Surgery Today

, Volume 44, Issue 7, pp 1375–1379

Elective laparoscopic surgery for sigmoid colon carcinoma incarcerated within an inguinal hernia: report of a case

Authors

  • Takashi Kanemura
    • Department of SurgeryKansai Rosai Hospital
    • Department of SurgeryKansai Rosai Hospital
  • Shigeyuki Tamura
    • Department of SurgeryKansai Rosai Hospital
  • Masatsugu Okishiro
    • Department of SurgeryKansai Rosai Hospital
  • Shin Nakahira
    • Department of SurgeryKansai Rosai Hospital
  • Rei Suzuki
    • Department of SurgeryKansai Rosai Hospital
  • Ken Nakata
    • Department of SurgeryKansai Rosai Hospital
  • Chiyomi Egawa
    • Department of SurgeryKansai Rosai Hospital
  • Hirohumi Miki
    • Department of SurgeryKansai Rosai Hospital
  • Yutaka Takeda
    • Department of SurgeryKansai Rosai Hospital
  • Takeshi Kato
    • Department of SurgeryKansai Rosai Hospital
Case Report

DOI: 10.1007/s00595-013-0664-8

Cite this article as:
Kanemura, T., Takeno, A., Tamura, S. et al. Surg Today (2014) 44: 1375. doi:10.1007/s00595-013-0664-8

Abstract

Primary colon carcinoma within an inguinal hernia sac is very rare and most reported cases were found at emergency open surgery for an incarcerated hernia. We report a case of incarcerated sigmoid colon carcinoma diagnosed preoperatively and treated with elective laparoscopic surgery. A 67-year-old man with a 2-year history of swelling of the scrotum and a breast lump was referred to us for surgical treatment of an irreducible left inguinal hernia and a right breast tumor. Blood examination results showed severe anemia. Computed tomography scan and endoscopic biopsy confirmed sigmoid colon carcinoma incarcerated in the left inguinal hernia. Thus, we performed definitive laparoscopic sigmoidectomy and conventional hernia repair for preoperatively diagnosed sigmoid colon carcinoma within an inguinal hernia.

Keywords

Sigmoid colonPrimary colon carcinomaIncarceratedInguinal herniaLaparoscopic sigmoidectomy

Introduction

Inguinal hernia is a common entity and involves incarceration in approximately 10 % of cases [1]. On the other hand, carcinoma within an inguinal hernia is very rare, with an estimated incidence of <0.5 % in the excised sac [2]. Tumors found in an inguinal hernia are classified into three types based on the anatomical relationship to the hernia sac: saccular, when primary or metastatic tumor involves the peritoneum; intrasaccular, when the sac contains an organ with a primary malignancy; and extrasaccular. Intrasaccular malignancies include cancers of the bladder, colon, appendix, and metastatic neoplasms involving the omentum [3]. Colon carcinoma is the most common of these [4]. A PubMed literature search identified 31 reported cases of intrasaccular primary colon carcinoma and, with the exception of one case of cecal carcinoma in a right inguinal hernia [5], all were treated by open surgery. We report a case of sigmoid colon carcinoma incarcerated within a left inguinal hernia, which was resected laparoscopically.

Case report

A 67-year-old man presented with an irreducible left inguinal hernia. The hernia had first been noticed 3 years earlier and had gradually increased in size. Examination revealed no signs of obstruction or strangulation of the hernia. The left scrotum was huge, measuring about 15 cm, and could not be reduced. Another mass with erosion in the right breast, which had enlarged during the same period, was suspected as breast cancer. Blood test results revealed severe anemia (hemoglobin 5.3 g/dl, hematocrit 18.8 %, red blood cell 3.42 × 106/μl). The results of other tests, including tumor markers, were within the normal ranges. We decided to focus first on the advanced breast cancer and investigate the cause of anemia.

