Hernia (2009) 13:149–153
DOI 10.1007/s10029-008-0446-1
ORIGINAL ARTICLE
Inguinal hernia in Nigerian female children: beware of ovary
and fallopian tube as contents
O. D. Osifo Æ M. E. Ovueni
Received: 23 July 2008 / Accepted: 7 October 2008 / Published online: 8 November 2008
Ó Springer-Verlag 2008
Abstract
Background The risk of injury to the ovary and fallopian
tube during herniotomy in female children is quite high,
and reports on the frequency of these organs as inguinal
hernia contents and, as such, prevention from injuries are
not available in this subregion. This study was designed to
determine the frequency of ovary and fallopian tube as
contents of inguinal hernias sacs in Nigerian female
children.
Methods An eight-year prospective study was undertaken
at two Nigerian healthcare institutions between July 2000
and June 2008. All female children treated with herniotomy
during the period had their hernia sacs opened and
inspected for their contents, which were documented on a
pro forma.
Results A total of 138 female children aged between
2 months and 12 years (mean 5 ± 3.4 years) were diag-
nosed with 176 inguinal hernias treated with herniotomy at
the two centers and comprised 11.1% of children with
hernias in eight years. On inspection, 145 (82.4%) hernias
contained either ovary and/or fallopian tube, with the ovary
being the only content in 82 (46.6%) sacs. The ovary and
fallopian tube were the contents in 43 (24.4%), while fal-
lopian tube alone was the content in 20 (11.5%) hernias. It
was only in 31 (17.6%) that they were not contents of the
hernia sacs, as 21 (11.9%) of these hernias contained per-
itoneal fluid, seven (3.9%) omentum, and three (1.7%) loop
O. D. Osifo (&)
M. E. Ovueni
Pediatric Surgery Unit, Department of Surgery,
University of Benin Teaching Hospital,
P.M.B. 1111, Benin City, Nigeria
e-mail: leadekso@yahoo.com
M. E. Ovueni
e-mail: apsonben@yahoo.com
of bowels. In the majority of children below the age of 5
years and in eight (4.5%) older children, the hernias were
sliding, with ovaries forming part of the inferomedial wall
with a high probability of injury during herniotomy.
Conclusion Ovary and fallopian tube were common
contents of inguinal hernia sacs in Nigerian female chil-
dren. Efforts should be made to inspect the contents of
hernia sacs during herniotomy, while blind transfixion
without first opening them to inspect and reduce the con-
tents should be avoided.
Keywords Inguinal hernias
Female
Children

Ovary
Fallopian tube
Introduction
The processus vaginalis is a prolongation of peritoneum
into the inguinal canal during the descent of the testis in the
male fetus and its persistence and patency after birth results
in indirect inguinal hernia in male children. Similar events
occur in the female fetus, though to a much lesser degree,
when the peritoneum herniates into the canal of Nuck
during the descent of the round ligament of the uterus, with
its persistence and patency after birth resulting in indirect
inguinal hernia in female children [1, 2]. Surgeons require
care to avoid injury to spermatic cord contents during
herniotomy in male children because of the close proximity
of the vas deferens and testicular vessels to the hernia sac,
although many such inadvertent injuries have been repor-
ted [3, 4]. Unfortunately, herniotomy on female children
are often carried out with less care because of the absence
of spermatic cord and its contents in the female inguinal
canal. However, much literature [5, 6] have reported inci-
dences of various forms of injury to the ovary and fallopian
123
150
tube in female children who had herniotomy. This is
because the majority of inguinal hernias in female children
are of the sliding variety with ovary and fallopian tube as
the main contents [7–9]. These vital reproductive organs
are, therefore, predisposed to injury in the hands of the
unwary surgeons.
In many resource-poor regions, routine ultrasound scan
is not performed to discover the contents of the hernia sacs
before performing herniotomy on children due to financial
constraints [10–12]. The risk of injury to these organs
could be reduced in such instances if preoperative assess-
ment highlights the contents of the hernia sacs. Although
many females have been reported [6, 13] with infertility
following inadvertent damage to these internal reproduc-
tive organs during herniotomy performed in childhood, few
studies have been done with the aim of reducing the
catastrophe. The non-availability of manpower and facili-
ties required to perform laparoscopic herniotomy and
microsurgical reconstructions of the fallopian tube further
compounds the problem [3, 14]. Also, few studies have
been undertaken in this subregion to determine the contents
of inguinal hernia sacs and the probable risk of injury to the
ovary and fallopian tube during herniotomy in female
children.
