SQU Med J, May 2012, Vol. 12, Iss. 2, pp. 225-227, Epub. 9th Apr 2012 Submitted 29th Sep 11 Revision Req. 8th Jan 12, Revision recd. 14th Feb 12 Accepted 15th Feb 12 Departments of 1Surgery, and 3Obstetrics & Gynaecology, Sultan Qaboos University Hospital, Muscat, Oman; 2College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman *Corresponding Author e-mail: surgeonkamran@yahoo.com فتق املبيض حالة نادرة كمران مالك، رقية ال�سحي، هاين القا�سي، موزه الكلباين، عبداهلل احلارثي امللخ�ص: ُيعّد فتق املبي�س من احلاالت النادرة جدا، اإذ ت�سكل %9.2 من حاالت الفتق االآربي القابلة للتدخل اجلراحي. نقدم هنا و�سفا حلالة غري اعتيادية من هذا النوع من الفتق عند امراأة بالغة قدمت اإلينا باأعرا�س ت�سابه الفتق املنحب�س باجلهة الي�رضى. احتوى كي�س الفتق على املبي�س االأي�رض على كي�س دموي مع بوق فالوب االأي�رض والرباط العري�س. خ�سعت احلالة جلراحه ا�ستئ�سال التكي�س الدموي املوجود باملبي�س واإ�سالح الفتق االأربي ب�سبكة طبية. مفتاح الكلمات: الفتق االآربي، املبي�س، تقرير حالة، ُعمان. abstract: Ovarian hernias are extremely rare. The prevalence of ovaries and fallopian tubes in operable inguinal hernias is only about 2.9%. We report here an unusual case of an ovary in a hernia sac in an adult female. She presented with symptoms and signs of an incarcerated left inguinal hernia. The left ovary contained a haemorrhagic cyst and, along with the left fallopian tube and broad ligament, these were found in the sac. She underwent a left ovarian cystectomy and the inguinal hernia was repaired with mesh. Keywords: Inguinal hernia; Ovary; Case report; Oman. Ovarian Hernia A rarity *Kamran A Malik,1 Ruqaiya M Al Shehhi,2 Hani Al Qadhi,1 Moza Al Kalbani,3 Abdullah Al Harthy1 CASE REPORT A hernia is defined as a protrusion of the small intestines or omentum through a defect in the abdominal wall. Hernias present as bulges in the groin area that can become more prominent when coughing, straining, or standing up. Although inguinal hernias are more common in males, they still can occur in females, most commonly in tandem with herniation of the omentum or small bowel. It is rare to find unusual contents in the hernia sac. A retrograde analysis of 1,950 cases of operable inguinal herniae showed that the vermiform appendix was present in 0.51% of the cases, ovaries and fallopian tubes in 2.9%, and urinary bladder in 0.36%.1 We report here on unusual contents within a hernia sac in an adult female who presented with symptoms and signs of an incarcerated left inguinal hernia. The left ovary, containing a haemorrhagic cyst along with the left fallopian tube and broad ligament, were found in the sac. After adequate resuscitation, the patient underwent an ovarian cystectomy and her hernia was repaired with mesh. Case Report A married 31-year-old woman with two children who was known to have sickle cell disease, presented to the Accident and Emergency Department of Sultan Qaboos University Hospital, Oman, with a 5-day history of left-sided inguinal swelling associated with colicky abdominal pain and loss of appetite. She denied any history of constipation, nausea or vomiting. She was also known to have bronchial asthma, which was controlled with inhalers. Clinically, she was in distress with haemodynamically normal vital signs. Local examination revealed a 7 x 5 cm non-pulsatile, smooth-surfaced, warm, tender, irreducible swelling with a positive cough impulse. The rest of the systemic examination was within normal limits. Her routine blood workups were normal except for a leucocytosis of 13 x 109/L. A diagnosis of strangulated inguinal hernia was made and she was taken for emergency surgery after adequate resuscitation with intravenous fluids and Ovarian Hernia A rarity 226 | SQU Medical Journal, May 2012, Volume 12, Issue 2 antibiotics. On exploration of the left inguinal canal, a thin sac containing a partially torted left ovarian cyst with a viable ovary and fallopian tube was found [Figures 1 and 2]. She underwent a left ovarian cystectomy and the inguinal hernia was repaired with Ethicon UltraPro mesh, (size 15 x 15 cm, Johnson & Johnson Medical Ltd., Ascot, UK). A histopathology study confirmed the finding of a haemorrhagic corpus luteum cyst. The patient had an uneventful recovery and was discharged home in a stable condition, with no recurrence seen on her recent follow-up appointment in the surgical clinic 6 months after surgery Discussion The inguinal canal in the female is not well- demarcated as compared to the inguinal canal in males. Normally, different