Indirect inguinal hernia with ectopic testis at subcutaneous plane of anterior abdominal wall

A 35-year-old man, presented with on-and-off swelling in the left inguinal and left iliac region occurring since 10 years after trauma to the left groin region. He had also history of absent left testis since birth.

On clinical examination

Inspection on standing position, diffuse soft ill defined partial reducible swelling was noted over left iliac region which appeared to extend to the base of the scrotum (Figures 1a and 1b). Swelling of doughy and granular consistency, which showed expansile cough impulse, was present in the left inguinal region. Large gap defect was identified at left inguinal region, near deep inguinal ring. On straining, there was increase in size of the left inguinal swelling, which seemed to move upward to the left flank region.

On US, a gap defect was noted in the left inguinal region with herniation of omentum (Figure 2), which extended to the left and lateral direction along subcutaneous plane of the left iliac region. A well-defined homogenous echogenic capsulated oval structure (Figure 3) with absent vascularity (Figure 4) was noted near the tip of herniated omentum. Contrast Enhanced CT of the abdomen for preoperative planning showed absent left testis in the left scrotal sac (Figure 5) and left-sided inguinal canal wall defect with herniation of omental fat (Figure 6) inferiorly in the inguinal region and superiorly in the anterior abdominal wall on left side up to infraumbilical region.

Ectopic testis was seen within the herniated omentum in the anterior abdominal wall at rhw level of iliac crest (Figure 7).

Imaging diagnosis was given as left inguinal hernia with ectopic testis within herniated omentum.

Testicular descent occurs in two phases: a transabdominal phase and an inguinoscrotal phase. The 1st phase, the transabdominal phase (8-15 weeks of gestation), is controlled by enlargement of the gubernaculum and regression of the cranial ligament. Insulin-like hormone 3 is the primary regulator of the 1st phase, possibly assisted by mullerian inhibiting substance/antimullerian hormone (MIS/AMH) and by regression of the cranial suspensory ligament induced by testosterone. The second phase (25-35 weeks of gestation), the inguinoscrotal phase, requires migration of the gubernaculums from the groin into the scrotum and its migration is guided by calcitonin gene-related peptide released by the genitofemoral nerve. The inguinoscrotal phase of testicular descent is regulated by androgens and by calcitonin gene-related peptide release by the sensory nucleus of the genitor femoral nerve [1].

Testicular ectopia is defined as a testis which is located away from the normal pathway of testicular descent and outside its ipsilateral hemiscrotum. Of the known ectopic sites, the anterior abdominal wall is one of the most infrequent locations [2].

There is one report of a male infant who had an interparietal hernia that contained testis in its wall. In this case, the hernia sac passed through the deep inguinal ring and extended superiorly to the anterior abdominal wall between the external oblique and internal oblique aponeurosis [3].

In contrast to this case, our case is an adult male patient who has normal developed inguinal canal with indirect sliding inguinal hernia containing omentum which runs in subcutaneous plane of abdominal wall with testis within.

In our case, initial clinical provisional diagnosis was subcutaneous lipoma with left inguinal hernia before US. US and CT scans were helpful for final diagnosis and helped for the preoperative approach.

Intraoperative findings

Patient underwent surgery. Inguinal gap defect was identified. Ectopic testis was resected by ligating cord and gap defect was repaired (Figure 8). Patient was hospitalized for 2 more days for observation which was uneventful, and then discharged.

All patient data have been completely anonymised throughout the entire manuscript and related files.