Inguinal endometriosis or irreducible hernia? A difficult preoperative diagnosis

Abstract

Two cases of endometriosis infiltrating the round ligament and associated with an inguinal hernia are presented. The initial diagnosis was irreducible hernia, since this rare association often causes unusual preoperative symptoms and diagnostic problems. Diagnosis is frequently made by histologic examination. Surgery is the treatment of choice both for hernia and for endometriosis, and is locally curative. However, in a fertile woman with a painful mass in the inguinal region the possibility of endometriosis should be considered, and if suspected at inguinal exploration a laparoscopy should be made to rule out the presence of intraperitoneal endometriosis.

A case of inguinal endometriosis with difficulty in preoperative diagnosis

“…Endometriosis is a common disease characterized by the presence of endometrial tissue at sites other than the uterine cavity [11]. It is said that Rokitansky first described endometriosis in 1860 [12], but that case is now thought to be more properly defined as adenomyosis.…”

“…More rare locations are the vagina, vulva, bladder, umbilicus, lymph nodes, skin, muscle, lung, pleura, kidney, heart, and bone [7]. In these cases patients are classified by the localization and not by the size of the lesions [11]. Endometriosis outside the pelvis presents unusual symptoms which often cause misdiagnosis.…”

“…The intra-and extraperitoneal portion of the round ligament, hernia sacs, skin, and scars has been cited as regions of endometrial involvement in the groin [1,5,10,14]. Clausen reported 30 cases of endometriosis in the inguinal area, which were often associated with an inguinal hernia [4], and Miranda reported another 25 cases [11]. There are two cases of endometriosis in a hernia sac that had no association with the round ligament [1,13].…”

Magnetic resonance imaging findings of extrapelvic endometriosis of the round ligament

“…9 The intra-and extraperitoneal portion of the round ligament, hernia sacs, skin, and postoperative scars of the abdominal wall have been cited as regions of endometrial involvement in the groin. 10 The round ligaments of the uterus originate at the uterine horns, where the uterus and the uterine tube meet. These ligaments pass through the inguinal canals and enter the labium majus.…”

Endometriosis of the round ligament revealed by an intermittent hernia

“…In the latter case it can be confused with other common affections of the inguinal region, such as primitive or metastatic lymph nodes, soft tissue tumours and foreign body granulomas. It rarely causes a clinical picture suggestive of irreducible or strangulated hernia that requires urgent surgery [8][9][10].…”