INGUINAL HERNIA IN FEMALES Lt Col S CHAWLA Abstract 9 patients of inguinal hernia in females were diagnosed in a total of 50 patients who presented with congenital groin problems, 8 of these were managed surgically. There were 6 small children, 1 young girl and 2 elderly ladies. All children were managed by herniotomy and herniorrhaphy was done in women. 2 patients under one year presented with irreducible hernia, one of them on exploration was found to be having sliding hernia with incarcerated ovary and tube as contents while other one had incarcerated loop of small intestine. Contents were reduced in both the patients after division of external ring as there was no sign of strangulation. One of our patients never turned up for surgery. All the operated patients were asymptomatic during the follow up period of 6 months to one year with no recurrence or wound infection. None presented on the contralateral side on follow up. Repair of inguinal hernia in females should be carried out at the earliest after a diagnosis is made, because incarceration occurs more frequently in the first year of life, as seen in this study. MJAFI 2001; 57 : 306-308 KEY WORDS :Females; Herniotomy; Incarcerated; Inguinal hernia.
Introduction
I
nguinal hernia in females is relatively uncommon as compared to males. It is interesting to note that 1 male in 5 and 1 female in 50 will eventually develop inguinal hernia in lifetime. The incidence of inguinal hernia in females is 1.9%, the ratio of boys to girls being 6: 1 [1]. In women, symptomatic but nonpalapable hernias often remain undiagnosed. The incidence of inguinal hernia in pregnancy is 1:1000. The site of presentation being 68.1% on the right side, 23.4% on the left and 8.5% bilateral [2]. The incidence of indirect hernia relates to congenital weakness at the internal abdominal ring. The sac is formed by the unobliterated portion of the prenatal peritoneal invagination of the canal of Nuck that runs along and partly covers the round ligament. Around 15% of the childhood hernias are incarcerated, especially those in young infants. In women, symptomatic but nonpalpable hernias often remain undiagnosed. Virtually nothing is known about risk factors for inguinal hernia in females. High sports activity is protective in inguinal hernia. Smoking, appendicectomy, abdominal operations and multiple deliveries are not associated with inguinal hernia in females [3]. Immediate operation should be done in all patients who are ill with obstructed or locally inflamed hernia, without attempting reduction.
children, 1 young girl and 2 elderly ladies. 2 children under one year presented with irreducible hernia (Fig-I), On emergency exploration one of them was found to be having incarcerated ovary, contents reduced back into peritoneal cavity after division of the external ring as there was no sign of strangulation. Sac was transfixed at bases and redundant sac was removed. Another 9 month old female child admitted for inguinal hernia repair developed features of obstruction during hospitalization. She was taken up for emergency surgery. On exploration, there was an incarcerated loop of smaIl intestine in the indirect sac. The exposed sac (Fig-2) was opened and the intestinal loop grasped with a Babcock forceps. The ileal loop. was examined for viability. external ring divided and internal oblique fibres laterally incised to allow reduction of the hernial contents. The sac was ligated at the base after irrigating the canal with saline solution and rest of the sac was removed. Wound was closed in layers without drain. The child had an uneventful postoperative period and was discharged after removal of sutures. 2 women who presented with inguinal hernia underwent Shouldice's herniorrhaphy. Rest of the 4 children underwent elective herniotomy in the same way. All these patients
Material and Methods 9 patients of inguinal hernia in females presented during Feb 96 to Dec 99 in service hospitals, 8 of them were managed surgically. Age group being 3 months to 65 years. 5 patients had right sided, rest presented as left sided inguinal swelling. There were 6 Classified Specialist (Surgery), Military Hospital. Bhopal- 31.
