Primary suprapubic hernia containing epiploic appendages mimicking an inguinal hernia in a postmenopausal woman

Primary suprapubic hernia containing epiploic appendages mimicking an inguinal hernia in a postmenopausal woman | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Primary suprapubic hernia containing epiploic appendages mimicking an inguinal hernia in a postmenopausal woman SRIKANTH THIYAGARAJAN, SIVAMARIESWARAN R, ABHISHEK REJI This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8434611/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Primary suprapubic hernias are exceptionally rare, particularly in women without prior pelvic or lower abdominal surgery. Owing to their close anatomical relationship to the inguinal region, these hernias may clinically and radiologically mimic inguinal hernias. Small suprapubic defects, especially those containing soft tissue such as fat or epiploic appendages, may remain occult on preoperative imaging. Case presentation: A 60-year-old woman presented with a left inguinal swelling that was clinically consistent with a direct inguinal hernia. Computed tomography (CT) imaging confirmed the inguinal hernia but did not reveal any suprapubic defect. During laparoscopic transabdominal preperitoneal (TAPP) repair, an unexpected primary suprapubic hernia containing epiploic appendages of the sigmoid colon was identified. Defect was reduced and repaired using a 3D Prolene mesh covering the entire myopectineal orifice. Postoperative recovery was uneventful, and follow-up demonstrated excellent functional and cosmetic outcomes without recurrence. Conclusion This case underscores that primary suprapubic hernias in women can closely mimic inguinal hernias and may be missed on preoperative imaging. Laparoscopic TAPP repair allows accurate intraoperative identification of occult defects and facilitates comprehensive anatomical repair with favorable outcomes. Suprapubic hernia Primary ventral hernia Inguinal hernia Epiploic appendages Laparoscopic TAPP repair Postmenopausal women case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Background Hernias in the suprapubic region are a rare subset of abdominal wall hernias. Most reported cases follow previous pelvic or lower abdominal surgery, such as midline laparotomy, suprapubic catheterization, or prostatectomy [ 1 ]. In contrast, true primary suprapubic hernias occurring in “virgin” abdomens without any prior surgical intervention are exceptionally uncommon. Their development is attributed to factors such as age-related weakening of fascial structures, postmenopausal connective tissue degeneration, chronic increases in intra-abdominal pressure (e.g., from multiparity or straining), obesity, and generalized fascial laxity. Anatomically, suprapubic hernias develop deep within the pelvis, in close proximity to the pubic symphysis, urinary bladder, and the space of Retzius. Owing to this location, they often produce subtle, atypical, or nonspecific symptoms and may evade detection on routine clinical examination. When the defect lies close to the inguinal floor or tracks superiorly or medially, a suprapubic hernia can closely mimic an inguinal hernia, leading to clinical misinterpretation. This diagnostic challenge is further amplified when the hernia sac contains soft tissue elements such as omentum, preperitoneal fat, or epiploic appendages which may be indistinguishable from surrounding pelvic adipose tissue on cross-sectional imaging. As a result, even advanced modalities such as computed tomography or magnetic resonance imaging may fail to identify these defects preoperatively [ 2 – 5 ]. Although isolated case reports have described supravesical or suprapubic hernias being misdiagnosed as inguinal hernias [ 2 – 4 , 6 ], reports of a true primary suprapubic hernia containing epiploic appendages are exceedingly rare. The presence of epiploic appendages as hernia content is unusual and adds to the diagnostic complexity, as their soft, fatty consistency may contribute to a misleading clinical impression of an inguinal hernia. This case therefore represents a rare and distinctive presentation, expanding the existing spectrum of suprapubic hernias and highlighting an important diagnostic pitfall. Case Presentation A 60‑year-old postmenopausal woman presented to our surgical outpatient department with a gradually enlarging swelling in the left groin region, associated with mild discomfort on exertion. Her past medical and surgical history was unremarkable, with no prior abdominal or pelvic surgeries, trauma, chronic cough, constipation, urinary symptoms, or weight loss. On physical examination, a 3 × 3 cm irreducible, soft, doughy mass with a positive cough impulse was