Rare Groin Hernias With Unusual Sac Contents: A Systematic Review of Anatomical Variants and Surgical Implications

Groin hernias are commonly encountered in general surgical practice. Most of these hernias have a typical anatomical structure and contain the usual type of hernia sac content. Still, in some rare cases, a hernia may show abnormal anatomy or contain unexpected material within the sac, which can affect both how it presents clinically and the surgical approach needed for treatment. This systematic review seeks to give an overview of rare groin hernias with unusual sac contents, detail their anatomical variations, describe their clinical features and diagnostic difficulties, and discuss the implications that may come up during surgical management. A systematic review with qualitative synthesis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search was carried out in PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE) and included studies on rare inguinal and femoral hernias in adult patients. A focused supplementary search was also performed for hernias containing Meckel's diverticulum. Studies were considered eligible when they described unusual hernia sac contents or relevant anatomical variations. Pediatric studies, review articles without original data, retracted publications, studies unrelated to inguinal or femoral hernias, and studies without a clear description of sac contents were excluded. In total, 43 studies were included in the final qualitative synthesis. Several uncommon inguinal and femoral hernias containing unexpected sac contents were found. The documented contents included the vermiform appendix, Meckel's diverticulum, segments of the colon, the urinary bladder, and bowel that became trapped after reduction. The main types described were Amyand hernia, De Garengeot hernia, Littré hernia, sliding inguinal hernia, and reduction en masse. Diagnosing these conditions before surgery was often challenging, since many cases looked like typical incarcerated or strangulated groin hernias. CT scans or ultrasonography were helpful in certain cases, but the diagnosis was usually established during the operation. The surgical approach depended on the sac's contents, the presence of inflammation or contamination, the viability of the bowel, and whether any organs were involved. Inguinal and femoral hernias that contain unusual sac contents are uncommon, but the cases reviewed indicate that they can influence both diagnosis and surgical management. The hernia sac might hold the appendix, Meckel's diverticulum, colon, urinary bladder, or bowel that becomes trapped after what appears to be a reduction. Since the clinical symptoms frequently mimic those of a typical incarcerated or strangulated groin hernia, making a preoperative diagnosis is challenging, and many of these cases are only identified during surgery. The surgical approach should be tailored to the specific sac contents, the presence of inflammation or contamination, the viability of the bowel, whether the bladder or colon is involved, and the overall condition of the patient. As most of the available evidence comes from case reports and small case series, it is not possible to make strong treatment recommendations, and there is a need for more consistent reporting.