Presentation
Premature infant with a history of congenital cytomegalovirus (CMV) and a left inguinal hernia complicated by worsening pain. Abdominal ultrasound is performed.
Patient Data
A tubular structure is visualized within the left inguinal canal demonstrating a sub-centimeter linear central echogenic stripe. These features favor a hernia uterine inguinale.
There is an additional, more anterior, tubular structure within the left inguinal canal without an echogenic stripe, without peristalsis, and without demonstration of follicles which are features of a herniated ovary.
Left inguinal canal is additionally patent distal to the to tubular structures with simple fluid.
Findings concerning for a uterine herniation into left inguinal canal with herniation of the left adnexa versus bowel into left inguinal canal.
Case Discussion
Based on these ultrasound findings, a diagnostic laparoscopy followed by an open hernia repair was performed to treat the patient. During the procedure, the left horn of a bicornuate uterus was found to be incarcerated, confirming the suspected uterine herniation into the left inguinal canal.
This case highlights the rare occurrence of a uterine herniation into the inguinal canal, specifically in a premature infant with a history of congenital CMV infection. While inguinal hernias are relatively common, uterine herniation is an extremely rare presentation 1. Prompt recognition and appropriate management are essential to prevent complications such as uterine ischemia and subsequent lifelong infertility 1,2.
The presence of a bicornuate uterus, in this case, may have contributed to the increased risk of herniation due to anatomical variations and a potential weakness in the uterine support structures 3,4. Although the exact etiology and risk factors for inguinal uterine herniation remain unclear, congenital anomalies and increased intra-abdominal pressure may play a role 4.
Diagnostic laparoscopy and open hernia repair findings:
The right ovary and fallopian tube and all the bowels appeared viable. It appeared that the left horn of a bicornuate uterus was incarcerated. The left fallopian tube and left ovary also appeared viable but edematous. Given that the hernia was incarcerated and difficult to reduce laparoscopically, an open inguinal hernia exploration was done. In the open approach, it was confirmed that the left horn of a bicornuate uterus was incarcerated in the hernia. The peritoneum was fused with the bicornuate uterus. The hernia was repaired with a Bassini tissue repair.
In conclusion, this case emphasizes the importance of considering uterine herniation in the differential diagnosis of inguinal hernias, especially in cases with atypical presentations or associated known anatomical anomalies. Diagnostic imaging techniques, such as abdominal ultrasound, can provide valuable information regarding the contents and nature of the hernia 5. Additionally, further studies with an inguinal MRI can be performed.
Thank you Khushi Saigal and Dr. Gaurav Saigal, MD from the University of Miami Health System and Jackson Memorial Hospital for your contribution and support in this case.
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