Figure 3 - uploaded by Andrea Laurenzi
Content may be subject to copyright.
After resection, the operative field of the femoral region is marked by surgical clips for further radiation therapy. RFA, right femoral artery.
Source publication
An inguinal hernia is a common surgical disease in elderly patients, but an association with intra-abdominal malignancies is rare.
We report a case of a 78-year-old Caucasian woman presenting with a right inguinal mass suspected to be an irreducible hernia. A computed tomography scan showed the presence of the cecum in her inguinal canal, with an i...
Context in source publication
Context 1
... malignancies presenting as inguinal hernias are rare and have been classified as saccular or intrasaccular tumors based on their relationship with the inguinal sac [1]. Saccular tumors are tumors of the peritoneal surface of the sac that can be primary (such as mesothelioma) or secondary (for example, peritoneal car- cinomatosis). Intrasaccular tumors are primary tumors of abdominal organs (for example, colonic cancer) contained within the inguinal sac. Intrasaccular tumors are rarer and the most commonly reported site is the left inguinal hernia containing a sigmoid cancer [2,3]. The treatment of this rare condition is not standardized and the correct surgical strategy may represent a challenge for the surgeon, especially in cases of advanced tumors. We report a rare case of an intrasaccular tumor due to an aggressive cecal cancer presenting within a right inguinal hernia in an elderly woman. A 78-year-old Caucasian woman was admitted to our hospital presenting with a painful mass in her right groin, without fever, rectal bleeding or any other bowel symptoms. She had no history of malignant diseases. A physical examination showed an irreducible palpable mass in her right inguinal region protruding through the external inguinal ring. Routine blood examinations showed she had chronic anemic status with an hemoglobin value of 8.9g/dL. Tumor markers values of carcinoembryonic antigen and carbohydrate antigen 19.9 were 4ng/mL and 24U/mL, respectively. A computed tomography scan of her abdomen showed the presence of the cecum in her inguinal canal, with an irregular thickening of its wall suggesting a cecal neoplasm within the inguinal hernia involving the femoral vessels (Figure 1). A colonoscopy was not completed due to the large involvement of the cecum into the hernia sac. Surgical ex- ploration was made through a midline laparotomy that confirmed the herniation of the cecum into her right inguinal canal (Figure 2), without the possibility of reduc- tion in her abdominal cavity owing to the tumor infiltration into her abdominal wall and inguinal structures. Thus, a right inguinal incision was made, which revealed an aggressive cecal tumor infiltrating her inguinal wall, right round ligament and femoral artery. The mass was resected en bloc , with complete vascular control of her femoral vessels, and reduced into her abdomen. Finally, a right colectomy was performed with a manual ileocolic anastomosis and her inguinal wall was repaired by a direct suture without mesh. The operative field of the femoral region was also marked with surgical clips for further postoperative radiation therapy (Figure 3). Histo- pathological examination of the specimen showed a poorly differentiated adenocarcinoma of the large bowel with lymphovascular and perineural invasion, microscopic involvement of the resection margins, and metastases of 8 out of 17 regional lymph nodes (pT4b pN2b M0, R1; Stage IIIC; Dukes C3) (Figure 4). The postoperative course was uneventful and our patient received adjuvant radiochemotherapy. Six months after surgery, our patient is alive and disease free. Inguinal hernias and colonic malignancies are frequent diseases in the elderly population, but their association is relatively rare. Two previous literature reviews [3,4] revealed that the sigmoid colon was involved in most cases and all patients were male. Out of 28 patients reported, only four had a cecal tumor, presenting in all cases as a right long-standing inguinal hernia that be- come painful or incarcerated. In our case, a female patient recently noticed a mass in her right groin, without any symptoms or signs of obstruction; she had no history of inguinal hernia or primary malignancy, only a general asthenia. A correct diagnosis in these cases may be difficult, especially in elderly patients, and computed tomography should always be performed to confirm the suspicion of an underlying malignancy. A colonoscopy may present with negative results as in our case owing to the involvement of the colon into the hernia. The best surgical treatment is not clear and depends on the patient ’ s