palpated in the left inguinal area (Fig. 1 ). No other abdominal or pelvic masses were detected. Routine laboratory investigations were within normal limits. Contrast-enhanced CT of the abdomen and pelvis revealed a left inguinal hernia. No suprapubic, supravesical, or other abdominal wall defect was identified (Figs. 2 and 3 ), leading to preoperative interpretation of the swelling as a direct inguinal hernia. The patient underwent laparoscopic TAPP repair. After establishing pneumoperitoneum and dissecting the peritoneal flap, the deep inguinal ring and surrounding structures were identified. Careful inspection of the preperitoneal space revealed a separate defect, located inferior and medial to the inguinal floor: a suprapubic hernia measuring approximately 2 × 1.5 cm. The hernial sac contained epiploic appendages of the sigmoid colon, which corresponded to the doughy consistency noted on clinical examination (Fig. 4 A and B). The suprapubic hernia sac was carefully dissected and fully reduced laparoscopically without difficulty or injury (Fig. 5 C and D). Once reduction was complete, the preperitoneal space was adequately exposed to cover the entire myopectineal orifice, extending medially to Cooper’s ligament and anteriorly to the abdominal wall to ensure coverage of both defects (Fig. 6 E and F). A 3D Prolene mesh was deployed over the myopectineal orifice, securely fixed to Cooper’s ligament and anterior abdominal wall, and the peritoneal flap was closed (Fig. 7 ). Postoperatively, the patient recovered without complications and was discharged on the second postoperative day. At follow-up, she remained asymptomatic with no signs of recurrence and reported satisfaction with the cosmetic and functional outcome. Discussion Primary suprapubic hernias, also referred to as supravesical hernias, are rare abdominal wall defects that typically occur after lower abdominal or pelvic surgery, including midline laparotomy, prostatectomy, or suprapubic catheter placement [ 1 – 3 ]. True primary suprapubic hernias arising in “virgin” abdomens are exceedingly uncommon. Risk factors include postmenopausal connective tissue weakening, age-related fascial attenuation, multiparity, chronic increases in intra-abdominal pressure, and obesity factors that are particularly relevant in older women [ 4 – 6 ]. Because of their deep location within the preperitoneal space bounded anteriorly by the rectus abdominis muscle, inferiorly by the pubic symphysis, and posteriorly by the space of Retzius suprapubic hernias may remain clinically occult or present with atypical symptoms [ 2 , 5 ]. When these defects are situated close to the inguinal floor or extend superiorly or medially, they can closely mimic inguinal hernias on both clinical examination and radiological assessment. As demonstrated in the present case, preoperative imaging, including contrast-enhanced computed tomography, may fail to identify small suprapubic defects, particularly when the hernia content consists of soft tissue such as omentum or epiploic appendages, which may blend with surrounding preperitoneal fat [ 6 – 8 ]. The uniqueness of this case lies in the presence of epiploic appendages of the sigmoid colon within a primary suprapubic hernia sac an exceptionally rare finding. Epiploic appendages are fat-filled peritoneal structures arising from the serosal surface of the colon, and their herniation outside typical inguinal or incisional hernias has only rarely been described [ 9 – 11 ]. In this patient, the soft, doughy consistency of the epiploic appendages contributed to the clinical misinterpretation of the swelling as an direct inguinal hernia, underscoring the diagnostic challenge posed by such atypical presentations. From a surgical standpoint, laparoscopic transabdominal TAPP repair offers significant advantages in managing these rare and deceptive hernias. The panoramic laparoscopic view allows comprehensive visualization of the myopectineal orifice, accurate differentiation between inguinal and suprapubic defects, and safe reduction of unusual hernia contents, including epiploic appendages [12–14]. Furthermore, meticulous preperitoneal dissection and placement of a three-dimensional mesh covering the entire myopectineal orifice, with secure fixation to Cooper’s ligament and the anterior abdominal wall, ensures reinforcement of all potential weak zones and minimizes the risk of recurrence. In contrast, open anterior approaches may fail to adequately expose suprapubic defects, increasing the likelihood of missed or incomplete repair. This case also highlights the limitations of preoperative imaging in the evaluation of groin swellings and reinforces the importance of maintaining a high index of suspicion for concealed suprapubic hernias, even in patients without prior surgical history. Particular attention should be paid to atypical clinical features, such as unusual consistency or location of the swelling, especially in postmenopausal women. Recognition of epiploic appendages as potential hernia contents is essential to avoid inadvertent injury during reduction and to ensure complete anatomical repair. In summary, this report contributes to the limited body of literature on primary suprapubic hernias by describing a rare and previously underreported presentation a primary suprapubic hernia containing epiploic appendages of the sigmoid colon, clinically and radiologically misinterpreted as an direct inguinal hernia, and successfully managed with laparoscopic TAPP repair. Conclusion Primary suprapubic hernias in women without prior pelvic or lower abdominal surgery are exceptionally rare and may clinically and radiologically mimic inguinal hernias. The presence of epiploic appendages as hernia content further complicates diagnosis due to their soft-tissue characteristics, which may obscure detection on preoperative imaging. This case highlights the importance of maintaining a high index of suspicion for concealed suprapubic hernias in postmenopausal women presenting with atypical groin swellings. Laparoscopic TAPP repair allows precise intraoperative identification of occult defects and facilitates comprehensive anatomical repair with favorable functional and cosmetic outcomes. Increased awareness of this rare entity is essential to improve diagnostic accuracy and optimize surgical management in women. Declarations Ethics approval and accordance: The requirement for ethical approval was waived by the Institutional Ethics Committee of SRM Medical College Hospital and Research Centre, as this study involved a single case report; therefore, protocol approval was also waived in accordance with institutional guidelines. Consent to participate: Informed consent was obtained from the patient for participation in this study. Consent to publish: Informed consent was obtained from the patient for publication. Data availability: All data generated or analyzed during this study are included in this published article. Competing interests: The authors declare no competing interests. Funding: No external funding was received. Clinical trial number: Clinical trial number: not applicable. Authors’ contributions: Author A: Drafted the manuscript. Author B: Managed clinical and surgical care. Author C: Managed clinical and surgical care All authors have read and approved the final manuscript. Acknowledgements: The authors would like to express their sincere gratitude to the entire 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. The authors gratefully acknowledge the financial support by “SRM Medical College Hospital and Research Centre, Faculty of medicine and health sciences, SRMIST, kattankulathur, for bearing the cost of publishing this article. References Watanabe Y, Kobayashi Y, Kikuchi D, Nakayama K, Urazumi K, Takenoshita S. A case of internal supravesical hernia with difficulties in making diagnosis preoperatively. Jpn J Surg Assoc. 2013;74(5):1408–12. Shyam DC. Primary supravesical hernia presented as direct inguinal hernia with an unusual internal opening – a case report. Asian J Case Rep Surg. 2019;2(1):25–8. Ghali MS, Shehata MS, Al Obahi M, Al–Zoubi RM, Zarour A. Uncommon presentation of complicated internal hernia through the appendices epiploicae ring of adhesion: a clinical case study. Front Surg. 2024;10:1288369. McArthur C, McArthur D. Epiploic appendagitis in a femoral hernia: a case report. Radiol Case Rep. 2019;13(5):10–4. Kulacoglu H, Tumer H, Aktimur R, Kusdemir A. Internal hernia caused by epiploic appendices successfully treated by laparoscopic surgery. Hernia. 2015;19(6):1011–3. Jain M, Khanna S, Sen B, Tantia O. Irreducible inguinal hernia with appendices epiploicae in the sac. J Minim Access Surg. 2008;4(3):85–7. Rudraiah HGM, Davis B. An unusual case of intestinal obstruction due to internal herniation of distal ileum through a rent between adhered inflamed vermiform appendix and appendices epiploicae. Int Surg J. 2021;8(12):3741–4. Nagula MR, Joshi AS. Acute small bowel obstruction due to entrapment under appendices epiploicae tourniquet – laparoscopic management. Int J Recent Surg Med Sci. 2024;10:134–7. Aboalsamh A, Bassi Y, Alhabib RK, et al. Internal hernia following laparoendoscopic single site surgery: a case report. BMC Nephrol. 2024;25:395. Cho MS, Hwang-Bo S, Choi UY, Kim HS, Hahn SH. Epiploic appendagitis: CT findings and clinical features. Abdom Imaging. 2014;39(2):364–70. Burkhardt JH, Arshansky Y, Munson JL, Scholz FJ. Diagnosis of inguinal region hernias on axial CT: the lateral crescent sign and other key findings. Radiographics. 2011;31(2):E1–12. Hess A, Puylaert JBCM. Primary epiploic appendagitis: clinical, ultrasound, and CT findings in 14 patients. Eur Radiol. 1994;4(7):715–22. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 23 Jan, 2026 Reviews received at journal 21 Jan, 2026 Reviewers agreed at journal 20 Jan, 2026 Reviews received at journal 20 Jan, 2026 Reviewers agreed at journal 20 Jan, 2026 Reviews received at journal 20 Jan, 2026 Reviewers agreed at journal 20 Jan, 2026 Reviewers invited by journal 20 Jan, 2026 Editor assigned by journal 20 Jan, 2026 Editor invited by journal 19 Jan, 2026 Submission checks completed at journal 07 Jan, 2026 First submitted to journal 07 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8434611","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":578387050,"identity":"76dce6f1-7105-47cd-bd51-1b92e90a6d3b","order_by":0,"name":"SRIKANTH THIYAGARAJAN","email":"","orcid":"","institution":"SRM Institute of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"SRIKANTH","middleName":"","lastName":"THIYAGARAJAN","suffix":""},{"id":578387051,"identity":"fe9f0dcb-f72c-494d-8330-98c29c16fffc","order_by":1,"name":"SIVAMARIESWARAN 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07:11:50","extension":"html","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":48065,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8434611/v1/36b8dd923f39b7dd93d97913.html"},{"id":100929007,"identity":"7edac5ed-4f3c-49fc-979a-2b5a0f0e3722","added_by":"auto","created_at":"2026-01-23 00:33:14","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":210174,"visible":true,"origin":"","legend":"\u003cp\u003eClinical photograph showing a 3 × 3 cm irreducible, soft, doughy swelling in the left groin, initially interpreted as a direct inguinal hernia.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8434611/v1/d10800c198c8da9193e3dbbd.jpeg"},{"id":100952158,"identity":"bf52d6d6-0b65-44c8-a9f5-223be95cddb5","added_by":"auto","created_at":"2026-01-23 07:12:05","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":170049,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative contrast-enhanced CT scan (coronal view) confirming the left inguinal hernia (white arrow). The suprapubic region appears normal, highlighting the limitation of imaging in detecting concealed defects.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8434611/v1/317af7bf01315a8b8a588b3a.jpeg"},{"id":100950902,"identity":"f17d8987-e945-4904-a92f-6eba570d3b1e","added_by":"auto","created_at":"2026-01-23 07:09:29","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":121550,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative contrast-enhanced CT scan (axial view) showing the left inguinal hernia (white arrow). The underlying suprapubic defect was not identified, illustrating preoperative misinterpretation.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8434611/v1/0eb183be5fe442c2c318eef7.jpeg"},{"id":100929009,"identity":"97407a6d-f795-43ab-bd76-f79977b7a10a","added_by":"auto","created_at":"2026-01-23 00:33:14","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":91076,"visible":true,"origin":"","legend":"\u003cp\u003eA : Intraoperative laparoscopic view showing the true suprapubic hernia defect (white arrow, approx. 2 × 1.5 cm) located medial to the inguinal floor and superior to the pubic symphysis, previously misdiagnosed as an direct inguinal hernia. Also shown are the deep inguinal ring (black arrow), inferior epigastric artery (red arrow), and gonadal vessels (blue arrow).4B : Hernial sac contents of the suprapubic hernia showing epiploic appendages of the sigmoid colon, explaining the doughy consistency that mimicked an inguinal hernia.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8434611/v1/20b35ffc1a0620445da417cd.jpeg"},{"id":100950884,"identity":"73c8ce9e-7345-41af-9075-ad5c44f1dfc6","added_by":"auto","created_at":"2026-01-23 07:09:27","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":74570,"visible":true,"origin":"","legend":"\u003cp\u003eC: Laparoscopic view after careful dissection of the suprapubic hernia sac, prior to reduction.Figure 5D: Complete laparoscopic reduction of epiploic appendages from the suprapubic hernia sac , demonstrating safe content reduction.\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8434611/v1/64b3aa38b89e423bbde957fd.jpeg"},{"id":100929011,"identity":"b3ad7f48-61de-4b4c-9edd-ad4e64cdba14","added_by":"auto","created_at":"2026-01-23 00:33:15","extension":"jpeg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":100784,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative laparoscopic views after complete reduction. (E) Preperitoneal view following reduction of suprapubic hernia contents.