Inguinal hernia is a common surgical disorder. It represents major groin hernia presentations. More than 20 million groin hernia repairs are done globally each year.¹,² Many inguinal hernias remain asymptomatic or are managed electively, but complications may occur when the hernial contents become irreducible, obstructed or strangulated. The transition from an uncomplicated hernia to an emergency may be subtle. An irreducible hernia indicates incarceration, and progressive obstruction and vascular compromise can lead to strangulation, ischemia, necrosis and perforation. Gallegos et al., in a study of 476 groin hernias, documented 34 cases of strangulation and demonstrated that the risk of strangulation was particularly relevant during the early period following presentation. ³ The contents of an inguinal hernia most commonly consist of small bowel or omentum. Involvement of the large bowel is less common. The caecum, ascending colon, appendix and transverse colon have all been described within inguinal or inguinoscrotal hernial sacs.⁴⁻⁹ When a segment of colon becomes trapped at the hernial neck, obstruction may occur. Progressive distension, vascular compromise and perforation can subsequently transform a localized groin problem into a life-threatening intra-abdominal emergency. The present case is unusual because of the extensive bowel involvement within a right indirect inguinoscrotal hernia. The hernial sac contained the caecum, terminal ileum, ascending colon, part of the right transverse colon and omentum. A constriction ring produced a closed-loop obstruction, followed by marked caecal distension and two caecal perforations with pneumoperitoneum and fecal peritonitis.

A 40-year-old male, who was a smoker, presented with a swelling in the groin that was irreducible and painful for 10 days. The clinical presentation was suggestive of a right inguinal hernia with obstructed bowel loops. The painful irreducibility raised concern for a complicated hernia with possible bowel compromise. Contrast-enhanced computed tomography (CECT) of the abdomen and pelvis showed right inguinoscrotal hernia containing multiple intra-abdominal structures. The hernial contents included the ascending colon, part of the right transverse colon, caecum, terminal ileum and omentum. A 10 × 5 cm right indirect hernial sac was identified. The sac contained an overdistended caecum along with the terminal ileum and ascending colon. A constriction ring was present at the hernial neck which caused closed-loop obstruction. Two approximately 1 × 1 cm perforations were seen in the caecum. Pneumoperitoneum was present on CECT, raising suspicion of bowel perforation, which was confirmed intraoperatively by identification of caecal perforations. Fecal peritonitis was noted intraoperatively. Te radiological findings showed complex obstructed inguinoscrotal hernia with: Right indirect inguinal hernia Herniation of caecum Herniation of terminal ileum Herniation of ascending colon Herniation of part of the right transverse colon Omental herniation 10 × 5 cm indirect hernial sac Constriction ring Closed-loop obstruction Markedly overdistended caecum Two caecal perforations measuring approximately 1 × 1 cm each Pneumoperitoneum In view of the complicated hernia with bowel perforation and fecal contamination, emergency surgical intervention was undertaken. The patient underwent exploratory laparotomy. The caecum, terminal ileum and ascending colon were involved in the obstructed hernial configuration. The constriction ring had resulted in a closed-loop obstruction, with marked distension of the caecum. Two perforations measuring 1 × 1 cm were identified in the caecum, consistent with the radiological finding of pneumoperitoneum. In view of the perforation and fecal peritonitis, the involved bowel was resected. The caecum, ascending colon and terminal ileum were resected, followed by creation of an end ileostomy. The right inguinal hernia was repaired.

