Uterus-containing Inguinal Hernia in a Female Infant: An Unusual Case with Pearls for Sonographic Diagnosis and Laparoscopic Repair

Introduction: Inguinal hernias are encountered much less frequently as congenital anomalies in female infants, relative to males. While the ovaries are encountered in up to 15-30% of female inguinal hernia repairs during infancy, the uterus is very rarely involved. Uterine involvement can be associated with Disorders of Sexual Development (DSD), or can occur as an isolated anomaly. In most previous reports in the literature, the diagnosis was made at the time of surgery, with standard open technique used to repair. Techniques for making a preoperative diagnosis, and completing the repair laparoscopically, are not well described.

Case Description: A female neonate was born at 37+6 weeks estimated gestational age. The prenatal course was complicated by gestational hypertension and intrauterine growth restriction. The newborn screening panel was normal. At one month of age, the parents noticed an asymptomatic, irreducible left groin mass. Ultrasound identified an inguinal hernia with the left ovary and uterus within the Canal of Nuck. Diagnostic laparoscopy confirmed the sonographic findings, and also identified a synchronous contralateral inguinal hernia. Under general anesthesia, the herniated uterus, left fallopian tube, and left ovary were reduced with a combination of external pressure and internal laparoscopic retraction. Both hernias were repaired laparoscopically, with percutaneous high ligation of the internal ring. Laparoscopy facilitated identification and protection of the adnexa during the procedure, and ensured organ viability. Her postoperative course was uncomplicated, and no other abnormalities have been identified by endocrinologic evaluation.

Discussion: The unusual finding of uterine involvement in an inguinal hernia presents several medical quandaries. Firstly, providers must be concerned for incarceration and strangulation of the female genitalia, including the ovary and fallopian tube. Secondly, the association of uterine involvement with DSD’s may make a preoperative diagnosis beneficial, though preoperative imaging is not standard. Finally, these patients may benefit from laparoscopic surgery, which is not uniformly offered by pediatric surgeons. Sonographic findings of uterine involvement are described herein, as are techniques for pelvic evaluation and laparoscopic hernia repair, with key attention to preservation of the female reproductive organs.

Conclusion: Uterine involvement in female infant inguinal hernias is a rare finding, which may warrant additional investigation. The uterus may be identified within the hernia sac on ultrasound. Laparoscopy may be beneficial in these cases to facilitate diagnosis of associated Disorders of Sexual Development (DSD) and synchronous contralateral hernias, and ensure careful preservation of the female adnexa during surgical repair.