(F) Final prepared preperitoneal space ready for mesh placement. Black arrow points at the deep ring and white arrow points at suprapubic hernia defect.\u003c/p\u003e","description":"","filename":"floatimage6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8434611/v1/8e0af65dd792018f3fcd1553.jpeg"},{"id":100952159,"identity":"4dcf9e7b-d72c-40e5-935a-7178c4355554","added_by":"auto","created_at":"2026-01-23 07:12:05","extension":"jpeg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":53611,"visible":true,"origin":"","legend":"\u003cp\u003eFinal intraoperative laparoscopic view after placement of 3D Prolene mesh covering the entire myopectineal orifice, fixed to Cooper’s ligament and anterior abdominal wall , with closure of the peritoneal flap.\u003c/p\u003e","description":"","filename":"floatimage7.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8434611/v1/07c5deb9f3715fa6b79422a8.jpeg"},{"id":101298902,"identity":"c5bd7e60-bda9-450f-9771-2bf694317a43","added_by":"auto","created_at":"2026-01-28 09:37:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1201995,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8434611/v1/a8d1c5c6-3c05-4f01-ae1a-014794b828c1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Primary suprapubic hernia containing epiploic appendages mimicking an inguinal hernia in a postmenopausal woman","fulltext":[{"header":"Background","content":"\u003cp\u003eHernias in the suprapubic region are a rare subset of abdominal wall hernias. Most reported cases follow previous pelvic or lower abdominal surgery, such as midline laparotomy, suprapubic catheterization, or prostatectomy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In contrast, true primary suprapubic hernias occurring in \u0026ldquo;virgin\u0026rdquo; abdomens without any prior surgical intervention are exceptionally uncommon. Their development is attributed to factors such as age-related weakening of fascial structures, postmenopausal connective tissue degeneration, chronic increases in intra-abdominal pressure (e.g., from multiparity or straining), obesity, and generalized fascial laxity.\u003c/p\u003e \u003cp\u003eAnatomically, suprapubic hernias develop deep within the pelvis, in close proximity to the pubic symphysis, urinary bladder, and the space of Retzius. Owing to this location, they often produce subtle, atypical, or nonspecific symptoms and may evade detection on routine clinical examination. When the defect lies close to the inguinal floor or tracks superiorly or medially, a suprapubic hernia can closely mimic an inguinal hernia, leading to clinical misinterpretation. This diagnostic challenge is further amplified when the hernia sac contains soft tissue elements such as omentum, preperitoneal fat, or epiploic appendages which may be indistinguishable from surrounding pelvic adipose tissue on cross-sectional imaging. As a result, even advanced modalities such as computed tomography or magnetic resonance imaging may fail to identify these defects preoperatively [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough isolated case reports have described supravesical or suprapubic hernias being misdiagnosed as inguinal hernias [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], reports of a true primary suprapubic hernia containing epiploic appendages are exceedingly rare. The presence of epiploic appendages as hernia content is unusual and adds to the diagnostic complexity, as their soft, fatty consistency may contribute to a misleading clinical impression of an inguinal hernia. This case therefore represents a rare and distinctive presentation, expanding the existing spectrum of suprapubic hernias and highlighting an important diagnostic pitfall.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 60‑year-old postmenopausal woman presented to our surgical outpatient department with a gradually enlarging swelling in the left groin region, associated with mild discomfort on exertion. Her past medical and surgical history was unremarkable, with no prior abdominal or pelvic surgeries, trauma, chronic cough, constipation, urinary symptoms, or weight loss.\u003c/p\u003e \u003cp\u003eOn physical examination, a 3 \u0026times; 3 cm irreducible, soft, doughy mass with a positive cough impulse was palpated in the left inguinal area (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). No other abdominal or pelvic masses were detected. Routine laboratory investigations were within normal limits. Contrast-enhanced CT of the abdomen and pelvis revealed a left inguinal hernia. No suprapubic, supravesical, or other abdominal wall defect was identified (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), leading to preoperative interpretation of the swelling as a direct inguinal hernia.