Inguinal hernias commonly contain small bowel or omentum, while herniation of the caecum and right colon is less frequent. The present case was unusual because the right indirect inguinoscrotal hernia contained the caecum, terminal ileum, ascending colon, part of the right transverse colon and omentum. A constriction ring at the neck produced a closed-loop obstruction, resulting in marked caecal distension and subsequent perforation. Caecal perforation associated with inguinal hernia has been described previously, but through different anatomical and pathological mechanisms. In the present case, the combination of an indirect hernial sac, extensive ileocaecal and right-colonic contents, a constriction ring causing closed-loop obstruction and two caecal perforations represents the main unusual feature. Skelly and Neill described an obstructed hepatic flexure contained within a right-sided inguinoscrotal sliding hernia, resulting in caecal perforation.⁴ Their patient developed acute colonic obstruction, and the hernial sac contained the hepatic flexure and omentum. The resulting proximal colonic obstruction led to caecal wall perforation. The authors informed the unusual nature of colonic obstruction caused by an inguinoscrotal hernia.⁴ The present case shares two major features with that report: right-sided inguinoscrotal herniation and caecal perforation secondary to obstruction. However, the anatomical configuration differs. Skelly and Neill described a sliding hernia involving the hepatic flexure, and our patient had a right indirect hernial sac measuring 10 × 5 cm containing the caecum, terminal ileum and ascending colon, with part of the right transverse colon and omentum. CECT in our case showed constriction ring producing a closed-loop obstruction. Another important comparison is the case reported by Tantia et al., in which a 55-year-old man presented with an irreducible right-sided indirect inguinal hernia. At operation, the caecum and proximal ascending colon were found within the hernial sac. A perforated caecal diverticulum was identified, and right hemicolectomy was done because malignancy could not initially be excluded. Histopathology demonstrated a perforated caecal diverticulum containing tablets, without malignancy.⁵ Kromka et al. reported a 46-year-old man with a right incarcerated inguinal hernia in which an inflamed gangrenous appendix and perforated caecum were found. The patient underwent ileocecectomy and hernia repair without mesh.⁶ This case shows another unusual pathway to caecal perforation within an inguinal hernia. Unlike the present case, however, appendiceal inflammation was central to the pathology, and the hernia was an Amyand's hernia. The current patient had no reported appendiceal pathology. Jha et al. reported a left-sided Amyand's hernia with perforated caecum in a 66-year-old man presenting with an obstructed inguinoscrotal hernia and suspected perforation. Emergency laparotomy revealed perforated caecum within the hernial sac.⁷ The authors highlighted the difficulty of diagnosis when unusual anatomy and bowel displacement are present. Though the side and anatomical arrangement differ from our case, the report supports the principle that caecal perforation can occur in an inguinal hernia and may be difficult to diagnose clinically.⁷ Kaushal-Deep et al. described a pediatric case of perforated caecum in a left Amyand's hernia, with free air and fecal fluid within the hernial sac.⁸ The case was associated with abnormal intestinal anatomy and a mobile caecum. Although this differs considerably from our adult patient, it shows how abnormal mobility of the caecum can facilitate unusual herniation and perforation. Ahmed et al. described a 75-year-old man with a massive right inguinoscrotal hernia containing the entire right colon. CT showed perforation of the ascending colon with abscess formation, and laparotomy revealed ischemia and congestion involving the terminal ileum, caecum, appendix, ascending colon and omentum. Right hemicolectomy and ileostomy were performed.⁹ This case has anatomical similarity to the present case. Both involved a right inguinoscrotal hernia containing terminal ileum, caecum, ascending colon and omentum, followed by bowel compromise and perforation requiring laparotomy, bowel resection and ileostomy.⁹ However, the present case differs in several important respects: the patient was 40 years old, the hernia was specifically characterized as an indirect hernia with a 10 × 5 cm sac, and CECT showedonstriction ring with closed-loop obstruction and two caecal perforations. Chang et al. recently reported a strangulated transverse colon inguinal hernia complicated by caecal perforation in a patient with sclerosing mesenteritis.¹⁰ This report is particularly relevant because it shows that transverse colon involvement within an inguinal hernia can contribute to severe proximal colonic complications. Tzortzis et al. reported another unusual right inguinoscrotal hernia containing the caecum, ascending colon and terminal ileum, but in that case the underlying pathology was perforated caecal carcinoma.