In view of this, an eight-year prospective study was
conducted on female children diagnosed with inguinal
hernias at two healthcare institutions in Nigeria. The aim
was to determine the contents of inguinal hernia sacs in
Nigerian female children, in order to heighten awareness
among surgeons, which may lead to a reduction of injury to
these vital reproductive organs during herniotomy.
Patients and methods
Study design
This eight-year prospective study was undertaken at two
healthcare institutions, University of Benin Teaching
Hospital (UBTH), Benin City, and Leadeks Medical Centre
(LMC), which are situated about 10 km apart in the Edo
State of Nigeria, between July 2000 and June 2008. The
UBTH is located in an urban city with a population of
approximately 2 million people, while the LMC is located
in a suburban community with an approximate population
of 600,000 people in the Ovia North-East Local Govern-
ment Area.
Recruitment
On obtaining approval from the local Ethics Committee
Board of the UBTH, consecutive cases of female children
123
Hernia (2009) 13:149–153
diagnosed with inguinal hernia were recruited for the study.
The procedure was carefully explained to parents/caregiv-
ers, following which, their consents were obtained. Only
the children whose parents/caregivers gave consent were
included, while the two children whose consents were
refused were excluded.
Methods
The children were stabilized before operation and were
received at the waiting area of the theater by the nurses and
transferred to the anesthetic room, where intravenous lines
were secured. Inhalational general anesthesia was admin-
istered via face/laryngeal mask. The inguinal canal was
accessed through a groin crease incision placed just lateral
to the pubic tubercle. After delivering the hernia sacs into
the wound, each were slit open on the superolateral portion
from the fundus down to the level of the deep ring, taking
care to protect the contents. Thereafter, the contents were
inspected and the findings documented on a preformed pro
forma. Herniotomy was then completed after the contents
were successfully reduced and the wound was closed in
layers.
Statistical analysis
The data obtained were analyzed using SPSS and presented
as count, frequency, and percentage. Continuous data were
expressed as mean ± standard deviation (SD).
Results
A total of 138 female children who were aged between
2 months and 12 years (mean 5 ± 3.4 years) were diag-
nosed with 176 inguinal hernias and were treated with
herniotomy at the two centers in eight years. They com-
prised 11.1% of 1,239 children treated with inguinal
hernias and hydrocele (M/F ratio 9:1) and contributed
12.2% to all herniotomies performed during the period. As
shown in Table 1, 76 (43.1%) hernias were bilateral as
diagnosed in 38 children, 55 (31.3%) right, and 45 (25.6%)
left. The hernias were reducible in the majority (91.5%) of
children while 15 (8.5%) were irreducible (Fig. 1), with no
incidence of obstructed or strangulated hernia recorded
among the children. Therefore, all of the hernias were
operated as elective cases. Also, the hernias were mainly
groin as seen in 124 (70.5%) and inguinolabial in 52
(29.5%) children.
On opening the hernia sacs, there was a high probability
of injury to the ovaries and fallopian tubes in 145 (82.4%)
cases as they were the contents. As shown in Fig. 2, the
Hernia (2009) 13:149–153 151

Table 1 The side distribution, contents, nature, and types of female

inguinal hernias treated over the eight years of the study
Side distribution Frequency Percentage

Bilateral 76 43.1
Right 55 31.3
Left 45 25.6
Total 176 100
Contents
Ovary alone 82 46.6
Ovary/fallopian tube 43 24.4
Peritoneal fluid alone 21 11.9
Fallopian tube alone 20 11.5
Omentum 7 3.9
Intestine 3 1.7
Total 176 100 Fig. 2 The same girl as in Fig. 1 after the hernia sac was mobilized
Nature into the wound during herniotomy. Note the ovary grasped between
the surgeon’s fingers with dissecting forceps pointing to it
Reducible 161 91.5
Irreducible 15 8.5
(3.9%) had omentum, and three (1.7%) had loop of bowels
Obstructed 0 0
with no evidence of obstruction. In the majority of children
Strangulated 0 0
below 5 years of age, the ovaries were small structures that
Total 176 100
loosely adhered to the inferomedial wall of the hernia sacs.
Type
Each could be mistaken for a pad of fat or lymph node but
Inguinal 124 70.5
careful inspection revealed their vascular appendages.
Inguinolabial 52 29.5
They were easily bluntly dissected and returned to the
Total 176 100
peritoneal cavity. Among the older girls, the hernias were
irreducible in eight (4.5%) who had only ovary as content
and seven (3.9%) of them with omentum.
