Incarcerated inguinal hernia: atypical presentation of an abdominal aortic aneurysm

Abstract

The diagnosis of an inguinal hernia, be it complicated or uncomplicated, is often simple and straight forward. Rarely, this simple presentation may be the external manifestation of a distant pathology, which is in communication with the inguinal canal through its anatomic relationship. We report a case of ruptured abdominal aortic aneurysm (AAA) that presented as a strangulated left inguinal hernia. To the best of our knowledge, this is the first reported case where the patient was stable on initial presentation, both clinically and biochemically. The only clue for our patient that pointed towards a potential aneurysm was the presence of intra-operative blood in the spermatic cord. We conclude that any patient presenting with symptoms suggestive of a hernia, particularly on the left side, should have a thorough assessment to rule out AAA.

Diagnosis and perioperative management of ruptured AAA mimicking symptomatic groin hernia

“…Rarely, RAAA can mimic incarcerated inguinal hernia, typically presenting as painful lump in the groin [7] . Literature search reveals in total 18 patients with ruptured aortoiliac aneurysms initially presenting as symptomatic/incarcerated hernia [2] , [3] , [4] , [8] , [9] , [10] , [11] , [12] . The fact that rupture of abdominal aneurysm appears as symptomatic hernia should not be surprising: First, there is increased activity of matrix metalloproteinases and their inhibitors in both abdominal wall (responsible for weakness of abdominal wall with subsequent hernia) and aortic walls (responsible for weakness of aortic wall and subsequent aneurysm formation) [13] .…”

“…Both cases finally turned out to be RAAA. This atypical presentation often undergoes erroneous preoperative management which frequently delays surgical treatment resulting in poor survival [10] . Thus we suggest, that patients with suspected symptomatic inguinal hernia combined with hypotension (leading to collapse) or the presence of blood in the spermatic cord while surgical hernia repair should immediately receive thoracoabdominal CTA for both diagnosing the RAAA and optimal preoperative planning.…”

An atypical presentation of aortic rupture: intuition and investigation can avoid disaster

“…6 Further case series have shown that patients have been taken for surgery based on an incorrect diagnosis. 7,8 Cases of retroperitoneal haematomas presenting as an incarcerated hernia are also documented, again with inappropriate operations being performed.…”