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European Journal of Radiology Open 3 (2016) 35–37
Contents lists available at ScienceDirect
European Journal of Radiology Open

journal homepage: www.elsevier.com/locate/ejro
Rarity in conspicuity—Ultrasound diagnosis of sliding left inguinal

hernia through canal of Nuck with uterus, fallopian tubes and ovaries
Sreekumar Muthiyal a,∗ , Vishwanatha Kini a , Avin Kounsal a , Ashraf Abdelhamid Ibrahim b
a
Dept. of Radiology, Hamad General Hospital, Doha, Qatar
b
Dept. of Paediatric Surgery, Hamad General Hospital, Doha, Qatar
a r t i c l e i n f o a b s t r a c t
Article history: We present a case of a one month old female infant who presented with left inguinal swelling. She was
Received 18 December 2015 prematurely born at 32 weeks of gestational age. Preoperative ultrasound showed features of sliding
Received in revised form 18 January 2016 indirect inguinal hernia with both ovaries, fallopian tubes and uterus; which were also evident per oper-
Accepted 20 January 2016
atively. Patient underwent successful hernia repair and uneventful post-operative period. Patient is on
Available online 10 February 2016
follow up currently. In conclusion, we attempt to highlight the exiguous prevalence of inguinal hernia
with uterus, fallopian tubes and ovaries; which has been sparsely reported in the literature and also the
Keywords:
importance of preoperative of sonography.
Sliding inguinal hernia
Canal of Nuck © 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
Uterus license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Ovaries fallopian tube
1. Introduction 2. Case report
Inguinal hernias are the most common causes of inguinal masses A 1-month-old female infant was referred to the pediatric
in infants, with incidence rates of 0.8–4.4%. Inguinal hernias occur, surgery clinic for left inguinal swelling. Clinical examination
even as many as 6 times, more often in male than in female infants. showed a partially reducible, mobile mass in her left groin that
Prematurity increases the incidence of inguinal hernias from 7% to appeared larger while crying or straining. There was no history
17%. Inguinal hernias are right sided in approximately 60% of cases, of persistent irritability or vomiting. She is one of the twins; pre-
left sided in 30%, and bilateral in 10% [3,5]. A female infant with maturely born at 31 weeks 6 days of gestational age; having low
an inguinal hernia should be thoroughly evaluated to determine birth weight. Because an inguinal sliding hernia was suspected,
whether contents are having ovaries or not because the ovaries sonography was performed using a high frequency (10 MHz) lin-
are at increased risk of incarceration and subsequent infarction. ear transducer. Ultrasonography exquisitely demonstrated a left
Ultrasonography with a high-frequency transducer is the imag- inguinal hernia which contained uterus, fallopian tubes and ovaries
ing modality of choice for evaluating the inguinal lesion because Figs. 1 and 2. On color Doppler, there was preserved vascularity in
it clearly has the ability to evaluate, characterize, and differentiate the ovaries Fig. 3. No features of herniation of bowel loops was seen.
these conditions. [2,5]. We describe such a case to demonstrate Patient underwent surgical exploration at 1 month of age. It
the sonological characteristics and emphasize the relevance of conﬁrmed the preoperative diagnosis of a sliding inguinal hernia
knowledge about the exiguous prevalence of this condition in the containing a healthy-appearing uterus, fallopian tube and ovaries.
premature infant; which are essential for timely detection and The hernial contents could be easily reduced, and high ligation of
prompt management. the hernia sac was performed. Post-operative period was unevent-
ful and currently she is on follow up.
3. Discussion
The processus vaginalis arises as an evagination of parietal peri-