In the eight children with irreducible hernias, the ovary
formed part of the inferomedial wall of the hernia sacs and
were difficult to reduce into the peritoneal cavity; efforts to
dissect it free failed. As a result, a purse string was applied
at the neck of the hernia sacs and tied under direct vision,
following which the sacs were invaginated into the peri-
toneal cavity. Preoperative ultrasound scan was not
routinely done except in the event of obstruction or stran-
gulation, which were not encountered in these cases. In the
event of strangulation, explorative laparotomy under
endotracheal intubation, and not the use of face/laryngeal
masks as in these uncomplicated hernias, is required. Also,
because of the endemicity of malaria infection and hel-
minthes infestation in this subregion, children who appear
Fig. 1 A 4-year-old girl with right irreducible hernia containing healthy may be having low hematocrit, which contraindi-
ovary cates surgery. Therefore, only preoperative hematocrit,
which helped to reduce the cost of treatment, was used on
ovary was a predominant content because it was the only healthy children. Consequently, 27 (19.6%) and 18 (13%)
content of the hernia sacs in 82 (46.6%) hernias. The ovary children were placed on combinations of hematinic/anti-
and fallopian tube were the contents in 43 (24.4%), while malaria and hematinic/antihelminthes due to malaria
fallopian tube alone was content in 20 (11.5%) hernias. It infection and helminthes infestation, respectively, and had
was only in 31 (17.6%) of the cases that the probability of their surgeries deferred for three weeks. Nevertheless, the
injury to the ovary or fallopian tube was low because 21 post operative course was uneventful in all of the children
(11.9%) of these hernias contained peritoneal fluid, seven and they were discharged home within 24 h of surgery.

123
152
Discussion
In comparison with male children, inguinal hernia is rare in
female children, accounting for 11.1% of children treated
with inguinal hernias during this study, which is similar to
other reports [15–17]. This is due to the absence of testis in
female children, whose descent results in the protrusion of
peritoneum into the inguinal canal that may persist after
birth and give rise to inguinal hernia. Although inguinal
hernia is rare in female children, reported [6–9] associated
injury to the internal reproductive organs during herniot-
omy in young girls is alarming. This has been attributed to
the high number of female hernias with vital reproductive
organs, particularly ovary and fallopian tube, as contents.
Of the 176 hernias whose contents were inspected in this
study, 145 (82.4%) were found to contain ovary and fal-
lopian tube in different combinations, and these organs ran
the risk of injuries by the unwary surgeons during herni-
otomy, as also noted in similar studies [13–18].
As seen in the majority of children below 5 years of age in
this study, the hernias were of the sliding variety, with
ovaries and fallopian tubes forming part of the inferomedial
wall of the hernia sacs, as reported earlier [19]. These ova-
ries were small structures which loosely adhered to the
hernia sacs and could be taken for a pad of fat or lymph node,
except for the vascular appendages. Although they were
easily dissected and returned to the peritoneal cavity, this
was not so among the older girls, eight (4.5%) in whom the
hernias were irreducible. The application of a purse string
suture which was carefully tied under direct vision with the
sacs invaginated into the peritoneal cavity was required to
protect them from being injured. This was similar to the
experiences of previous authors [8, 15–17] and these ovaries
were the most prone to inadvertent injuries. The possibility
of injury to ovaries and fallopian tubes was supposedly low
in 31 (17.6%) hernias. Injury to these organs would have
been avoided because 21 (11.9%) of these hernias contained
peritoneal fluid and seven (3.9%) contained omentum.
On the other hand, the risk of injury to the intestine in
this series was low because there were only three (1.7%)
hernias that contained intestine, although inadvertent injury
to the intestine in female hernia has been reported [20].
This is contrary to what is encountered in male children
with hernias, in whom the intestine is the most frequent
content which runs the risk of strangulation and injury
during herniotomy, as reported in earlier studies [20, 21].
The reason for the intestine being a more common content
in male hernias and rarely so in females is not clear. No
female children presented with obstruction or strangulation
of their hernias during this study, which is also at variance
with male hernias, in which strangulation and incarceration
are frequent occurrences, especially among the younger
infants [15, 16, 21]. This is perhaps because intestine,
123
Hernia (2009) 13:149–153
which is very prone to obstruction and strangulation, was
rarely content in this series. None of the patients had a
preoperative ultrasound scan that would have diagnosed
and determined the viability of the contents before surgery,
as reported [10–12] in sophisticated centers, in order to
reduce cost. Therefore, hematocrit was the usual preoper-
ative investigation, except in the event of obstruction or
strangulation, which require laparotomy under endotra-
cheal intubation. Hematocrit is routinely done in this
subregion because of malaria infection and helminthes
infestation, which resulted in many healthy looking chil-
dren being anemic in this series. Open herniotomy through
a groin crease incision placed lateral to the pubic tubercle
using face/laryngeal masks gave satisfactory results in this
study, which was comparable to the results of laparoscopic
repair reported [14] in other centers.
