Endometriosis in a right inguinal hernia sac

Extrapelvic endometriosis is rare but can be found in abdominal wall, lungs, brain, and intestines.[,] We present here a case of right inguinal hernia sac endometriosis which started as a tender lump in the inguinal region, presenting as an incarcerated inguinal hernia. We advise that while dealing with a lump in the inguinal region, we must keep in mind endometriosis especially when the patient is a woman of child-bearing age. Imaging techniques, such as ultrasonography (USG) and magnetic resonance imaging, can help to diagnose such cases preoperatively. In this case, USG and computed tomography (CT) scan could not diagnose endometriosis. The diagnosis was confirmed with excision and histopathological examination. Case Report A 40-year-old female presented to our outpatient department with complaints of a painful tender and nonreducible mass in the right inguinal region for the last 1 month. There was no bowel or urinary complaints. She had normal and regular menstruation. She had no gynecological complaints. She had one 7-year-old son who was delivered by lower-segment cesarean section. She also noticed that the size of the lump was same and was not increasing. Physical examination revealed a 6 cm × 4 cm oval lump in the right inguinal region, which was tender and nonreducible [Figure 1]. There was no cough impulse. Clinical diagnosis was an incarcerated right inguinal hernia. Ultrasonography (USG) revealed an incarcerated right inguinal omentocele. CT whole abdomen also agreed with diagnosis of incarcerated right inguinal omentocele. The patient was admitted for right inguinal hernioplasty. On exploration, a right-sided indirect inguinal hernia was found with a nodule in the omentum, which was adherent to the wall of hernia sac. The nodule was excised and sent for biopsy. The nodule was 5 cm × 2.5 cm in size. Hernioplasty was done with prolene mesh after reduction of omentum. The patient was discharged next day without any complications. The histopathology report mentioned “sections show fibro-adipose tissue with marked hemorrhage and congested vessels. Focal presence of endometrial glands with stroma is seen in the fibrous tissue, negative for neoplasia. Impression was omentum-endometric deposit.” The patient was referred to a gynecologist for further evaluation.

Endometriosis is the presence of endometrial tissue out of uterus. Endometriosis can affect any organ. Pelvic endometriosis is more common than extrapelvic endometriosis. More than 80% of all the reproductive age group has an estimated prevalence of 1%–15% for endometriosis.[] Inguinal endometriosis is the presence of endometrial tissue around round ligament in the inguinal canal; it is extremely rare. The origin of endometriosis is unknown, but there are several theories to explain its pathogenesis. Vascular spread, tubal regurgitation, metaplasia of mesothelial cells, and direct extension along the round ligament from a neighboring process in the pelvis are implicated.[,] Inguinal endometriosis around round ligament was first described by Cullen in 1986. The right side is far more frequently involved (94% of the cases), while bilateral involvement is exceptional (only one case described).[] Affliction with <60 cases reported in the literature,[] and the best available estimate suggests that it may affect 0.3%–0.6% of patients with endometriosis whereas inguinal hernia sac endometriosis[] is rarest of rare. Catamenial symptoms, such as variation in size and tenderness of the mass, are present in 50% of cases and should raise the index of suspicion for inguinal endometriosis.[] Surgical excision is the treatment.[] Albutt et al. have reported a case of endometriosis within a left-sided inguinal hernia sac. Surgical excision and repair of left indirect inguinal hernia with mesh were performed.[] Radiological evaluation such as USG/CT scan/magnetic resonance imaging has been reported to help in preoperative assessment using fluctuations in tumor size with the menstrual cycle as a diagnostic aid.[] It represents a disease of specific interest to the general surgeon due to extrapelvic localization, especially the skin (umbilical scar, surgical scars), viscera (small intestine, left colon, rectum, and appendix), and the groin.[,] Sari et al. stated that “endometriosis can present a diagnostic challenge to the general surgeon…. Endometriosis should be considered in the differential diagnosis of all premenopausal women who present with umbilical swelling and pain.”[] Endometriosis should be considered when dealing with the inguinal region lump in a female patient of child-bearing age. 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.

We thank Dr. Charvi Chawla for her efforts to arrange and other information required for this research work. We are also thankful to Mr. Vipin Sharma for preparation of the manuscript.

- 1. Endometeriosis: Condition Information. 2017[Last accessed on 2019 Dec 24] Available from: http://nichd.nih.gov. - 2. Endometriosis. 2017[Last accessed on 2019 Dec 24] Available from: http://women'shealth.gov. - 3. Barbieri RL. Etiology and epidemiology of endometriosis Am J Obstet Gynecol. 1990;162:565–7 - 4. Kernal UA, Fahri Y, Mehmet Y, Ozden K, Mehmet O. Inguinal endometriosis: A report of two cases and a review of literature Turkey J Med Sci. 2000;30:389–92 - 5. Kaushik R, Gulati A. Inguinal endometriosis: A case report J Cytol. 2008;25:73–5 - 6. Candiani GB, Vercellini P, Fedele L, Vendola N, Carinelli S, Scaglione V. Inguinal endometriosis: Pathogenetic and clinical implications Obstet Gynecol. 1991;78:191–4 - 7. Albutt K, Glass C, Odom S, Gupta A. Endometriosis within a left-sided inguinal hernia sac J Surg Case Rep. 2014:2014 pii: rju046 - 8. Licheri S, Pisano G, Erdas E, Ledda S, Casu B, Cherchi MV, et al Endometriosis of the round ligament: Description of a clinical case and review of the literature Hernia. 2005;9:294–7 - 9. Miranda L, Settembre A, Capasso P, Piccolboni D, De Rosa N, Corcione F. Inguinal endometriosis or irreducible hernia? A difficult preoperative diagnosis Hernia. 2001;5:47–9 - 10. Moris D, Michalinos A, Vernadakis S. Endometriosis in a spigelian hernia sac: An unexpected finding Int Surg. 2015;100:109–11 - 11. Kirkpatrick A, Reed CM, Bui-Mansfield LT, Russell MJ, Whitford W. Radiologic-pathologic conference of Brook Army Medical Center: Endometriosis of the canal of Nuck AJR Am J Roentgenol. 2006;186:56–7 - 12. Singh KK, Lessells AM, Adam DJ, Jordan C, Miles WF, Macintyre IM, et al Presentation of endometriosis to general surgeons: A 10-year experience Br J Surg. 1995;82:1349–51 - 13. Anne H, David H, Jean-Jacques B. Endometriosis of the round ligament revealed by an intermittent hernia Gynaecoll Surg. 2006;3:295–7 - 14. Green SH, Waxman KS, Morris PL, Shadle BD Umbilical Hernia and Endometriosis: A Diagnostic Consideration. 2007 Shadle HCP Live Network