structures pass through it including the round ligament of the uterus, a vein, an artery from the uterus that forms a cruciate anastomosis with the labial arteries, and extra peritoneal fat.2 It is reported in literature that ovarian hernias are extremely rare in premenopausal women. On the contrary, most cases of gonadal hernias were reported in the paediatric age group in association with other genital tract anomalies.3 T. Okada et al. suggested a few hypotheses as to the mechanism by which this may occur.4 One of these hypotheses speculates that weakness of the broad ligaments or ovarian suspensory ligaments can contribute to ovarian herniation into the inguinal ring. This can be augmented by high intra-abdominal pressure as a result of carrying heavy things, or due to a chronic cough secondary to respiratory disease, as could be the case with our patient. Although considered extremely rare, there have been case reports of different unusual contents found in inguinal hernia sacs, including parts of the genitourinary tract. McMillan reported a case of a rudimentary uterus in a 30-year-old female which had presented as a right groin lump for eight years.5 Despite the efforts made to diagnose the contents of inguinal hernias prior to surgery, most of them are made intraoperatively, as in our patient. Yao et al. suggested that in premenopausal women the morphological characteristics of the ovary in the hernia sac can be assessed through sonographic examinations, which provide information on ovarian function that cannot be obtained in younger females. These characteristics include eliciting a mass with multiple small sonolucent cysts indicating the ovary. A hyperechoic portion of the mass surrounded by an arterial flow can be observed on colour Doppler ultrasonography consistent with the presence of a corpus luteum. Furthermore, transabdominal sonographic scans of the pelvis may reveal the absence of one ovary in the lower pelvis on the same side as the inguinal hernia.6 Although ovarian cysts are not commonly encountered by surgeons, a high index of suspicion is required in order to avoid any delay in diagnosis and treatment. It was reported that about 4–37% of female inguinal hernias, which have been found intraoperatively, present with non-reducible Figure 1: Left indirect hernia . Figure 2: HC: left ovarian hemorrhagic cyst; HS: hernia sac; FT: left fallopian tube. Kamran A Malik, Ruqaiya M Al Shehhi, Hani Al Qadhi, Moza Al Kalbani and Abdullah Al Harthy Case Report | 227 ovaries. Ovarian torsion and infarction have been encountered in 2–33% of these patients, which necessitates treating all cases, even when asymptomatic.7 Ovarian cysts can be dealt with effectively with the help of laparoscopy, particularly if the cyst is benign, with concomitant repair of inguinal hernia if the diagnosis is made preoperatively.8 This was not applicable in our patient as our preoperative diagnosis was a strangulated inguinal hernia. Conclusion In most cases, the contents of the hernia sac can be detected intraoperatively. Although considered to be a very rare entity, the possibility of ovarian hernia should be kept in mind in a female patient presenting with an irreducible swelling in the inguinal or femoral region in order to avoid serious complications. Whenever suspected, it must be treated as a surgical emergency. References 1. OOzkan OV, Semerci E, Aslan E, Ozkan S, Dolapcioglu K, Besirov E. A right sliding indirect inguinal hernia containing paraovarian cyst, fallopian tube, and ovary: a case report. Arch Gynecol Obstet 2009; 279:897–9. 2. Gurer A, Ozdogan M, Ozlem N, Yildirim A, Kulacoglu H, Aydin R. Uncommon content in groin hernia sac. Hernia 2006; 10:152–5. 3. Golash V, Cummins RS. Ovulating ovary in an inguinal hernia. Surgeon 2005; 3:48. 4. Okad T, Sasaki S, Honda S, Miyagi H, Minato M, Todo S. Irreducible indirect inguinal hernia containing uterus, ovaries, and fallopian tubes. Hernia 2011; 1:1–3. 5. McMillan WM. Unusual viscera in indirect inguinal hernia. Ann Surg 1942; 116:266–70. 6. Yao L, MouY, Wang HX. Sonographic diagnosis of an ovary-containing inguinal hernia with the formation of a corpus luteum in an adult female. Ultrasound Obstet Gynecol 2009; 34:359–60. 7. Al Omari W, Hashimi H, Al Bassam MH. Inguinal uterus, fallopian tube, and ovary associated with adult Mayer-Rokitansky-Kuster-Hauser syndrome. Fertil Steril 2011; 95:1119–23. 8. 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