∗ Corresponding author at: Dept. of. Radiology, Hamad General Hospital, P.O. Box
toneum at around the sixth month after conception [1]. The female
3050, Doha, Qatar.
E-mail addresses: kumardr6@hotmail.com, drkumar68@yahoo.co.in
counterpart of the processus vaginalis is relatively small and com-
(S. Muthiyal), drmvkini@gmail.com (V. Kini), avin1587@hotmail.com (A. Kounsal), monly disappears by 8 months of gestation, although patency may
aibrahim@hamad.qa (A.A. Ibrahim). persist into postnatal life. Failed obliteration is a cause of hydrocele
http://dx.doi.org/10.1016/j.ejro.2016.01.001
2352-0477/© 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.
0/).
36 S. Muthiyal et al. / European Journal of Radiology Open 3 (2016) 35–37
Fig. 1. Ultrasonography of the left groin reveals herniation of uterus into the inguinal canal.
Fig. 2. Ultrasonography of the left groin reveals herniation of ovaries into the inguinal canal.
Fig. 3. On color Doppler ultrasonography vascularity is seen in both ovaries.
or hernia [1]. If patency persists, the patent processus is termed the uterine cornuae, the chance of herniation of the ovary and uterus
canal of Nuck [1,3]. Because of patency of the processus vaginalis, into the inguinal canal is increased [1,4].
this condition is more likely to occur in a premature infant or in Early diagnosis is important when the hernia contains an ovary,
the neonatal period in female infants [2]. Inguinal hernias are more because incarceration of the ovary is common. Incarceration of the
common on the right side, occurring in approximately 60% of cases, ovary is common and has been reported in up to 43% of cases [2,3].
with 30% on the left side, and 10% bilateral [3,5]. In our study it was Bowel hernia, lymphadenopathy, hydrocele in the canal of Nuck,
on the left side. cystic lymphangioma, epidermal inclusion cyst, or a malignant
It has been reported to contain the ovary with or without por- tumor (e.g., rhabdomyosarcoma or metastasis) should be consid-
tions of the fallopian tube in 15–20% of the time [2]. However, a ered in the differential diagnosis of a pathologic groin mass in a
hernia in female infant containing the uterus is very rare [1–6]. female infant [2,5].
Embryologically, there is no good explanation why the uterus Sonography should be used as the imaging modality of choice
should herniate in girls, unless there is an anatomic abnormality of in these patients because it clearly has the ability to evaluate, char-
the ligaments that suspends the uterus. One previous report offered acterize, and differentiate among these conditions. Preoperative
the hypothesis that if there is failure of fusion of the Mullerian ducts US using a high-frequency transducer is therefore very helpful in
leading to excessive mobility of the ovaries plus non fusion of the reaching a diagnosis with an efﬁcacy considered to be almost 100%
[2,4]. Color and pulsed Doppler evaluation is also complementary
S. Muthiyal et al. / European Journal of Radiology Open 3 (2016) 35–37 37
to exclude strangulation. This will facilitate early effective manage- References

ment and avoid trivial complication like ovarian incarceration and
infarction. [1] Y.C. Ming, C.C. Luo, H.C. Chao, S.M. Chu, Inguinal hernia containing uterus and
uterine adnexa in female infants: report of two cases, Paediatr. Neonatol. 52
(April (2)) (2011) 103–105.
4. Conclusion [2] Faye C. Laing, Brent A. Townsend, J. Ruben Rodriguez, Ovary-containing hernia
in a premature infant sonographic diagnosis, J. Ultrasound Med. 26 (2007)
985–987.
Inguinal hernial sac containing uterus, fallopian tube, and ovary [3] Dal Mo Yang, Hyun Cheol Kim, Sang Won Kim, Sung Jig Lim, Seung Jin Park, Joo
in the female is very rare. The lesions can be diagnosed by the Won Lim, Ultrasonographic diagnosis of ovary-containing hernias of the canal
characteristic sonographic appearance. By presenting this case we of Nuck, Ultrasonography 33 (2014) 178–183.
[4] Kıvılcim Karadeniz Cerit, Rabia Ergelen, Emel Colak, Tolga E. Dagli, Inguinal
attempt to highlight the exiguous prevalence of this clinical entity hernia containing uterus, fallopian tube and ovary in a premature new born, J.
and potential of ultrasonography in early detection which will Case Rep. Paediatr. 2015 (2015) 3, Article ID 807309.
explicitly contribute to clinical decision making and further man- [5] Hakan Artas, Nilifer Gurbuzer, Inguinal hernia containing both ovaries and the
uterus in an infant, J. Ultrasound Med. 31 (2012) 1137–1139.
agement. [6] Elvira K. George, Anne Marie Oudesluys-Murphy, Gerard C. Madern, Pieter
Cleyndert, Joost G.A.M. Blomjous, Inguinal hernias containing the uterus,
Appendix A. Supplementary data fallopian tube, and ovary in premature female infants, J. Pediatr. 136 (May (5))
(2000) 696–698.
Supplementary data associated with this article can be found, in

the online version, at http://dx.doi.org/10.1016/j.ejro.2016.01.001.

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European Journal of Radiology Open 3 (2016) 35–37

Contents lists available at ScienceDirect

European Journal of Radiology Open

Rarity in conspicuity—Ultrasound diagnosis of sliding left inguinal

1. Introduction 2. Case report

The processus vaginalis arises as an evagination of parietal peri-

Fig. 3. On color Doppler ultrasonography vascularity is seen in both ovaries.

to exclude strangulation. This will facilitate early effective manage- References

Supplementary data associated with this article can be found, in

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