Asymptomatic herniation of ureter in the routine inguinal hernia: A dangerous trap for general surgeons

Inguinoscrotal hernias of the ureter are an extremely rare phenomenon. They can pose a threat to the unprepared general surgeon performing routine herniorrhaphy.

A 72 year old man presented with a one year history of a lump in the left groin causing occasional discomfort. On examination a partially reducible left sided inguinal hernia was found. He had no urinary symptoms and was otherwise fit and healthy. He had a right inguinal hernia similar to this repaired 20 years ago.

Intraoperatively the patient had a large sliding inguinoscrotal hernia with a bulky amount of retroperitoneal fat. A white tubular structure was found amongst the hernia contents but demonstrated peristalsis on stimulation with forceps. It was initially thought to be a duplicated vas deferens. The hernia contents were pushed back in and a Lichtenstein repair was performed. Postoperatively the patient was found to have normal renal function and a CT IVP showed mild dilatation of the left ureter amidst irregular retroperitoneal fat (reduced hernia contents). There was no evidence of a stricture or ureteral damage. The urologists managed the patient conservatively with bi-annual imaging of the renal tract.

Many ureteral inguinal hernias reported in the literature have been on renal transplant patients, while rarely on native kidneys. This case suggests no inguinal hernia repair is routine. Awareness of this anomaly is important, to avoid ureteral injury during herniorrhaphy.