Indirect inguinal hernia containing portosystemic shunt vessel: A case report

Abstract

Background: Inguinal hernia repair is one of the most common general surgical operations worldwide. We present a case of indirect inguinal hernia containing an expanded portosystemic shunt vessel.

Case summary: We report a 72-year-old man who had a 4 cm × 4 cm swelling in the right inguinal region, which disappeared with light manual pressure. Abdominal-pelvic computed tomography (CT) revealed a right inguinal hernia containing an expanded portosystemic shunt vessel, which had been noted for 7 years due to liver cirrhosis. We performed Lichtenstein's herniorrhaphy and identified the hernia sac as being indirect and the shunt vessel existing in the extraperitoneal cavity through the internal inguinal ring. Then, we found two short branches between the expanded shunt vessel and testicular vein in the middle part of the inguinal canal and cut these branches to allow the shunt vessel to return to the extraperitoneal cavity of the abdomen. The hernia sac was returned as well. We encountered no intraoperative complications. After discharge, groin seroma requiring puncture at the outpatient clinic was observed.

Conclusion: If an inguinal hernia patient has portal hypertension, ultrasound should be used to determine the contents of the hernia. When atypical vessels are visualized, they may be shunt vessels and additional CT is recommended to ensure the selection of an adequate approach for safe hernia repair.

Keywords: Case report; Inguinal hernia; Lichtenstein’s herniorrhaphy; Portal hypertension; Portosystemic shunt; Shunt vessel.

Figure 1

Computed tomography findings 7 years before surgery. A: A portosystemic venous shunt vessel was evident (triangles); B: Portosystemic venous shunt vessel near the abdominal wall (triangle); C and D: A portosystemic venous shunt had formed between the ileocolic and testicular veins. Triangle: Shunt vessel; Double triangles: Testicular vein flowing into the inferior vena cava; Arrow: Femoral vein; Double arrows: Superior mesenteric vein; Circle: Inferior epigastric artery.

Figure 2

Preoperative computed tomography and ultrasound findings. A: Preoperative computed tomography revealed a portosystemic venous shunt vessel located in the ventral part of the femoral vein (arrow) and entered the internal inguinal ring (triangle); B: Abdominal ultrasound detected the shunt vessel just under the groin.

Figure 3

Photograph taken during surgery. A: The expanded (2-cm-diameter) shunt vessel existing in the extraperitoneal cavity entered the inguinal canal through the internal inguinal ring. An indirect hernia sac and two short branches connecting the shunt vessel and the testicular vein were identified; B: Shunt vessel after cutting short branches. Triangle: Shunt vessel; Double triangles: Indirect hernia sac; Triple triangles: Vas deferens and testicular artery and vein; Arrow: Two short branches between the shunt vessel and testicular vein; Double arrows: Extraperitoneal fat; Stars: Cut-off stumps of ligated short branches.

Figure 4

Postoperative computed tomography findings. The computed tomography scans indicated that the shunt vessel was no longer located near the right internal inguinal ring, and it had separated from the femoral vein. Triangle: Shunt vessel; Arrow: Femoral vein.

Figure 5

Timeline from diagnosis to treatment. AAA: Abdominal aortic aneurysm; CT: Computed tomography; US: Ultrasound.