A synchronized unique presentation of inguinal hernia in infantile twins

Background Female structures such as the ovaries, fallopian tubes, ligaments, and uterus are rarely encountered inside a hernial sac. The prevalence of groin hernias containing parts of female genitalia remains unknown. Occur- rence in monozygotic twins is exceptionally uncommon and has not been reported previously. Case presentation We report a unique case of 4-month-old monozygotic female twins who presented with unilat- eral, non-reducible groin swellings. Ultrasonography confirmed herniation of ovaries and fallopian tubes in both cases. Prompt laparoscopic herniotomy using the percutaneous internal ring suturing (PIRS) technique was performed. Intraoperatively, viable adnexal structures were identified without torsion or ischemia. Both patients had uneventful postoperative recovery.The simultaneous occurrence in twins suggests a potential genetic or embryological predis- position. Prompt surgical repair is essential to avoid torsion and preserve fertility.

This is the first documented case of monozygotic twins with ovary-containing inguinal hernias. It high- lights the importance of early imaging, high clinical suspicion, and minimally invasive surgical intervention in female infants presenting with groin swellings. The simultaneous presentation in twins raises the possibility of a shared genetic or developmental predisposition, warranting further study.

Inguinal hernia, Twins, Ovary herniation, Paediatric laparoscopy, Case report

Inguinal hernia is one of the most common surgical con - ditions in infancy and childhood, with a higher incidence among premature infants due to improved neonatal sur - vival [1]. While more frequent in males, inguinal hernias in females may rarely contain adnexal structures such as the ovary, fallopian tube, or uterus [2, 3]. Ovarian hernia- tion accounts for approximately 6–7% of female paediat - ric inguinal hernias [4–6]. Clinical presentation is usually as a groin or labial swelling, which carries a risk of com - plications such as strangulation or torsion if not managed promptly. Simultaneous occurrence of ovary-containing hernias in twins is exceptionally rare. To the best of our knowledge, this is the first reported case of monozygotic twins presenting with ovary-containing inguinal hernias, raising the possibility of a shared genetic or embryologi - cal predisposition. Case presentation Two 4-month-old monozygotic female twins presented with irreducible groin swellings. Twin A: Born preterm with very low birthweight, required a 2-month neonatal intensive care unit (NICU) stay with ventilatory support. She was thriving well and presented with a right irreducible inguinal swelling (Fig. 1). Twin B: The identical twin, with the same perinatal his- tory, presented with a left irreducible inguinal swelling. Both infants were active, afebrile, and systemically well at *Correspondence: Srikanth Thiyagarajan [email protected] 1 Department of General surgery, SRM Institute of Science and Technology, Kattankulathur, India 2 Department of Paediatric Surgery, SRM Institute of Science and Technology, Kattankulathur, India Page 2 of 5Thiyagarajan et al. Egyptian Pediatric Association Gazette (2025) 73:89 admission. There was no relevant family history, comor - bidity, or similar complaints in relatives (Fig. 1). Both swellings were firm, non-reducible, and unchanged with crying, without skin changes or signs of incarceration. Irreducibility was due to ovaries and fallopian tubes being engaged within the sacs, though vascularity was preserved. Routine labs were normal. Ultrasonography confirmed ovarian tissue with follicles and omentum in the sacs, without torsion or ischemia (Figs. 2 and 3). Although present since birth, the swellings remained asymptomatic, so elective laparoscopic repair was sched - uled at 4 months once the infants were clinically stable. Intervention Both infants underwent elective laparoscopic herniotomy using the percutaneous internal ring suturing (PIRS) technique under general anaesthesia, following standard Fig. 1 Twin A with right labial swelling and Twin B with left groin swelling Fig. 2 Arrow points to a defect of size 9.4 mm seen in the right inguinal region with herniation of omental fat and right ovary Fig. 3 Arrow points to a defect of size 9 mm seen in the left inguinal region with herniation of omental fat and left ovary Page 3 of 5 Thiyagarajan et al. Egyptian Pediatric Association Gazette (2025) 73:89 preoperative evaluation and preparation. This minimally invasive approach was chosen for its safety, efficacy, and reduced postoperative morbidity in paediatric patients. Procedure The operations were performed by an experienced pae - diatric surgical team at a tertiary care centre. In Twin A, laparoscopic herniotomy was done using a 5 mm umbili - cal port; the hernial contents were reduced with gentle external pressure, and the internal ring was closed with a non-absorbable suture. In Twin B, a similar 5 mm port was created, but as the contents could not be reduced externally, an additional 3 mm working port was intro - duced for laparoscopic reduction, followed by internal ring closure. In both cases, the ovaries and fallopian tubes were viable with no evidence of torsion (Figs.  4 and 5). Postoperative care Postoperative recovery was uneventful in both infants. Feeds were resumed four hours after surgery and were well tolerated. Surgical wounds healed appropriately with no signs of infection. Both infants remained stable, active, and pain-free throughout the hospital stay. Follow‑ups and outcomes At two weeks follow-up, both infants demon - strated good wound healing with no recurrence or Fig. 4 Laparoscopic view shows right inguinal hernia with ovary herniating through the deep ring. (A) Uterus, B left fallopian tube, C right fallopian tube, circle—deep ring Fig. 5 Laparoscopic view shows left inguinal hernia with ovary herniating through deep ring. A Left fallopian tube, circle—deep ring Page 4 of 5Thiyagarajan et al. Egyptian Pediatric Association Gazette (2025) 73:89 complications. Subsequent outpatient reviews con - firmed normal growth, development, and preserved ovarian viability.