Fig. 1: Obstructed inguinal hernia (right) in a female child
307
Inguinal Hernia in FCIl'IIcs
Fig. 2: Indirect sac dissected in a female patient
Fig. 3: Inguinal hernia (right) in a young girl
were followed up in surgical OPD every month for six months and three monthly for one year for recurrence or appearance of inguinal hernia on the contralateral side.
incarceration occurs in the first year of life. 2 patients in this study presented with incarcerated hernia and 1 infant had sliding component containing ovary and tube. The incarcerated viscus in girls particularly infants is frequently an ovary. It has solid almond like feel, is generally located in the labium majus distal to the external ring and is somewhat mobile. An incarcerated ovary especially if oedematous is less likely to be reduced than intestine. Reduction of an incarcerated ovary is not as urgent as reduction of incarcerated intestinal loop but still it should be done at the earliest. Sliding hernias of the tube, ovaries and uterus occur occasionally in newborn female infants, but are rare in older women. [6]. When found in a woman of reproductive age, these are commonly associated with defects in genital tract development [7]. Some authors suggest ultrasonography for the diagnosis of inguinal hernia in premature female infants [8]. Vaginal bleeding in a child with inguinal hernia may occur when the uterus is the sliding component of the hernia [9]. An incarcerated ovary in a girl is usually a part of a sliding hernia as was seen in one of the infants in this study. The mesenteric attachment of the tube and ovary frequently form part of the hernial sac in girls [10]. Hernia uterus inguinale is a rare congenital anomaly found in hermaphrodites and surgeon should be careful to preserve and reposit the ovary in the abdominal cavity during exploration [11].
Results Out of 50 patients who presented with inguinal hernia. there were 41 males and 9 females in the age group of 3 months to 65 years (Table-I). There were 2 women, 1 young girl (Fig-S) and rest were small children. None presented with bilateral inguinal hernia. 8 female patients underwent surgery, 2 of them were taken up for emergency exploration. as they developed signs of obstruction. Herniotomy was done in 6 patients while 2 women underwent herniorrhaphy. There was no recurrence or appearance of hernia on contralateral side on follow up for one year. TABLE 1 Age distribution of patients Age (Yrs)
No. of patients
Male
4 7
10
6 11 8
15
3
2
5
5
;}
10
10
50 - 74
7
5
0
I 5 10
-
-
1 5
15 34
Female
2 4
8
2
Discussion All inguinal hernias in females occur as indirect protrusions. Many of these are in fact sliding hernias containing genital structures such as ovaries, fallopian tubes or even the uterus. Although no risk factors for inguinal hernia in females are known, independent risk factors are positive family history and obstination. Protective effects of sports activity in females can be explained by optimizing the resistance of the abdominal musculature protecting the relatively small inguinal weak point (4J. Because of the stress of childbearing, the transversalis fascia is stronger in the floor of the inguinal canal and hence has protective effect, so direct hernia in females is unusual [5]. Once a diagnosis of inguinal hernia in a female is made, repair should be carried out promptly because MJAFI. VOL 57. NO.4. ZOO]
The ligament which runs along an inguinal hernia sac in females is believed to be round ligament of uterus, is actually the suspensory ligament of the ovary and terminates in the hernia sac [12]. It is supposed to be female gubernaculum that has altered anatomy and localization because of absence of androgen responsiveness. Its modified presentation in a processus vaginalis raises the suspicion that ovary in the hernia sac may not be simply prolapsed, but is a descended gonad mimicking the descent of the testis
308
[13]. The sac wall may seem too thick in the medial or lateral quadrants in these cases and there may he difficulty in reducing the contents back within the peritoneal cavity. The sac shoull be opened in a normal appearing portion, and the walls inspected for a sliding component. The mesenteric attachment of the inner sac wall is divided in the bloodless plane within the sac. The freed up tube and ovary is then reduced easily with no compromise to the blood supply and the neck of the sac is closed in the usual way. When the sac is closed, the canal should be irrigated thoroughly with saline solution and closed primarily. Inguinal hernia in females should raise the surgeons suspicion about the child's nuclear sex, particularly if the condition is bilateral. About 2% of the girls with inguinal hernia have been reported to be having an intersex differentiation syndrome [14]. Approximately 1.6% of these children presenting with inguinal hernia and having apparent female genitalia, prove to be of male nuclear sex with intra abdominal testes but female anatomy and endocrine function - the testicular feminization syndrome. On exploration, fallopian tubes and ovaries should be examined in each patier.t by pulling on the round ligament which exposes the internal genitalia. None of our patients had such signs. The most common cause is testicular feminization syndrome, which is a result of end androgen resistance. In such patients a gonadectomy on one side and isolation of the other gonad in superficial position is done until puberty permits secondary sexual characteristics to develop. Bilateral exploration in all female patients has been recommended by some authors I15], because 90% of these girls have bilateral patency of the processus vaginalis, 40% have sliding hernias of the tubes and ovary, and none have vital structures in the canal likely to be injured such as the vas or testicular vessels as in males. However, this procedure was not followed in this study as none of the patients had bilateral presentation or developed contralateral hernia on follow up. Routine contralateral exploration is felt unjustified, since only 10% of children with unilateral repair subsequently developed a contralateral hernia [16]. Other authors have used pneumoperitoneum [17], preoperative herniogram, intraoperative laparoscopy [18], or probing to detect a possible contralateral patency. To conclude prompt surgical repair should be done in all female patients presenting with inguinal hernia in view of high incidence of incarceration of ovary and tubes in first year of life. Therefore, in female children the sac must be opened and its contents examined before it is tied off and excised. Young age
Chawla
should not contraindicate repair. All female children with inguinal hernia shoulJ have their nuclear sex ascertained and skilled paediatric advice should be sought where such anomalies are found. References 1. Read RC, White JJ. Inguinal herniation 1777-1977. Am 1 Surg 1978;136:651-7. 2. Devlin HB. Inguinal hernia in babies and children. In.Dudley H, Walter P, Carter D, editors. Rob & Smith operative surgery 4,h ed. Butterworths 1983;449-54. 3. Liem MS, Graaf VY, Zwart RC et al. Risk factors for inguinal hernia in women: a case control study. Am J Epidemiology 1997;146(9):721-7. 4. Kaplan SA, Synder WH, Little S. Inguinal hernia in females and testicular feminization syndrome. Am J Dis Children 1969;117:43-51. 5. Gnidec AA, Marshall DG. Incarcerated direct inguinal hernia containing urerns, both ovaries and fallopian tubes. 1 Paedratric Surg 1986:21 :986. 6. Chen CL, Liu TP. Uterus, fallopian tube and ovary within a sliding hernia: a case report. Chung Hua I Hsueh Tsa Chih (Taipei) 1-)t)4;53:31-4. 7. Bradshaw Kl), Carr f1R. Ovarian and tubal inguinal hernia. Obskt G) naecol 19S6;(,8:50S-52S. 8. George I'K, Oudesluys-Murphy AM, Madero GC 1'1al. Inguinal hernia containing the uterus, fallopian lube and ovary in premature female infants. 1 Paediatrics 2000;136:696-703. 9. Zitsrnan JL, Cirincione E, Margossian H. Vaginal bleeding in an infant secondary to sliding inguinal hernia. Obstet Gynaecol 1997;89:40-2.
10. Amarin ZO, Hart DM. Inguinal ovary and fallopian tube-an unusual hernia. In J Ggynaecol Obstet 1988;27:141-4. 11. Kriplani A, Banerjee N, Aminni AC et al. Hernia uterus inguinale in a 46, XX female. A case report. J Reprod Med 2000;45:48-50. 12. Ando H, Kaneko K, Ito F et al. Anatomy of the round ligarnent in female infants and children with inguinal hernia. Br 1 Surg 1997;84:404-9. 13. Ozbey II, Ratschek M, Schimpl G et al. Ovary in hernia sac: prolapsed or descended gonad? J Paedtr Surg 1999; 34(6): 977-80. 14. Griffin JE, Wilson 1D. The syndromes of androgen resistance. N Eng J Med 1980; 302 : 198-20 I. 15. Given JP, Rubin 5Z. Occurrence of contralateral inguinal hernia following unilateral repair in a paediatric hospital. J Paediatric Surg 1989; 24(10):963-7. 16. Golladay ES, Lambert J8. Congenital inguinal hernia:Management of the contralateral side. J Arkansas Med Soc 1980; 76:494-9. 17. Christenberry DP, Powell RW. Intraoperative diagnostic pneumoperitoneum (Goldstein lest) in infant and child with unilateral inguinal hernia. Am 1 Surg 1987;154:628-35. 18. Lobe TE, Schropp DW. Inguinal hernia in paediatrics: Initial experience withh laparoscopic inguinal exploration of the aymptornatic contralateral,side (Letter). 1 Laparoendoscopic Surg 1992;2(3):135-7. MiAFl.
~'OL
57. NO.4.
zoot
Introduction
I
nguinal hernia in females is relatively uncommon as compared to males. It is interesting to note that 1 male in 5 and 1 female in 50 will eventually develop inguinal hernia in lifetime. The incidence of inguinal hernia in females is 1.9%, the ratio of boys to girls being 6: 1 [1]. In women, symptomatic but nonpalapable hernias often remain undiagnosed. The incidence of inguinal hernia in pregnancy is 1:1000. The site of presentation being 68.1% on the right side, 23.4% on the left and 8.5% bilateral [2]. The incidence of indirect hernia relates to congenital weakness at the internal abdominal ring. The sac is formed by the unobliterated portion of the prenatal peritoneal invagination of the canal of Nuck that runs along and partly covers the round ligament. Around 15% of the childhood hernias are incarcerated, especially those in young infants. In women, symptomatic but nonpalpable hernias often remain undiagnosed. Virtually nothing is known about risk factors for inguinal hernia in females. High sports activity is protective in inguinal hernia. Smoking, appendicectomy, abdominal operations and multiple deliveries are not associated with inguinal hernia in females [3]. Immediate operation should be done in all patients who are ill with obstructed or locally inflamed hernia, without attempting reduction.
children, 1 young girl and 2 elderly ladies. 2 children under one year presented with irreducible hernia (Fig-I), On emergency exploration one of them was found to be having incarcerated ovary, contents reduced back into peritoneal cavity after division of the external ring as there was no sign of strangulation. Sac was transfixed at bases and redundant sac was removed. Another 9 month old female child admitted for inguinal hernia repair developed features of obstruction during hospitalization. She was taken up for emergency surgery. On exploration, there was an incarcerated loop of smaIl intestine in the indirect sac. The exposed sac (Fig-2) was opened and the intestinal loop grasped with a Babcock forceps. The ileal loop. was examined for viability. external ring divided and internal oblique fibres laterally incised to allow reduction of the hernial contents. The sac was ligated at the base after irrigating the canal with saline solution and rest of the sac was removed. Wound was closed in layers without drain. The child had an uneventful postoperative period and was discharged after removal of sutures. 2 women who presented with inguinal hernia underwent Shouldice's herniorrhaphy. Rest of the 4 children underwent elective herniotomy in the same way. All these patients
Material and Methods 9 patients of inguinal hernia in females presented during Feb 96 to Dec 99 in service hospitals, 8 of them were managed surgically. Age group being 3 months to 65 years. 5 patients had right sided, rest presented as left sided inguinal swelling. There were 6 Classified Specialist (Surgery), Military Hospital. Bhopal- 31.
Fig. 1: Obstructed inguinal hernia (right) in a female child
307
Inguinal Hernia in FCIl'IIcs
Fig. 2: Indirect sac dissected in a female patient
Fig. 3: Inguinal hernia (right) in a young girl
were followed up in surgical OPD every month for six months and three monthly for one year for recurrence or appearance of inguinal hernia on the contralateral side.
incarceration occurs in the first year of life. 2 patients in this study presented with incarcerated hernia and 1 infant had sliding component containing ovary and tube. The incarcerated viscus in girls particularly infants is frequently an ovary. It has solid almond like feel, is generally located in the labium majus distal to the external ring and is somewhat mobile. An incarcerated ovary especially if oedematous is less likely to be reduced than intestine. Reduction of an incarcerated ovary is not as urgent as reduction of incarcerated intestinal loop but still it should be done at the earliest. Sliding hernias of the tube, ovaries and uterus occur occasionally in newborn female infants, but are rare in older women. [6]. When found in a woman of reproductive age, these are commonly associated with defects in genital tract development [7]. Some authors suggest ultrasonography for the diagnosis of inguinal hernia in premature female infants [8]. Vaginal bleeding in a child with inguinal hernia may occur when the uterus is the sliding component of the hernia [9]. An incarcerated ovary in a girl is usually a part of a sliding hernia as was seen in one of the infants in this study. The mesenteric attachment of the tube and ovary frequently form part of the hernial sac in girls [10]. Hernia uterus inguinale is a rare congenital anomaly found in hermaphrodites and surgeon should be careful to preserve and reposit the ovary in the abdominal cavity during exploration [11].
Results Out of 50 patients who presented with inguinal hernia. there were 41 males and 9 females in the age group of 3 months to 65 years (Table-I). There were 2 women, 1 young girl (Fig-S) and rest were small children. None presented with bilateral inguinal hernia. 8 female patients underwent surgery, 2 of them were taken up for emergency exploration. as they developed signs of obstruction. Herniotomy was done in 6 patients while 2 women underwent herniorrhaphy. There was no recurrence or appearance of hernia on contralateral side on follow up for one year. TABLE 1 Age distribution of patients Age (Yrs)
No. of patients
Male
4 7
10
6 11 8
15
3
2
5
5
;}
10
10
50 - 74
7
5
0
I 5 10
-
-
1 5
15 34
Female
2 4
8
2
Discussion All inguinal hernias in females occur as indirect protrusions. Many of these are in fact sliding hernias containing genital structures such as ovaries, fallopian tubes or even the uterus. Although no risk factors for inguinal hernia in females are known, independent risk factors are positive family history and obstination. Protective effects of sports activity in females can be explained by optimizing the resistance of the abdominal musculature protecting the relatively small inguinal weak point (4J. Because of the stress of childbearing, the transversalis fascia is stronger in the floor of the inguinal canal and hence has protective effect, so direct hernia in females is unusual [5]. Once a diagnosis of inguinal hernia in a female is made, repair should be carried out promptly because MJAFI. VOL 57. NO.4. ZOO]
The ligament which runs along an inguinal hernia sac in females is believed to be round ligament of uterus, is actually the suspensory ligament of the ovary and terminates in the hernia sac [12]. It is supposed to be female gubernaculum that has altered anatomy and localization because of absence of androgen responsiveness. Its modified presentation in a processus vaginalis raises the suspicion that ovary in the hernia sac may not be simply prolapsed, but is a descended gonad mimicking the descent of the testis
308
[13]. The sac wall may seem too thick in the medial or lateral quadrants in these cases and there may he difficulty in reducing the contents back within the peritoneal cavity. The sac shoull be opened in a normal appearing portion, and the walls inspected for a sliding component. The mesenteric attachment of the inner sac wall is divided in the bloodless plane within the sac. The freed up tube and ovary is then reduced easily with no compromise to the blood supply and the neck of the sac is closed in the usual way. When the sac is closed, the canal should be irrigated thoroughly with saline solution and closed primarily. Inguinal hernia in females should raise the surgeons suspicion about the child's nuclear sex, particularly if the condition is bilateral. About 2% of the girls with inguinal hernia have been reported to be having an intersex differentiation syndrome [14]. Approximately 1.6% of these children presenting with inguinal hernia