Conclusion
Although female children with inguinal hernias were rare
in this study, the majority of hernias had ovary and fallo-
pian tube, which were prone to injury in the hands of the
unsuspecting surgeons, particularly in the setting where
preoperative imaging is not routinely performed in order to
discover the contents of the hernia sacs before surgery.
Efforts should be made to inspect the contents of hernia
sacs in female children during herniotomy, while blind
transfixion of hernias sacs without first opening them to
inspect and reduce the contents should be avoided. This is
important in order to prevent inadvertent injury to the
ovary and fallopian tube, which are common contents.
References
1. Lloyd DA, Rintala RJ (1998) Inguinal hernia and hydrocele. In:
O’Neill JA, Rowe MI, Grosfeld JI, Fonkalsrud EW, Coran GA
(eds) Pediatric surgery, vol 2, 5th edn. Mosby Year Book Inc.,
Philadelphia, pp 1071–1086
2. Wei BPC, Castles L, Stewart KA (2002) Hydrocele of the canal
of Nuck. ANZ J Surg 72:603–605
3. Matsuda T, Muguruma K, Hiura Y et al (1998) Seminal tract
obstruction caused by childhood inguinal herniorrhaphy: results
of microsurgical reanastomosis. J Urol 159:837–840
4. Matsuda T, Horii Y, Yoshida O (1992) Unilateral obstruction of
the vas deferens caused by childhood inguinal herniorrhaphy in
male infertility patients. Fertil Steril 58:609–613
5. Urman BC, McComb PF (1991) Tubal occlusion after inguinal
hernia repair. A case report. J Reprod Med 36:175–176
6. Cam C, Celik C, Sancak A et al (2008) Inguinal herniorrhaphy in
childhood may result in tubal damage and future infertility. Arch
Gynecol Obstet (in press)
7. George E, Oudesluys-Murphy A, Madern G et al (2002) Inguinal
hernias containing the uterus, fallopian tube, and ovary in pre-
mature female infants. J Pediatr 136:696–698
Hernia (2009) 13:149–153
8. Laing FC, Townsend BA, Rodriguez JR (2007) Ovary-containing
hernia in a premature infant: sonographic diagnosis. J Ultrasound
Med 26:985–987
9. Zitsman JL, Cirincione E, Margossian H (1997) Vaginal bleeding
in an infant secondary to sliding inguinal hernia. Obstet Gynecol
89:840–842
10. Stickel WH, Manner M (2004) Female hydrocele (cyst of the
canal of Nuck): sonographic appearance of a rare and little-
known disorder. J Ultrasound Med 23:429–432
11. Oh SN, Jung SE, Rha SE et al (2007) Sonography of various
cystic masses of the female groin. J Ultrasound Med 26:1735–
1742
12. Maizlin ZV, Mason AC, Brown C et al (2007) CT findings of
normal and inflamed appendix in groin hernia. Emerg Radiol
14:97–100
13. Hansen KA, Eyster KM (2006) Infertility: an unusual compli-
cation of inguinal herniorrhaphy. Fertil Steril 86:217–218
14. Becmeur F, Dimitriu C, Lacreuse I et al (2007) Laparoscopic
treatment of congenital inguinal hernias in children (212
patients). Arch Pediatr 14:985–988
153
15. Ameh EA (1999) Incarcerated and strangulated inguinal hernias
in children in Zaria, Nigeria. East Afr Med J 76:499–501
16. Ameh EA (2002) Morbidity and mortality of inguinal hernia in
the newborn. Niger Postgrad Med J 9:233–234
17. Huang C-S, Luo C-C, Chao H-C et al (2004) The presentation of
asymptomatic palpable movable mass in female inguinal hernia.
Eur J Pediatr 162:493–495
18. Kolesnik AV, Sadovskiı̌ IG (1995) Simultaneous strangulation of
a fallopian tube and the appendix in an inguinal hernia. Klin Khir
2:52–53
19. Fowler CL (2005) Sliding indirect hernia containing both ovaries.
J Pediatr Surg 40:e13–e14
20. Nussbaumer P, Weber D, Hollinger A (2000) Traumatic perfo-
ration of the small intestine—a rare complication of inguinal
hernia. Praxis 89:934–936
21. Niedzielski J, Kr I R, Gawłowska A (2003) Could incarceration
of inguinal hernia in children be prevented? Med Sci Monit
9:CR16–CR18
123