Ovary-containing inguinal hernias, though uncommon, are clinically significant due to the risk of torsion and infarction if untreated [5]. In female infants, the ovary is the most frequent organ found within the hernia sac, typically presenting as a groin or labial swelling. Most reports describe unilateral herniation; however, our case highlights the rare simultaneous occurrence in twins, not previously documented [7]. The twins were clinically identical and reported as monozygotic, though genetic confirmation was not per - formed, which is a limitation. Several embryological mechanisms may explain ovarian descent into the ingui - nal canal, including non-fusion of the Müllerian ducts, congenitally elongated ovarian ligaments, or weakness of supporting ligaments under raised intra-abdominal pres - sure [8, 9]. Ultrasonography was essential in establishing the diag - nosis and guiding timely repair, confirming ovarian tissue with preserved vascularity [10]. Although open repair remains the standard, we used laparoscopic herniotomy with the percutaneous internal ring suturing (PIRS) tech- nique, which provided excellent visualization and favora - ble cosmetic outcomes in these infants. The simultaneous occurrence in twins suggests a pos - sible genetic predisposition. Population-based studies support a familial link, showing higher hernia risk in children with affected parents or siblings, particularly between mothers and daughters [11, 12]. Similar clus - tering has been observed in adults, further suggesting a hereditary component. Although genetic testing was not performed in our patients, future cases would benefit from genetic evalu - ation to clarify the role of heredity and connective tissue development in hernia formation.

Ovary-containing inguinal hernias are uncommon but clinically important due to the risk of torsion and loss of ovarian viability. This case represents the first reported occurrence in monozygotic twins, suggesting a possible genetic or embryological predisposition. Although our patients remained stable and were managed electively at 4 months, timely recognition and repair are essential to prevent complications. Genetic evaluation, though not performed here, should be considered in future cases to better define potential hereditary factors. Supplementary Information The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s43054- 025- 00438-8. Supplementary Material 1.

The authors would like to express their sincere gratitude to the entire Paediatric Surgery team for their unwavering dedication, expertise, and compassionate care provided to the patients throughout the course of this study. The authors deeply appreciate the team’s role not only in delivering high-quality patient care but also in supporting the broader goals of this research endeavour. Authors’ contributions Analysis and interpretation: all authors Writing original draft: all authors Review & editing: all authors Final approval of the article: all authors. Funding No funding received. Data availability No datasets were generated or analysed during the current study. Declarations Ethics approval and consent to participate Written consent for the publication of this case report was obtained from the patient. Approval for case report by the institutional ethics committee is not required. Consent for publication Written informed consent for the publication of this case report and for the accompanying images was obtained from the patient. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Competing interests The authors declare no competing interests. Received: 19 July 2025 Accepted: 4 September 2025

1. Kapur P , Caty MG, Glick PL (1998) Pediatric hernias and hydroceles. Pediatr Clin North Am 45:773–789 2. Ravi K, Hamer DB (2003) Surgical treatment of inguinal hernia in children. Hernia 7:137–140 3. Okada T, Sasaki S, Honda S et al (2012) Irreducible indirect inguinal hernia containing uterus, ovaries, and fallopian tubes. Hernia 16:471–473 4. Lee J, Scampoli N (2015) Incarcerated ovarian inguinal hernia in a 10-month-old girl. CMAJ 187:596–598 5. Josefsson ML, Mitra S, Gupta S (2013) Inguinal ovary in adult women– case report and literature review. Springerplus 2(1):545 6. Heineck AP (1912) Hernias of the ovary, of the fallopian tube, and of the ovary and the fallopian tube: An analytical review of all undoubted cases of this nature reported in the French, German, and English medical lit- erature from 1890 to 1910, inclusive, with a report of unpublished cases. Surg Gynecol Obstet 15:63–71 7. Prodromidou A, Machairas N, Garoufalia Z, Kostakis ID, Kyriakidis AV, Spartalis E, Sotiropoulos GC (2020) Ovarian inguinal hernia. Ann R Coll Surg Engl 102(2):75–83. https:// doi. org/ 10. 1308/ rcsann. 2019. 0137 8. Thomson GR (1948) Complete congenital absence of the vagina associated with bilateral hernia of uterus, tubes, and ovaries. Br J Surg 36:99–100 Page 5 of 5 Thiyagarajan et al. Egyptian Pediatric Association Gazette (2025) 73:89 9. Fowler CL (2005) Sliding indirect hernia containing both ovaries. J Pediatr Surg 40:e13–e14 10. Bijnens E, Broeckx J, Hoffbauer R et al (1992) Sonographic diagnosis of an incarcerated inguinal hernia containing uterus and left adnexa. J Ultrasound Med 11:249–250 11. Öberg S, Sæter AH, Rosenberg J (2023) The inheritance of groin hernias: an updated systematic review with meta-analyses. Hernia 27(6):1339– 1350. https:// doi. org/ 10. 1007/ s10029- 022- 02718-3 12. Burcharth J, Pedersen M, Bisgaard T, Pedersen CB, Rosenberg J (2017) Familial clustering and risk of groin hernia in children. BJS Open 1:46–49. https:// doi. org/ 10. 1002/ bjs5 Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations.