An unusual finding of ipsilateral pantaloon hernia with contralateral direct inguinal hernia in a male cadaver

S John Bino; Sipra Rout

doi:10.4103/cjhr.cjhr_146_20

CASE REPORT

Year : 2021 | Volume : 8 | Issue : 3 | Page : 201-204

An unusual finding of ipsilateral pantaloon hernia with contralateral direct inguinal hernia in a male cadaver

S John Bino¹, Sipra Rout²
¹ Department of Anatomy, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
² Department of Anatomy, All India Institute of Medical Sciences, Bibinagar, Hydrabad, Telengana, India

Date of Submission	22-Oct-2020
Date of Acceptance	29-Jul-2021
Date of Web Publication	04-Mar-2022

Correspondence Address:
Sipra Rout
Department of Anatomy All India Institute of Medical Sciences Bibinagar, Hyderabad
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/cjhr.cjhr_146_20

Abstract

The presence of unilateral Pantaloon's hernia with contralateral direct hernia coexisting together is a rare occurrence. We noticed such a case, where in one male cadaver aged 78 years on routine cadaveric dissection. A case of unilateral Pantaloon hernia was observed where both direct and indirect hernial sac were observed in the inguinal region on the right side while on the left side a huge direct inguinal hernial sac was present with coils of sigmoid colon as its content. Here, we have discussed this rare occurrence of composite hernias with their contents in a single body in detail with the associated morphological distortions and possible complications.

Keywords: Direct hernia, Pantaloon's hernia, sigmoid colon

How to cite this article:
Bino S J, Rout S. An unusual finding of ipsilateral pantaloon hernia with contralateral direct inguinal hernia in a male cadaver. CHRISMED J Health Res 2021;8:201-4

How to cite this URL:
Bino S J, Rout S. An unusual finding of ipsilateral pantaloon hernia with contralateral direct inguinal hernia in a male cadaver. CHRISMED J Health Res [serial online] 2021 [cited 2022 May 28];8:201-4. Available from: https://www.cjhr.org/text.asp?2021/8/3/201/339042

Introduction

Protrusion of any viscus covered by peritoneal sac through the inguinal region due to weakness within anterior abdominal wall is called as inguinal hernia.^[1] Inguinal hernias account for about 75%–80% of abdominal hernias. These herniations occur in both sexes and more common in males (approximately 80%) than in females.^[2],[3] They are more common on the right than on the left. Anatomically, inguinal hernias are of two types: indirect and direct. In indirect variety protrusion occurs through the deep inguinal ring, inguinal canal, and superficial inguinal ring into the scrotum. In this hernial sac is narrow and passes down in the inguinal canal on lateral aspect of spermatic cord lateral to inferior epigastric vessels. Direct inguinal hernia arises medial to inferior epigastric vessels and through Hasselbach's triangle and is further classified into medial and lateral types by means of obliterated umbilical artery.^[4] Here the protrusion occurs due to weakness in the abdominal wall muscles that develop over time. It is always acquired in nature and associated with straining factors such as chronic cough and occurs in much older men.^[5] The hernial sac is wider lies medial to inferior epigastric vessels and posterior to the spermatic cord.^[6] In females, this type of inguinal hernia is rare. Indirect inguinal hernia is the commonest type and congenital in nature due to the patent processus vaginalis, which usually gets obliterated after birth due to the descent of the testis.^[6],[7] Hernia with congenital background can occur soon after birth or may be evident at later stages of life. It is important to realize even in the latter case that the sac into which the hernia occurs may have existed since birth.^[8] Complications that can develop as a result of an inguinal hernia include obstruction and strangulation to the gut. Contents of an inguinal hernia include part of small intestine (ileum commonly), Meckle's diverticulum, piece of omentum and rarely appendix, fallopian tube, ovary, urinary bladder, cecum, ascending colon on right, and sigmoid colon on the left.^[9] Many hernias occur because of lifting heavy weights and are much more common in men than women. The symptoms of an inguinal hernia may include pain, discomfort, or a heavy feeling in the groin area, bulging of either side of the pubic bone or swelling near the testicles in men. Associated straining factors such as chronic cough, chronic constipation, and lifting heavy weights usually in older age groups in whom muscle tone are less may lead to direct hernia. The inguinal hernia usually presents as swelling in the inguinal region, which increases in size with coughing.

