Necrotic Epiploica Appendix as the Sole Content of Strangulated Inguinal Hernia

Background: Small bowel loops or a part of omentum is the usual content of inguinal hernia. However, certain parts of the colon, urinary bladder, vermiform appendix, Meckel’s diverticulum, uterine tube and ovary, and other tissues may be observed in a strangulated groin hernia much less frequently. Epiploic appendages of the colon are considered to be one of the rarest types of such hernia content. Case report: A 60 year male is brought to ER for severe pain in left inguinal region of several hours duration. Based on clinical history, physical examination findings of tender, irreducible lump at the left deep inguinal ring; along with leukocytosis, the patient was taken for emergency inguinal exploration. Findings of necrotic epiploica appendix adherent to normal sigmoid colon as the sole content of the hernial sac was surprising and indeed a rare event. A tension free mesh hernioplasty was accomplished. Conclusion: Surprising hernial content as necrotic epiploica appendix may be encountered in clinical practice rarely, and can be managed with mesh repair if the wound is considered relatively clean. INTRODUCTION It is well known that the most common content of a strangulated inguinal hernia is a small bowel loop or part of the major omentum [1]. Certain parts of the colon, urinary bladder, vermiform appendix, Meckel’s diverticulum, uterine tube and ovary, and other tissues may be observed in a strangulated groin hernia much less frequently [1]. Epiploic appendages of the colon are considered to be one of the rarest types of such hernia content [2]. This clinical situation (the strangulation of an epiploic appendage in an inguinal hernia) was described, independently and for the first time, by Serve and Muscatello in 1906, [3]. Likewise, we would like to present a similar but rare case of the strangulation and necrosis of an epiploic appendage of the sigmoid colon in a left indirect inguinal hernia. CASE REPORT A 60-year male who never had noticed a groin lump beforehand, is brought to emergency room with increasingly severe pain and a tender lump at left groin of 8-hour duration after a single event of harsh straining while working in the woods. The patient gives history of 2 episodes of projectile vomiting but denies obstipation or abdominal distension. The patient has no trauma to groin, pain in scrotum, negative for substance abuse except for cigarette smoking. The patient was in understandable agony with a heart rate of 110 beats per minute, blood pressure of 160/60 mmHg supine, SpO2 96% in room air. Examination, hindered by pain, of the Left groin revealed a tender, irreducible mass of 4X3cm in the left inguinal region. There were no skin changes. A diagnosis of strangulated left inguinal hernia was made and patient shifted to operation theatre after hematological work up. There was leukocytosis, total count 16,400 with neutrophilia. Rest of blood investigations was normal. X-ray abdomen showed no abnormality except for a loop of large bowel in left lower quadrant. Under spinal anesthesia, left inguinal region was explored with a liberal incision over the swelling. An indirect inguinal hernial sac was dissected open to reveal small necrotic tissue covered by inflamed adipose elements. After suction and lavage of the area with normal saline, the sac of hernia was incised as to allow inspection of deeper structures. It was revealed that the necrotic and hypertrophied tissue Pangeni et al. (2017) Email: Ann Emerg Surg 2(3): 1013 (2017) 2/3 Central Bringing Excellence in Open Access 