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient underwent laparoscopic TAPP repair. After establishing pneumoperitoneum and dissecting the peritoneal flap, the deep inguinal ring and surrounding structures were identified. Careful inspection of the preperitoneal space revealed a separate defect, located inferior and medial to the inguinal floor: a suprapubic hernia measuring approximately 2 \u0026times; 1.5 cm. The hernial sac contained epiploic appendages of the sigmoid colon, which corresponded to the doughy consistency noted on clinical examination (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA and B).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe suprapubic hernia sac was carefully dissected and fully reduced laparoscopically without difficulty or injury (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eC and D). Once reduction was complete, the preperitoneal space was adequately exposed to cover the entire myopectineal orifice, extending medially to Cooper\u0026rsquo;s ligament and anteriorly to the abdominal wall to ensure coverage of both defects (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eE and F). A 3D Prolene mesh was deployed over the myopectineal orifice, securely fixed to Cooper\u0026rsquo;s ligament and anterior abdominal wall, and the peritoneal flap was closed (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePostoperatively, the patient recovered without complications and was discharged on the second postoperative day. At follow-up, she remained asymptomatic with no signs of recurrence and reported satisfaction with the cosmetic and functional outcome.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePrimary suprapubic hernias, also referred to as supravesical hernias, are rare abdominal wall defects that typically occur after lower abdominal or pelvic surgery, including midline laparotomy, prostatectomy, or suprapubic catheter placement [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. True primary suprapubic hernias arising in \u0026ldquo;virgin\u0026rdquo; abdomens are exceedingly uncommon. Risk factors include postmenopausal connective tissue weakening, age-related fascial attenuation, multiparity, chronic increases in intra-abdominal pressure, and obesity factors that are particularly relevant in older women [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBecause of their deep location within the preperitoneal space bounded anteriorly by the rectus abdominis muscle, inferiorly by the pubic symphysis, and posteriorly by the space of Retzius suprapubic hernias may remain clinically occult or present with atypical symptoms [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. When these defects are situated close to the inguinal floor or extend superiorly or medially, they can closely mimic inguinal hernias on both clinical examination and radiological assessment. As demonstrated in the present case, preoperative imaging, including contrast-enhanced computed tomography, may fail to identify small suprapubic defects, particularly when the hernia content consists of soft tissue such as omentum or epiploic appendages, which may blend with surrounding preperitoneal fat [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe uniqueness of this case lies in the presence of epiploic appendages of the sigmoid colon within a primary suprapubic hernia sac an exceptionally rare finding. Epiploic appendages are fat-filled peritoneal structures arising from the serosal surface of the colon, and their herniation outside typical inguinal or incisional hernias has only rarely been described [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In this patient, the soft, doughy consistency of the epiploic appendages contributed to the clinical misinterpretation of the swelling as an direct inguinal hernia, underscoring the diagnostic challenge posed by such atypical presentations.\u003c/p\u003e \u003cp\u003eFrom a surgical standpoint, laparoscopic transabdominal TAPP repair offers significant advantages in managing these rare and deceptive hernias. The panoramic laparoscopic view allows comprehensive visualization of the myopectineal orifice, accurate differentiation between inguinal and suprapubic defects, and safe reduction of unusual hernia contents, including epiploic appendages [12\u0026ndash;14]. Furthermore, meticulous preperitoneal dissection and placement of a three-dimensional mesh covering the entire myopectineal orifice, with secure fixation to Cooper\u0026rsquo;s ligament and the anterior abdominal wall, ensures reinforcement of all potential weak zones and minimizes the risk of recurrence. In contrast, open anterior approaches may fail to adequately expose suprapubic defects, increasing the likelihood of missed or incomplete repair.