Rare Case: When a Hernia Isn't What It Seems
"A 71-year-old's acute abdomen led doctors to a surprising discovery, highlighting the challenges of diagnosing unusual hernias."
When you think of a hernia, you probably picture a loop of intestine poking through a weak spot in your abdominal wall. While that's often the case, the human body loves to keep us on our toes. Sometimes, what seems like a typical hernia turns out to be something far more unusual.
Epiploic appendices (EA) are small, fat-filled sacs that hang off the colon. They're usually harmless, but when they become inflamed or twisted, they can cause a lot of pain. And, in very rare cases, they can even get trapped inside a hernia.
A recent case report details one such instance, where a 71-year-old man presented with symptoms suggesting a strangulated inguinal hernia. However, what surgeons found during the operation was a surprise: a hypertrophied (enlarged) epiploic appendage, strangulated within the hernia sac. This is the first documented case of its kind, presenting as an acute abdomen.
From Ancient Descriptions to Modern Repair
Hippocrates, around 400 BC, distinguished hernia from hydrocele, describing hernia as reducible and hydrocele as transilluminable. He discussed inguinal hernia in De Morbis and De Affectionibus and suggested enema therapy. Aulus Cornelius Celsus, who lived from 14 BC to AD 50, was among the first to describe a surgical approach to inguinal hernia. The history of groin-hernia repair subsequently became a long record of techniques developed in search of a cure for a condition affecting people for thousands of years.
The Case Unfolds: A Twist in the Hernia Story
The 71-year-old patient arrived at the emergency department with intense pain, redness, and a noticeable mass in his left inguinal region and scrotum. These symptoms had appeared suddenly after a bout of sneezing and persisted for about 24 hours. The size of the hernia made the General Practitioner not try and reduce the mass.
- Symptoms: Pain, redness, mass in the groin/scrotum
- Cause: Developed after sneezing
- Key Finding: Elevated CRP levels (inflammation)
- Suspicion: Possible bowel strangulation
An Unusual Hernia Sac Finding
Recent case reports have described epiploic appendages within hernia sacs. The literature most often reports strangulated sigmoid epiploic appendages in left inguinal hernias, but one reported case found the appendage on the right side. Another report notes that the function of epiploic appendages remains uncertain, although they have been proposed to assist colonic peristalsis, colonic absorption, and omentum-like immune functions. These findings illustrate why an apparent inguinal hernia may contain an unexpected structure.
A Rare and Easily Misread Presentation
Appendix epiploica within an incarcerated inguinal hernia sac is described as very rare. Strangulation of an epiploic appendage has previously been reported inside a hernia sac together with bowel herniation, but it is rarely reported as the only incarcerated structure. This unusual presentation can complicate assumptions about what a hernia contains. The available reports are case-based, so they establish rarity rather than a general frequency.
Open, Laparoscopic, and Robotic Approaches
Inguinal hernia repair can be performed through open, laparoscopic, or robotic techniques, and each approach has its advocates. Prior studies have compared pairs of techniques, while newer work has highlighted the limited amount of long-term evidence directly comparing all three approaches. Robotic repair may offer improved visualization of inguinal anatomy and facilitate more accurate dissection, but only a few studies have compared robotic and laparoscopic repair. An indirect inguinal hernia is described as entering the inguinal canal through the deep or internal inguinal ring, lateral to the Hesselbach triangle.
Lessons Learned: Thinking Outside the (Hernia) Box
This unusual case highlights the importance of considering rare conditions when diagnosing abdominal pain and hernias. While bowel strangulation is a serious concern, other possibilities, such as a strangulated epiploic appendage, should be kept in mind.
Persistent Questions After Repair
Postoperative pain remains a public-health concern following the common surgery for inguinal hernia. A 2026 discussion describes the postoperative period as a reproducible setting in which this problem warrants attention. Expert-witness resources identify bariatric surgery and other surgical specialties among fields that may contribute opinions, reports, or testimony on inguinal hernia matters. Separate commentary on recurrent inguinal hernia examines recurrence causes, mesh choices, differences in redo operations, risk factors, and management strategies.
Forecasting Need and Innovation
A 2025 study uses Global Burden of Disease 2021 data to examine the burden and future trends of inguinal, femoral, and abdominal hernias among older adults from 1990 through 2021. Market forecasts point to continued expansion in the inguinal-hernia treatment sector, although the reported estimates come from industry research rather than the burden study. One market report values the global inguinal hernia market at USD 4.2 billion in 2024 and projects USD 6.6 billion by 2031, with a reported compound annual growth rate of 7.89%. Together, these sources frame the future in terms of both population health planning and healthcare-market demand.
Unequal Global Burden
Research using the Global Burden of Disease 2021 database evaluates inguinal, femoral, and abdominal hernias among people aged 60 years and older from 1990 to 2021. The analyses consider incidence, prevalence, deaths, and disability-adjusted life years, with attention to age, sex, and regional differences. Another study reports that the global burden remains significant, particularly in low- and middle-income countries, despite medical advances. That work examines trends and cross-country inequalities from 1990 to 2021 and projects future trends to 2035.
The case also underscores the role of surgical intervention in confirming diagnoses and providing treatment. In this instance, proceeding directly to surgery allowed for a definitive diagnosis and prompt resolution of the patient's condition.
While imaging techniques like ultrasound and CT scans can be helpful in diagnosing epiploic appendagitis, they shouldn't delay surgery if there's a strong suspicion of strangulation. As this case demonstrates, sometimes the best way to know for sure is to take a look inside.