and having apparent female genitalia, prove to be of male nuclear sex with intra abdominal testes but female anatomy and endocrine function - the testicular feminization syndrome. On exploration, fallopian tubes and ovaries should be examined in each patier.t by pulling on the round ligament which exposes the internal genitalia. None of our patients had such signs. The most common cause is testicular feminization syndrome, which is a result of end androgen resistance. In such patients a gonadectomy on one side and isolation of the other gonad in superficial position is done until puberty permits secondary sexual characteristics to develop. Bilateral exploration in all female patients has been recommended by some authors I15], because 90% of these girls have bilateral patency of the processus vaginalis, 40% have sliding hernias of the tubes and ovary, and none have vital structures in the canal likely to be injured such as the vas or testicular vessels as in males. However, this procedure was not followed in this study as none of the patients had bilateral presentation or developed contralateral hernia on follow up. Routine contralateral exploration is felt unjustified, since only 10% of children with unilateral repair subsequently developed a contralateral hernia [16]. Other authors have used pneumoperitoneum [17], preoperative herniogram, intraoperative laparoscopy [18], or probing to detect a possible contralateral patency. To conclude prompt surgical repair should be done in all female patients presenting with inguinal hernia in view of high incidence of incarceration of ovary and tubes in first year of life. Therefore, in female children the sac must be opened and its contents examined before it is tied off and excised. Young age
Chawla
should not contraindicate repair. All female children with inguinal hernia shoulJ have their nuclear sex ascertained and skilled paediatric advice should be sought where such anomalies are found. References 1. Read RC, White JJ. Inguinal herniation 1777-1977. Am 1 Surg 1978;136:651-7. 2. Devlin HB. Inguinal hernia in babies and children. In.Dudley H, Walter P, Carter D, editors. Rob & Smith operative surgery 4,h ed. Butterworths 1983;449-54. 3. Liem MS, Graaf VY, Zwart RC et al. Risk factors for inguinal hernia in women: a case control study. Am J Epidemiology 1997;146(9):721-7. 4. Kaplan SA, Synder WH, Little S. Inguinal hernia in females and testicular feminization syndrome. Am J Dis Children 1969;117:43-51. 5. Gnidec AA, Marshall DG. Incarcerated direct inguinal hernia containing urerns, both ovaries and fallopian tubes. 1 Paedratric Surg 1986:21 :986. 6. Chen CL, Liu TP. Uterus, fallopian tube and ovary within a sliding hernia: a case report. Chung Hua I Hsueh Tsa Chih (Taipei) 1-)t)4;53:31-4. 7. Bradshaw Kl), Carr f1R. Ovarian and tubal inguinal hernia. Obskt G) naecol 19S6;(,8:50S-52S. 8. George I'K, Oudesluys-Murphy AM, Madero GC 1'1al. Inguinal hernia containing the uterus, fallopian lube and ovary in premature female infants. 1 Paediatrics 2000;136:696-703. 9. Zitsrnan JL, Cirincione E, Margossian H. Vaginal bleeding in an infant secondary to sliding inguinal hernia. Obstet Gynaecol 1997;89:40-2.
10. Amarin ZO, Hart DM. Inguinal ovary and fallopian tube-an unusual hernia. In J Ggynaecol Obstet 1988;27:141-4. 11. Kriplani A, Banerjee N, Aminni AC et al. Hernia uterus inguinale in a 46, XX female. A case report. J Reprod Med 2000;45:48-50. 12. Ando H, Kaneko K, Ito F et al. Anatomy of the round ligarnent in female infants and children with inguinal hernia. Br 1 Surg 1997;84:404-9. 13. Ozbey II, Ratschek M, Schimpl G et al. Ovary in hernia sac: prolapsed or descended gonad? J Paedtr Surg 1999; 34(6): 977-80. 14. Griffin JE, Wilson 1D. The syndromes of androgen resistance. N Eng J Med 1980; 302 : 198-20 I. 15. Given JP, Rubin 5Z. Occurrence of contralateral inguinal hernia following unilateral repair in a paediatric hospital. J Paediatric Surg 1989; 24(10):963-7. 16. Golladay ES, Lambert J8. Congenital inguinal hernia:Management of the contralateral side. J Arkansas Med Soc 1980; 76:494-9. 17. Christenberry DP, Powell RW. Intraoperative diagnostic pneumoperitoneum (Goldstein lest) in infant and child with unilateral inguinal hernia. Am 1 Surg 1987;154:628-35. 18. Lobe TE, Schropp DW. Inguinal hernia in paediatrics: Initial experience withh laparoscopic inguinal exploration of the aymptornatic contralateral,side (Letter). 1 Laparoendoscopic Surg 1992;2(3):135-7. MiAFl.
~'OL
57. NO.4.
zoot