characteristics (age, general condition), local findings (infiltration of organs or vessels) and the surgeon ’ s experience [4]. In the majority of the reported cases, a laparotomic resection of the colon followed a traditional inguinal repair through two separate incisions [2,4]. In cases of perforation or occlusion, most authors performed a colonic resection through the inguinal incision to prevent the peritoneal cavity from contamination and completed the operation via a midline laparotomy [3,5]. Other authors described a transverse left iliac fossa incision for a sigmoid cancer incarcerated into a left inguinal hernia [6]. More recently, a laparoscopic approach has been described in one case [7]: the tumor was reduced and resected by laparoscopy, while the inguinal defect was repaired by a traditional approach. Despite our experience with laparoscopic colorectal surgery, and considering the advanced local status of the tumor, we decided to perform a midline laparotomy and found an irreducible cecal tumor within the inguinal canal. A secondary inguinal incision was necessary to take control of vascular structures, performing an en bloc resection of the tumor with the inguinal wall. Mark- ing the operative field with metallic clips for postoperative radiotherapy could be a good solution in cases of aggressive tumors suitable for adjuvant radiotherapy after microscop- ically incomplete resections. As to neoadjuvant treatment, we decided to address the patient directly to surgery due to the risk of obstruction and tumor progression during pre- operative radiochemotherapy, but it might otherwise be considered, especially when positive margins are expected after resection. Inguinal hernias containing a colonic malignancy are not frequent, but should be evaluated in elderly patients presenting with an irreducible mass in the inguinal region as- sociated with gastrointestinal symptoms or non-specific features such as asthenia or anemia. The surgical treatment can be achieved either by an open or laparoscopic approach but should always respect the oncological stan- dards of a radical resection, especially when adjacent structures are involved. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this ...
Similar publications
This report describes an extremely rare case of extrarenal Wilms’ tumor in a 4-year-old girl who presented with abdominal mass and pain. Computed tomography (CT) scanning revealed a well-defined mass lesion measuring 10 cm on the right side of her lower abdomen and pelvic cavity. The mass was surgically removed. Histologically, the tumor showed a t...
Citations
... Intrasaccular tumour arises from a left-sided abdominal organ commonly the sigmoid colon. 4 A preoperative diagnosis of a carcinoma in the context of an inguinal hernia is challenging, but some sinister details in the history may raise suspicion. Slater et al. 3 revealed that the clinician should have a high index of suspicion in elderly males, patients with long-standing hernia with recent onset pain or incarceration, patients with a history of intra-abdominal malignancy presenting with a new onset hernia, and other common sinister features such as unexplained weight loss, altered bowel habits, and per rectal bleeding should indicate the possibility of underlying carcinoma. ...
... Similar to the index case, most previous literature reported cases presenting with painful inguinal lump which was diagnosed as strangulated inguinal hernia. 4,5 However, some were asymptomatic on presentation. Although perforation of a carcinoma is rare within a hernia sac, the symptoms may resemble Fournier's gangrene which warrants immediate operative exploration. ...
Inguinal hernia is a potentially occult common surgical condition. Its association with asymptomatic adenocarcinoma is uncommon. However, malignancy-associated perforation of the large bowel within an irreducible hernia is rare. We report a case of 78-year-old male presenting with a long-standing inguinal hernia with a 2-day history of irreducibility. Examination revealed a large left-sided irreducible inguinal hernia. Patient underwent urgent inguinal herniotomy, during which multiple perforations were noted in the sigmoid colon. Patient underwent Hartmann’s procedure following bowel resection. Histology revealed a mucinous adenocarcinoma with extensive metastasis involving the resection margins. Elderly patients with long-standing inguinal hernia presenting with acute symptoms should be evaluated further for this rare but sinister diagnosis.
... Intrasaccular tumors are primary tumors of abdominal organs (for example, bladder, colon and appendix cancers) contained within the inguinal sac [5]; left colon carcinoma is the most common of these [6]. ...
Incarcerated inguinal hernia is a common diagnosis in patients presenting a painful and nonreducible groin mass. Although the diagnosis is usually made by physical examination, the content of the hernia sac and the extent of the surgical operation may vary and can require multimodal imaging integration (e.g., ultrasonography, computed tomography); the usual finding is a segment of small bowel and, less commonly, large bowel. We present an extremely rare case of a sigmoid cancer incarcerated in a left inguinal hernia and infiltrating the spermatic cord. The patient underwent whole-body computed tomography (CT) with contrast agent injection for staging, followed by a left hemicolectomy paralleled by a unilateral orchiectomy.
... This case describes a rare combined presentation of two common surgical issues: colorectal cancer and inguinal hernias are both common in the elderly population, with over 36 000 new colorectal cancer cases arising in the UK each year (of which approximately 20% arise from the caecum), 1 and an estimated incidence of abdominal wall hernias in the over 65s of 13/1000. 2 However, less than 30 cases of colon cancer herniating into the inguinal canal have been described in the literature thus far, 3 and of these only four involved carcinoma of the caecum. 4 The treatment of inguinal hernias containing colon cancer is not standardised, 5 and in most cases a two-phase approach appears to be preferred, involving a midline laparotomy to allow resection of the tumour, followed by a traditional inguinal hernia repair. To this author's knowledge, this is the first description of a herniated caecal tumour reduced and resected through a single transverse incision on the right. ...
... Although Pernazza et al 3 demonstrated an oncologically sound laparoscopic resection of a similar malignancy, it was ultimately deemed necessary to perform an open hernia repair to minimise the risk of contamination of the mesh. Other demonstrated approaches to herniated caecal tumours include midline laparotomy with a secondary right inguinal incision, 5 and oblique right groin incision with a secondary transverse scrotal incision directly over the tumour mass. 1 In both cases, the approach taken was determined by the characteristics of the tumour in relation to local structures in order to facilitate en bloc resection. It would appear that this is the first documented case of a herniating caecal tumour being repaired through a single incision, although it is important to emphasise that, as long as the goals of treatment are achieved (in this case R0 resection and reduction of the hernia), there are many potential surgical approaches to such cases. ...
An 84-year-old man with multiple comorbidities presented from a residential care home with a 1-month history of asthenia and moderate abdominal pain. On examination, he was found to have an irreducible right-sided inguinoscrotal hernia. Subsequent blood tests revealed a significant anaemia (haemoglobin 48 g/L), for which he was transfused. A CT scan of the abdomen and pelvis revealed a large caecal tumour, herniating through the right inguinal canal into the scrotum. The patient underwent an elective open right hemicolectomy with inguinal hernia defect repair, from which he recovered well. He was discharged from the ward 12 days postoperatively and is awaiting outpatient follow-up.
... La presencia de un cáncer de colon como contenido de una hernia inguinal es una situación infrecuente, habiéndose publicado menos de 50 casos en la literatura hasta el momento actual (1)(2)(3)(4)(5)(6)(7)(8) , habiendo sido uno de ellos comunicado en Uruguay por Palacio (9) en el año 1993. ...
Carcinoma of the colon in an incarcerated inguinal hernia is rather an unusual condition. Few cases have been reported in literature. Usually it appears in left inguinal hernias and involves the sigmoid colon. Palpation of a tumor in a hernia that did not exist previously and the presentation of intestinal symptoms aid diagnosis. Barium enema constitutes the gold standard in paraclinical studies to confirm diagnosis. Surgical treatment is advised, although several tactics and approaches are possible. The study presents the clinical case of an 82 year-old patient with sigmoid colon cancer in an incarcerated left inguinal hernia which appeared as a tumor in the hernia and alterations in the intestinal alterations. The ultrasound suggested a possible diagnosis and the Barium enema confirmed the intrinsic colon lesion. Both lesions were solved by an inguinal approach. An oncological sigmoidectomy was performed and herniorrhaphy with no complications with a satisfactory oncological resection was achieved.
... Intra-abdominal malignancies like colonic cancers, presenting as inguinal hernias are known to occur. However, less than 1 out of 200 cases of these malignant colonic carcinomas is localized within an inguinal hernia, and have been known to cause colonic obstruction [74][75][76]. Liposarcoma makes up 7% of all paratesticular sarcomas, of which 12% occur in the inguinal canal [77]. ...
... [5] Based on their relationship to the hernial sac, intra-abdominal malignancies can be classified as saccular or intra-saccular. [6] Saccular tumours are primary tumours arising from the peritoneal surface of the sac and intra-saccular tumours are tumours arising from the intra-abdominal organs contained in the sac. While inguinal hernias and colorectal carcinoma are common findings individually, the occurrence of colorectal carcinoma as an intrasaccular finding is rare. ...
Irreducible inguinal hernias are commonly encountered in an emergency setting. The content is usually small bowel or omentum and diagnosis is made by physical examination. We present a case of an irreducible inguinal hernia, which on opening of the sac revealed a perforated sigmoid colonic growth as the content.
Introduction and importance:
Giant inguinoscrotal hernias (GIH) are a rare form of inguinal hernia. There have been few reported cases of GIH containing colon adenocarcinoma.
Case presentation:
This case describes a 72-year-old male with a right GIH containing the right colon, terminal ileum, and associated mesentery with a large heterogenous, irregular mass with necrosis involving the cecum and ascending colon measuring 14 × 8 × 9 cm. The patient initially presented with pain and evidence of partial large bowel obstruction. Due to suspected extensive local invasion of tumor, the patient was scheduled for evaluation for possible neoadjuvant chemotherapy. Unfortunately, the patient re-presented with a large bowel obstruction and was subsequently taken for an exploratory laparotomy with trans-scrotal incision for en bloc resection of cecal adenocarcinoma and involved hernia contents.
Clinical discussion:
Due to the rarity of this pathology, there is not a standard approach to management or optimal surgical technique described. In this case, a trans-scrotal incision paired with an exploratory laparotomy allowed for superior access to the adhered cancer containing bowel as well as skin excision, following standard oncologic principle of high ileocolic mesenteric excision.
Conclusion:
The complexity of management of GIH containing colon cancer has been documented, however a standard oncologic approach has not been described. This case report presents exploratory laparotomy with trans-scrotal incision as an approach.
Background:
Inguinal hernias and colorectal cancers are common conditions, but the presentation of a loop of bowel containing cancer within a hernia is rare. Principles of surgery include oncological resection of the involved colonic segment as well as lymphatic drainage. Based on case reports of the last several decades, there have been no reports of a case where the reduction of an inguinoscrotal hernia and oncological colectomy were performed completely laparoscopically. We present the first instance of a completely laparoscopically assisted resection and hernia repair on a patient with T4 ascending colon cancer. A literature search on recent case reports over the last 30 years has also been presented with a focus on trends in treatment.
Case presentation:
An 83-year-old man presented for further investigation of his iron deficiency anaemia and was diagnosed with adenocarcinoma of the ascending colon. This was demonstrated radiologically to be found within a large right inguinoscrotal hernia. He underwent a laparoscopically assisted right hemicolectomy and laparoscopic closure of the internal ring and recovered well.
Conclusions:
Colorectal cancers within inguinal hernias are rare and can often present with complications such as perforation. As such, treatment has mostly involved an open operation. The last few years have shown feasibility of a laparoscopic approach and can be attempted safely when indicated.
We present a 70-year-old male patient with an unusual incidental finding at an elective repair of an indirect left inguinal hernia (LIH). A black nodule resembling a melanoma metastasis in a lymph node was discovered attached to the spermatic cord. There was no contiguity with the large bowel on the same side. Histological examination showed an isolated, detached colonic diverticulum containing a faecolith. We postulate derivation from an incarcerated colonic diverticulum that became 'parasitised' onto the spermatic cord.
