Journal of Pediatric Surgery Case Reports 64 (2021) 101716

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Journal of Pediatric Surgery Case Reports

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Torsion of pediatric indirect inguinal hernia sac: A rare case

Basem Saied Abdelkader 1, Mahmoud Ahmed Ahmed Abdelbary *, 1, Amer Nihal Ahmed 1
Department of Pediatric Surgery, Saudi German Hospital, Jeddah, Saudi Arabia

A R T I C L E I N F O A B S T R A C T

Keywords: Torsion of the hernia sac is a rare condition that presents as an acute scrotum. There are 11 cases reported in the
Acute scrotum English literature at the best of our knowledge, this case is the 12th case. We report a case, a 2.5 -year-old boy,
Hernia sac who presented to the emergency room with tender right sided scrotal swelling. Ultra-sonography revealed intra-
Torsion
scrotal extra-testicular cystic lesion with normal right testis and epididimys. At surgery, a necrotic cyst with dark
altered fluid was identified extending into the scrotum, it was connected to the peritoneal cavity, not connected
to the testis or the epididymis, and it was twisted.

1. Introduction hemorrhagic fluid, neither bowel nor omentum was included within the
sac.
Acute scrotum in children is caused by group of conditions which The cyst was communicating directly with the peritoneal cavity that
should alert the attention to diagnose and treat them properly. Torsion was confirmed after untwisting and opening the cyst. Also it was
of hernia sac is a rare unusual cause. Incarcerated inguinal hernia also completely separable from the testis and the epididimys. The color of the
can present with acute scrotum. Coexisting communicating hydroceles right testis and epididymis was normal. Proper herniotomy was per­
are often present and it may be difficult to distinguish between a hernia formed which went uneventfully and the child was discharged well the
and a pure hydrocele, especially in infants. day after Figs. 1, 2 and 3.

2. Case presentation 3. Discussion

A 2.5-year-old boy attended the emergency room complaining of Acute scrotum is a surgical emergency which requires rapid inter­
painful swelling in the right inguinal region that was noticed one day vention [1]. The commonest causes encountered in children are torsion
before. His physical examination revealed a right inguinal hernia which of testicular appendages (70%), testicular torsion (12%), and
was reduced with gargling sensation with normal abdominal examina­ epididymo-orchitis (11%) [2]. It may requires exploratory surgery
tion. The child was scheduled for hernia repair. On the following day, despite the ultra-sonographic findings to rule out testicular torsion [5].
they revisited the emergency room with tender right sided scrotal A rare cause of acute scrotum in children is torsion of an inguinal
swelling. It was transilluminating, very tender and the cremastric reflex hernia sac [1]. There are 11 cases reported in the English literature [7],
was normal. in addition to the present case. The true incidence is unknown respective
Ultra-sonography showed a right inguinal hernia sac with clear fluid of etiology [4], and the mechanism also needs further investigations [6].
extending into the right hemiscrotum as intrascrotal extratesticular Regarding the age, it ranged between 2 and 10 years (2.5 years in this
cystic lesion and normal shape of the right testis and epididimys with case). The right sided hernia dominated which presented in 8 cases
normal blood supply. including this case while 4 cases in the left side [8]. Shiraishi et al.,.
The child was taken to surgery. Inguinal approach through right reported that preoperative diagnosis was difficult inspite of detailed
lower transverse abdominal crease incision was employed. The sper­ history taking, examination and radiological findings; however, only
matic cord was identified with dissection of the sac which revealed to be one case of them was diagnosed preoperatively with the help of contrast
a twisted necrotic cyst extending into the scrotum and filled with enhanced MRI [9].

* Corresponding author.
E-mail addresses: [email protected] (Basem Saied Abdelkader), [email protected], [email protected] (Mahmoud Ahmed Ahmed
Abdelbary), [email protected] (Amer Nihal Ahmed).
1
4 Baterjee street, Al-Zahraa District, Jeddah, P⋅O.Box 2250 Jeddah 21461Saudi Arabia.

https://doi.org/10.1016/j.epsc.2020.101716
Received 22 October 2020; Accepted 13 November 2020
Available online 22 November 2020
2213-5766/© 2020 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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Basem Saied Abdelkader et al. Journal of Pediatric Surgery Case Reports 64 (2021) 101716

Fig. 3. The sac is dissected till the proper neck.

date signed. It also contains the name of the baby and his hospital file
number.
The consent stated that the father completely understand that the
Fig. 1. Ultra-sonography revealed intra-scrotal extra-testicular cystic lesion. information regarding the case of his baby will be published without
name attached.
Also the consent stated that he, the father, understand that the text
and any pictures or videos published in the article will be freely avail­
able on the internet and may be seen by the general public, appear on
other websites or in print, may be translated into other languages or
used for commercial purposes. The consent was included in the file of
the patient.

Funding

No funding or grant support.

Authorship

All authors attest that they meet the current ICMJE criteria for
authorship.

Declaration of competing interest

The authors declare that they have no known competing financial

interests or personal relationships that could have appeared to influence
the work reported in this paper.

References

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A consent was obtained from the father including his name, signa­
ture, the date signed, the name of the authors, their signatures and the

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29, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
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29, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.