¹¹ The report shows that malignant disease can occasionally present as a strangulated inguinoscrotal hernia. But, there is no evidence of malignancy in the clinical information provided for our patient, and malignancy should not be inferred in the present case. Taken together, these reports demonstrate that caecal perforation associated with an inguinal hernia is not a single pathological entity. Different mechanisms may be responsible, including: Closed-loop obstruction Strangulation Caecal diverticular perforation Appendiceal pathology Abnormal caecal mobility Malignancy Extensive colonic herniation The present case is distinguished by the combination of indirect inguinal herniation, extensive ileocaecal and right-colonic contents, a constriction ring, closed-loop obstruction and two caecal perforations. The role of imaging is important in unusual or complicated hernias. Although uncomplicated inguinal hernias can often be diagnosed clinically, cross-sectional imaging can provide additional information when the hernia is irreducible, painful or suspected to contain complicated bowel. In the present case, CECT showed the anatomy of the hernia and its contents before surgery. It identified the caecum, terminal ileum, ascending colon, part of the transverse colon and omentum within the hernial sac. It also showed the constriction ring and closed-loop obstruction and identified pneumoperitoneum, raising the possibility of perforation. CT is useful in assessing bowel obstruction and can provide signs suggestive of strangulation. Kim et al. evaluated CT criteria in 136 patients with simple or strangulated small-bowel obstruction and found that CT findings like poor bowel-wall enhancement, mesenteric haziness and a serrated beak were useful, but CT was not completely sufficient on its own and clinical criteria improved diagnostic interpretation.¹² So, imaging should complement rather than replace clinical assessment. In the present case, the combination of the clinical finding of a painful irreducible hernia and the CT findings of closed-loop obstruction and pneumoperitoneum provided strong evidence of an advanced surgical emergency. From Closed-Loop Obstruction to Caecal Perforation The pathological sequence in this case can be conceptualized as: Indirect inguinal hernia → incarceration/irreducibility → constriction ring → closed-loop obstruction → progressive caecal distension → perforation → pneumoperitoneum → fecal peritonitis. In the present case, the presence of two separate caecal perforations emphasizes the severity of the process. The treatment of a complicated hernia depends on the condition of the herniated bowel and the degree of contamination. Acutely irreducible groin hernias are life-threatening and require urgent surgical assessment and intervention, particularly when strangulation is suspected.¹³ The management of complicated abdominal wall hernias depends on bowel viability and the degree of contamination. Once perforation and fecal peritonitis are present, simple reduction of the hernia is inadequate. The source of contamination must be controlled, nonviable or perforated bowel must be removed, and the hernia defect must be addressed. In the present case, exploratory laparotomy was done followed by resection of the caecum, ascending colon and terminal ileum, creation of an end ileostomy, and right inguinal hernia repair. The operative management is consistent with the principle that, in an emergency hernia complicated by perforated bowel, treatment must prioritize control of contamination and removal of the diseased bowel before definitive management of the hernia defect. The choice of hernia repair technique in a contaminated field should be individualized. The WSES guidelines shows increased risk of wound infection and other complications in emergency hernia repair associated with bowel resection and contamination.2 The unseen pathology included: A 10 × 5 cm indirect hernial sac Caecal herniation Terminal ileal herniation Ascending-colon herniation Partial transverse-colon herniation Omental herniation Constriction at the hernial neck Closed-loop obstruction Marked caecal distension Two caecal perforations Pneumoperitoneum, Fecal peritonitis Thus, the groin swelling was only the external manifestation of a complex intra-abdominal emergency.

Obstructed indirect inguinoscrotal hernia with caecal perforation is an uncommon but serious presentation. In this case, a constriction ring produced closed-loop obstruction with marked caecal distension, resulting in two caecal perforations and faecal peritonitis. CECT was useful in demonstrating the hernial contents, closed-loop obstruction and pneumoperitoneum before surgery. A painful, irreducible inguinoscrotal hernia should therefore raise suspicion of significant bowel compromise and prompt early imaging and surgical management.

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