\u003c/p\u003e \u003cp\u003eThis case also highlights the limitations of preoperative imaging in the evaluation of groin swellings and reinforces the importance of maintaining a high index of suspicion for concealed suprapubic hernias, even in patients without prior surgical history. Particular attention should be paid to atypical clinical features, such as unusual consistency or location of the swelling, especially in postmenopausal women. Recognition of epiploic appendages as potential hernia contents is essential to avoid inadvertent injury during reduction and to ensure complete anatomical repair.\u003c/p\u003e \u003cp\u003eIn summary, this report contributes to the limited body of literature on primary suprapubic hernias by describing a rare and previously underreported presentation a primary suprapubic hernia containing epiploic appendages of the sigmoid colon, clinically and radiologically misinterpreted as an direct inguinal hernia, and successfully managed with laparoscopic TAPP repair.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePrimary suprapubic hernias in women without prior pelvic or lower abdominal surgery are exceptionally rare and may clinically and radiologically mimic inguinal hernias. The presence of epiploic appendages as hernia content further complicates diagnosis due to their soft-tissue characteristics, which may obscure detection on preoperative imaging. This case highlights the importance of maintaining a high index of suspicion for concealed suprapubic hernias in postmenopausal women presenting with atypical groin swellings. Laparoscopic TAPP repair allows precise intraoperative identification of occult defects and facilitates comprehensive anatomical repair with favorable functional and cosmetic outcomes. Increased awareness of this rare entity is essential to improve diagnostic accuracy and optimize surgical management in women.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and accordance:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe requirement for ethical approval was waived by the Institutional Ethics Committee of SRM Medical College Hospital and Research Centre, as this study involved a single case report; therefore, protocol approval was also waived in accordance with institutional guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Informed consent was obtained from the patient for participation in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Informed consent was obtained from the patient for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this\u003c/p\u003e\n\u003cp\u003epublished article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthor A: Drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eAuthor B: Managed clinical and surgical care.\u003c/p\u003e\n\u003cp\u003eAuthor C: Managed clinical and surgical care\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their sincere gratitude to the entire 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. The authors gratefully acknowledge the financial support by “SRM Medical College Hospital and Research Centre, Faculty of medicine and health sciences, SRMIST, kattankulathur, for bearing the cost of publishing this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWatanabe Y, Kobayashi Y, Kikuchi D, Nakayama K, Urazumi K, Takenoshita S. A case of internal supravesical hernia with difficulties in making diagnosis preoperatively. Jpn J Surg Assoc. 2013;74(5):1408\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShyam DC. Primary supravesical hernia presented as direct inguinal hernia with an unusual internal opening \u0026ndash; a case report. Asian J Case Rep Surg. 2019;2(1):25\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhali MS, Shehata MS, Al Obahi M, Al\u0026ndash;Zoubi RM, Zarour A. Uncommon presentation of complicated internal hernia through the appendices epiploicae ring of adhesion: a clinical case study. Front Surg. 2024;10:1288369.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcArthur C, McArthur D. Epiploic appendagitis in a femoral hernia: a case report. Radiol Case Rep. 2019;13(5):10\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKulacoglu H, Tumer H, Aktimur R, Kusdemir A. Internal hernia caused by epiploic appendices successfully treated by laparoscopic surgery. Hernia. 