Case Report

During routine anatomy dissection class for 1^st year MBBS students, we came across a huge scrotum on the left side in a formalin fixed adult male cadaver of about 78 years. This cadaver was donated to the department of anatomy for teaching purpose. The cause of death documented was of cardiac arrest.

On examination, we noticed a huge swelling on the left side initially. It seemed to be a left-sided direct inguinal on inspection. On the right side a moderate inguinal swelling was also observed indicating a suspicion of bilateral inguinal hernia. Further we dissected and reflected the layers of scrotum with a longitudinal incision extending from superficial ring to the base of scrotum. Thus, we exposed hernial sac of both sides.

It was observed that on the right side, it presented with two hernia sacs [Figure 1]. Taking into anatomical consideration, it was confirmed that one was moderate sized direct inguinal hernia sac while other was a small direct inguinal hernia sac on this side. The direct inguinal hernial sac measured 6 cm in length, 3 cm in width at its neck [Figure 1]. On palpation, it appeared collapsed. On further exploration of the scrotal sac, an elongated sac containing greater omentum was observed which was seen extending till the base of scrotum with the neck related lateral to the inferior epigastric artery. The spermatic cord appeared normal and occupied lateral position with normally appearing testis [Figure 2].

Figure 1: (a) Right side inguinal region showing indirect inguinal hernial sac [ yellow star]. (b) figure showing a closer view of hernial sac (white arrow)

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Figure 2: Left side inguinal region showing direct inguinal sac containing sigmoid colon [ ] T: Testis SC: Spermatic cord

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On the left side, we observed that it was a direct inguinal hernia sac. It measured 20 cm in length. The neck of the sac it measured around 6 cm in width and the widest diameter at the base of the sac was approximately 12 cm. Dissection of the hernia sac revealed coils of sigmoid colon and omentum as its content [Figure 2]. The spermatic cord was associated with a mass of lipoma surrounding it. However, the testis appeared normal. The spermatic cord lied deep to the hernial sac.

Dispositions of other abdominal organs were normal. Due to dragging of sigmoid colon into hernial sac into scrotum, the inferior mesenteric vein showed acute angulation draining into splenic vein in the abdomen [Figure 3].

Figure 3: Image showing the dragging of inferior mesenteric vein which is draining into splenic vein. SV: Splenic vein SA: Splenic artery

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Discussion

Inguinal hernias account for about 75%–80% of abdominal hernias. The hernial sac can enclose coils of small intestines, colons, ovary, urinary bladder, and appendix and greater omentum.^[10] These hernias can involve both the sexes though more commonly seen in case of males with 80% of incidences.^[2],[3] In the present case a 78 years male cadaver presented with bilateral inguinal hernias. This supported report that inguinal hernias are around 10 times more common in men than in women.^[2]

This case presented with simultaneous presence of both direct and indirect inguinal hernia on right side and a direct inguinal hernia on left side. Although it is understood that direct inguinal hernia increases with age with gradual laxity of the abdominal muscles, it is reported that prevalence of all types of hernia seems to increase with age. In addition, some studies have reported a major risk factor for inguinal hernia is a familial history of collagen disorders like Marfan syndrome, Osteogenesis imperfecta, Ehler–Danlos Syndromes, Hurler syndromes, and Hunter syndromes.^[11] Other medical conditions reported to be associated with increased risk include chronic obstructive pulmonary disease, smoking, high intra-abdominal pressure, lower body-mass index, thoracic or abdominal aortic aneurysm, history of open appendectomy, and peritoneal dialysis.^[12]

On right side both the direct and indirect hernial sac contained the greater omentum. The indirect inguinal hernial sac extended till the base of scrotum. There was no whirling and strangulated feature of greater omentum was noted at the deep inguinal ring. Inguinal hernia with greater omentum contained in it, is a common condition but not frequently related with torsion of the omentum. Torsion of the omentum presents clinically like any other causes of acute surgical abdomen which is often diagnosed during surgery. Testis with spermatic cord was found to be physically normal and descended completely into scrotum in the current case. Primary torsion is commonly seen on the right side due to its greater length and size in relation to the left side with higher mobility. These torsions could be possibly an outcome of local structural omental anomalies such as bifid omentum, accessory omentum or presence of redundant omental veins, though the exact pathogenesis has to be explored still further.^[13] A secondary cause includes postsurgical adhesions, inflammatory foci, scars, tumors. The current case did not show any visible anatomical abnormality related to omentum.

