses/by/4.0/.\nEgyptian Pediatric\nAssociation Gazette\nA synchronized unique presentation \nof inguinal hernia in infantile twins\nSrikanth Thiyagarajan1*, Prathiba Nanjundaiah2 and Saravana balaji Muthukrishnan2 \nAbstract \nBackground Female structures such as the ovaries, fallopian tubes, ligaments, and uterus are rarely encountered \ninside a hernial sac. The prevalence of groin hernias containing parts of female genitalia remains unknown. Occur-\nrence in monozygotic twins is exceptionally uncommon and has not been reported previously.\nCase presentation We report a unique case of 4-month-old monozygotic female twins who presented with unilat-\neral, non-reducible groin swellings. Ultrasonography confirmed herniation of ovaries and fallopian tubes in both cases. \nPrompt laparoscopic herniotomy using the percutaneous internal ring suturing (PIRS) technique was performed. \nIntraoperatively, viable adnexal structures were identified without torsion or ischemia. Both patients had uneventful \npostoperative recovery.The simultaneous occurrence in twins suggests a potential genetic or embryological predis-\nposition. Prompt surgical repair is essential to avoid torsion and preserve fertility.\nConclusion This is the first documented case of monozygotic twins with ovary-containing inguinal hernias. It high-\nlights the importance of early imaging, high clinical suspicion, and minimally invasive surgical intervention in female \ninfants presenting with groin swellings. The simultaneous presentation in twins raises the possibility of a shared \ngenetic or developmental predisposition, warranting further study.\nKeywords Inguinal hernia, Twins, Ovary herniation, Paediatric laparoscopy, Case report\nBackground\nInguinal hernia is one of the most common surgical con -\nditions in infancy and childhood, with a higher incidence \namong premature infants due to improved neonatal sur -\nvival [1]. While more frequent in males, inguinal hernias \nin females may rarely contain adnexal structures such as \nthe ovary, fallopian tube, or uterus [2, 3]. Ovarian hernia-\ntion accounts for approximately 6–7% of female paediat -\nric inguinal hernias [4–6]. Clinical presentation is usually \nas a groin or labial swelling, which carries a risk of com -\nplications such as strangulation or torsion if not managed \npromptly. Simultaneous occurrence of ovary-containing \nhernias in twins is exceptionally rare. To the best of our \nknowledge, this is the first reported case of monozygotic \ntwins presenting with ovary-containing inguinal hernias, \nraising the possibility of a shared genetic or embryologi -\ncal predisposition.\nCase presentation\nTwo 4-month-old monozygotic female twins presented \nwith irreducible groin swellings.\nTwin A: Born preterm with very low birthweight, \nrequired a 2-month neonatal intensive care unit (NICU) \nstay with ventilatory support. She was thriving well \nand presented with a right irreducible inguinal swelling \n(Fig. 1).\nTwin B: The identical twin, with the same perinatal his-\ntory, presented with a left irreducible inguinal swelling. \nBoth infants were active, afebrile, and systemically well at \n*Correspondence:\nSrikanth Thiyagarajan\nsr7347@srmist.edu.in\n1 Department of General surgery, SRM Institute of Science \nand Technology, Kattankulathur, India\n2 Department of Paediatric Surgery, SRM Institute of Science \nand Technology, Kattankulathur, India\n\nPage 2 of 5Thiyagarajan et al. Egyptian Pediatric Association Gazette           (2025) 73:89 \nadmission. There was no relevant family history, comor -\nbidity, or similar complaints in relatives (Fig. 1).\nBoth swellings were firm, non-reducible, and \nunchanged with crying, without skin changes or signs \nof incarceration. Irreducibility was due to ovaries and \nfallopian tubes being engaged within the sacs, though \nvascularity was preserved. Routine labs were normal. \nUltrasonography confirmed ovarian tissue with follicles \nand omentum in the sacs, without torsion or ischemia \n(Figs. 2 and 3).\nAlthough present since birth, the swellings remained \nasymptomatic, so elective laparoscopic repair was sched -\nuled at 4 months once the infants were clinically stable.\nIntervention\nBoth infants underwent elective laparoscopic herniotomy \nusing the percutaneous internal ring suturing (PIRS) \ntechnique under general anaesthesia, following standard \nFig. 1 Twin A with right labial swelling and Twin B with left groin swelling\nFig. 2 Arrow points to a defect of size 9.4 mm seen in the right \ninguinal region with herniation of omental fat and right ovary\nFig. 3 Arrow points to a defect of size 9 mm seen in the left inguinal region with herniation of omental fat and left ovary\n\nPage 3 of 5\nThiyagarajan et al. Egyptian Pediatric Association Gazette           (2025) 73:89 \n \npreoperative evaluation and preparation. This minimally \ninvasive approach was chosen for its safety, efficacy, and \nreduced postoperative morbidity in paediatric patients.\nProcedure\nThe operations were performed by an experienced pae -\ndiatric surgical team at a tertiary care centre. In Twin A, \nlaparoscopic herniotomy was done using a 5 mm umbili -\ncal port; the hernial contents were reduced with gentle \nexternal pressure, and the internal ring was closed with \na non-absorbable suture. In Twin B, a similar 5 mm port \nwas created, but as the contents could not be reduced \nexternally, an additional 3 mm working port was intro -\nduced for laparoscopic reduction, followed by internal \nring closure. In both cases, the ovaries and fallopian \ntubes were viable with no evidence of torsion (Figs.  4 and \n5).\nPostoperative care\nPostoperative recovery was uneventful in both infants. \nFeeds were resumed four hours after surgery and were \nwell tolerated. Surgical wounds healed appropriately \nwith no signs of infection. Both infants remained stable, \nactive, and pain-free throughout the hospital stay.\nFollow‑ups and outcomes\nAt two weeks follow-up, both infants demon -\nstrated good wound healing with no recurrence or \nFig. 4 Laparoscopic view shows right inguinal hernia with ovary herniating through the deep ring. (A) Uterus, B left fallopian tube, C right fallopian \ntube, circle—deep ring\nFig. 5 Laparoscopic view shows left inguinal hernia with ovary herniating through deep ring. A Left fallopian tube, circle—deep ring\n\nPage 4 of 5Thiyagarajan et al. Egyptian Pediatric Association Gazette           (2025) 73:89 \ncomplications. Subsequent outpatient reviews con -\nfirmed normal growth, development, and preserved \novarian viability.\nDiscussion\nOvary-containing inguinal hernias, though uncommon, \nare clinically significant due to the risk of torsion and \ninfarction if untreated [5]. In female infants, the ovary \nis the most frequent organ found within the hernia sac, \ntypically presenting as a groin or labial swelling. Most \nreports describe unilateral herniation; however, our case \nhighlights the rare simultaneous occurrence in twins, not \npreviously documented [7].\nThe twins were clinically identical and reported as \nmonozygotic, though genetic confirmation was not per -\nformed, which is a limitation. Several embryological \nmechanisms may explain ovarian descent into the ingui -\nnal canal, including non-fusion of the Müllerian ducts, \ncongenitally elongated ovarian ligaments, or weakness of \nsupporting ligaments under raised intra-abdominal pres -\nsure [8, 9].\nUltrasonography was essential in establishing the diag -\nnosis and guiding timely repair, confirming ovarian tissue \nwith preserved vascularity [10]. Although open repair \nremains the standard, we used laparoscopic herniotomy \nwith the percutaneous internal ring suturing (PIRS) tech-\nnique, which provided excellent visualization and favora -\nble cosmetic outcomes in these infants.\nThe simultaneous occurrence in twins suggests a pos -\nsible genetic predisposition. Population-based studies \nsupport a familial link, showing higher hernia risk in \nchildren with affected parents or siblings, particularly \nbetween mothers and daughters [11, 12]. Similar clus -\ntering has been observed in adults, further suggesting a \nhereditary component.\nAlthough genetic testing was not performed in our \npatients, future cases would benefit from genetic evalu -\nation to clarify the role of heredity and connective tissue \ndevelopment in hernia formation.\nConclusion\nOvary-containing inguinal hernias are uncommon but \nclinically important due to the risk of torsion and loss of \novarian viability. This case represents the first reported \noccurrence in monozygotic twins, suggesting a possible \ngenetic or embryological predisposition. Although our \npatients remained stable and were managed electively at \n4 months, timely recognition and repair are essential to \nprevent complications. Genetic evaluation, though not \nperformed here, should be considered in future cases to \nbetter define potential hereditary factors.\nSupplementary Information\nThe online version contains supplementary material available at https:// doi. \norg/ 10. 1186/ s43054- 025- 00438-8.\nSupplementary Material 1.\nAcknowledgements\nThe authors would like to express their sincere gratitude to the entire \nPaediatric Surgery team for their unwavering dedication, expertise, and \ncompassionate care provided to the patients throughout the course of this \nstudy. The authors deeply appreciate the team’s role not only in delivering \nhigh-quality patient care but also in supporting the broader goals of this \nresearch endeavour.\nAuthors’ contributions\nAnalysis and interpretation: all authors Writing original draft: all authors Review \n& editing: all authors Final approval of the article: all authors.\nFunding\nNo funding received.\nData availability\nNo datasets were generated or analysed during the current study.\nDeclarations\nEthics approval and consent to participate\nWritten consent for the publication of this case report was obtained from the \npatient. Approval for case report by the institutional ethics committee is not \nrequired.\nConsent for publication\nWritten informed consent for the publication of this case report and for the \naccompanying images was obtained from the patient. A copy of the written \nconsent is available for review by the Editor-in-Chief of this journal.\nCompeting interests\nThe authors declare no competing interests.\nReceived: 19 July 2025   Accepted: 4 September 2025\nReferences\n 1. Kapur P , Caty MG, Glick PL (1998) Pediatric hernias and hydroceles. Pediatr \nClin North Am 45:773–789\n 2. Ravi K, Hamer DB (2003) Surgical treatment of inguinal hernia in children. \nHernia 7:137–140\n 3. Okada T, Sasaki S, Honda S et al (2012) Irreducible indirect inguinal hernia \ncontaining uterus, ovaries, and fallopian tubes. Hernia 16:471–473\n 4. Lee J, Scampoli N (2015) Incarcerated ovarian inguinal hernia in a \n10-month-old girl. CMAJ 187:596–598\n 5. Josefsson ML, Mitra S, Gupta S (2013) Inguinal ovary in adult women–\ncase report and literature review. Springerplus 2(1):545\n 6. 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