2015;19(6):1011\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJain M, Khanna S, Sen B, Tantia O. Irreducible inguinal hernia with appendices epiploicae in the sac. J Minim Access Surg. 2008;4(3):85\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRudraiah HGM, Davis B. An unusual case of intestinal obstruction due to internal herniation of distal ileum through a rent between adhered inflamed vermiform appendix and appendices epiploicae. Int Surg J. 2021;8(12):3741\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNagula MR, Joshi AS. Acute small bowel obstruction due to entrapment under appendices epiploicae tourniquet \u0026ndash; laparoscopic management. Int J Recent Surg Med Sci. 2024;10:134\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAboalsamh A, Bassi Y, Alhabib RK, et al. Internal hernia following laparoendoscopic single site surgery: a case report. BMC Nephrol. 2024;25:395.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCho MS, Hwang-Bo S, Choi UY, Kim HS, Hahn SH. Epiploic appendagitis: CT findings and clinical features. Abdom Imaging. 2014;39(2):364\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurkhardt JH, Arshansky Y, Munson JL, Scholz FJ. Diagnosis of inguinal region hernias on axial CT: the lateral crescent sign and other key findings. Radiographics. 2011;31(2):E1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHess A, Puylaert JBCM. Primary epiploic appendagitis: clinical, ultrasound, and CT findings in 14 patients. Eur Radiol. 1994;4(7):715\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Suprapubic hernia, Primary ventral hernia, Inguinal hernia, Epiploic appendages, Laparoscopic TAPP repair, Postmenopausal women, case report","lastPublishedDoi":"10.21203/rs.3.rs-8434611/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8434611/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePrimary suprapubic hernias are exceptionally rare, particularly in women without prior pelvic or lower abdominal surgery. Owing to their close anatomical relationship to the inguinal region, these hernias may clinically and radiologically mimic inguinal hernias. Small suprapubic defects, especially those containing soft tissue such as fat or epiploic appendages, may remain occult on preoperative imaging.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eA 60-year-old woman presented with a left inguinal swelling that was clinically consistent with a direct inguinal hernia. Computed tomography (CT) imaging confirmed the inguinal hernia but did not reveal any suprapubic defect. During laparoscopic transabdominal preperitoneal (TAPP) repair, an unexpected primary suprapubic hernia containing epiploic appendages of the sigmoid colon was identified. Defect was reduced and repaired using a 3D Prolene mesh covering the entire myopectineal orifice. Postoperative recovery was uneventful, and follow-up demonstrated excellent functional and cosmetic outcomes without recurrence.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis case underscores that primary suprapubic hernias in women can closely mimic inguinal hernias and may be missed on preoperative imaging. Laparoscopic TAPP repair allows accurate intraoperative identification of occult defects and facilitates comprehensive anatomical repair with favorable outcomes.\u003c/p\u003e","manuscriptTitle":"Primary suprapubic hernia containing epiploic appendages mimicking an inguinal hernia in a postmenopausal woman","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-23 00:33:10","doi":"10.21203/rs.3.rs-8434611/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-23T06:17:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-21T17:08:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22937424644904645213661494146223186537","date":"2026-01-20T18:13:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-20T09:50:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"243696696176264003323366472486272761341","date":"2026-01-20T09:43:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-20T09:11:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304022546186461353776123074974956818075","date":"2026-01-20T09:06:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-20T06:52:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-20T06:30:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-19T06:46:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-07T15:28:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Medicine","date":"2026-01-07T15:23:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8284dcac-14f5-49ee-9122-487b86175b9c","owner":[],"postedDate":"January 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T09:10:47+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-23 00:33:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8434611","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8434611","identity":"rs-8434611","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}