Indirect or oblique inguinal hernias usually are congenital type and it results from a patent processus vaginalis which generally gets obliterated shortly after birth once the descent of testis to scrotum is complete. Indirect hernias are common on the right side owing to the closure of right side processus vaginalis later than left side.^[14] At times, a person with an untreated undescended testis and an occult inguinal hernia can also present at any time with symptoms and complications typical of any inguinal hernia.^[15]

This current case also presented with a left sided direct inguinal hernia extending from the posterior wall of the inguinal canal into the scrotum producing a huge mass. The left testis with spermatic cord lied deep to the sac. The hernial sac contained coils of sigmoid colon in it which was huge and clearly irreducible with firm consistency. The wall of the sigmoid colon appeared normal with no signs of any palpable mass, strangulation, or incarceration. This could be most probably because of the wide neck of the hernial sac which did not compromise the blood supply to the organ. Usually left sided inguinal hernia with coils of sigmoid colon presents with incarcerated loop due to long term redundancy which presents as pain and calls for treatment. It has been reported that in most instances, the sigmoid colon which usually herniated through the left inguinal canal^[16] and it is often long-standing and does not cause symptoms. Previous literature reviews have reported that carcinoma of an inguinal sac mostly originated from the sigmoid colon and becomes incarcerated in the left groin.^[17],[18] It almost exclusively seen in the elderly men. Rarely, but a right-sided strangulated hernia too reported to present with coils of sigmoid colon.^[19] Incarceration of bowel loops in inguinal hernia occurs in around 10% of cases which can lead to complications such as infarction, strangulation, and intestinal obstruction. Strangulation has been the most potent lethal consequence among all.^[17],[18] Inguinal hernia sacs in 0.5% of cases contain malignancies affecting from herniated organ, usually sigmoid colon, caecum.^{[19],[20],[21]} A primary colonic malignancy of the hernial sac has been reported rarely. The first case was reported by GY Tan et al. in 1938. Malignancies of hernial sac reported in <0.5% cases obstructing sigmoid cancer with local invasion in an incarcerated inguinal hernia.^[22] In the present case, we have not look for histological confirmation of any malignant change involving sigmoid colon as grossly it appeared normal and without any palpable obvious mass or thickening affecting its wall. On the abdominal exploration we encountered the dragging of inferior mesenteric vein draining into splenic vein, which can be a cause of venous obstruction on long standing cases and should be kept in mind.

Unilateral Pantaloon's hernia with concomitant direct and indirect type hernia occurrence is unique and rare. Only a single study has been reported the incidence of Pantaloon hernia to be 1.8% in females and 5.6% in males from a single center.^[23] In females, it may be associated with testicular feminization syndrome in young. In males it might be associated with cryptorchidism which goes unnoticed even till 40 years of age.^[17] Meticulous exploration of the groin thus is mandatory for diagnosis of a possible cryptorchidism testis on surgical exploration.

Conclusion

Bilateral inguinal hernias do occur in adults though not very often, while Pantaloon hernias are extremely rare and when present, may be associated with the cryptorchidism in young children. The present case is reported with the purpose of documenting the extreme rarity of Pantaloon hernia in adult male cadaver in the exiting scientific literature.

Even though extensive literature is available on the etiology, signs, symptoms and also the treatment options concerning inguinal hernia, present report may be one of its kind mainly focusing on the structural deformation, morphological changes that occurred in the abdominal cavity due to mal-positioning of intestinal loops in a long standing inguinal hernia.

To conclude, even though inguinal hernia is a common finding, challenge lies in the reduction, probably because of the wide variation in the content of the hernia sac and the deformation occurring in the abdominal cavity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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