Positron emission tomography/computed tomography (PET–CT) scan showed 18F-fluorodeoxy glucose (FDG) uptake in both the right breast and hernia sac (Fig. 1a). Subsequent computed tomography (CT) demonstrated the presence of sigmoid colon inside the sac, with circumferential wall thickening (Fig. 1b). Colonoscopy showed an annular stricture of the sigmoid colon caused by a tumor, indicative of malignancy (Fig. 2). Microscopic examination of a biopsy specimen revealed well-to-moderately differentiated adenocarcinoma and the final diagnosis was confirmed as sigmoid colon cancer incarcerated in the hernia sac. We suspected that the anemia was related to the tumor. Although the patient also had advanced breast cancer, we decided to treat the colonic lesion first because it had caused almost complete luminal obstruction.
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Fig. 1

a Positron-emission computed tomography (PET–CT) scan, showing FDG uptake in the left inguinal hernia. b CT scan showing wall-thickened sigmoid colon in the left inguinal hernia

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Fig. 2

Endoscopic view, showing the sigmoid colon almost completely obstructed by the tumor

We performed laparoscopy-assisted sigmoid colon resection and hernia repair, but as the incarcerated sigmoid colon was too huge to reduce, we approached the inferior mesenteric artery before reducing the tumor (Fig. 3a). After dividing the artery at its origin and performing lymph node dissection, we released the adhesion around the hernia sac and reduced the incarcerated tumor. These maneuvers allowed us to successfully reduce the incarcerated sigmoid colon into the abdominal cavity (Fig. 3b). Subsequently, the colon was mobilized and removed outside through a small median incision. The colon was then resected, followed by an end-to-end hand-sewn anastomosis. The reconstructed colon was returned to the abdominal cavity, and the trocar sites and median incision were closed. In the final step, the hernia was repaired by high ligation via a standard oblique incision in the left inguinal region. To avoid possible infection, we did not place mesh over the site of herniorrhaphy.
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Fig. 3

a Operative view. The internal approach commenced before reduction of the hernia. Arrow the incarcerated hernia. b The hernia was reduced after the release of adhesions around the hernia orifice. Arrow the hernia orifice

Histopathological examination of the resected tumor revealed moderately differentiated adenocarcinoma with 24 lymph nodes free of metastasis and no tumor infiltration of the lateral or vertical margins. The American Joint Committee on Cancer (AJCC) stage was T3N0M0. The patient was discharged on postoperative day 12 after an uneventful recovery.

About 1 month after the colectomy, we performed right mastectomy and axial lymphadenectomy for the breast cancer. Histopathological examination revealed invasive ductal carcinoma with nine metastatic lymph nodes. The stage was T4bN2aM0; therefore, adjuvant chemotherapy was provided for the breast cancer after discharge.

Discussion

Only a few cases of incarcerated inguinal hernia containing colon carcinoma have been reported and most intrasaccular tumors are colonic [4]. Ruiz-Tovar et al. [6] reported 28 cases of primary colon cancer incarcerated within an inguinal hernia. A literature search of the 1900–2011 PubMed database, entering “colon carcinoma” and “inguinal hernia” as key words, identified 31 cases of primary colon carcinoma (Table 1). All of the patients were elderly men, which stands to reason considering that inguinal hernia is much more likely to develop in boys or men and in elderly people, and that male gender and advanced age are considered risk factors for colorectal cancer. Sigmoid colon carcinomas were found in 25 cases, with cancer of the cecum (n = 4), cancer of the ascending colon (n = 1), and cancer of the transverse colon (n = 1) accounting for the rest.
Table 1

Reported cases of primary colon carcinoma incarcerated within an inguinal hernia (1900–2011)

Case

Reference

Years

Sex

Age

Hernia side

Segment

Preoperative diagnosis

Emergency

Stageb

1

Gerhardta

1938

M

54

Left

Sigmoid

No

NS

NS

2

Fieber [14]

1955

M

60

Left

Sigmoid

No

Yes

IV

3

Bruce [15]

1958

M

66

Left

Sigmoid

Yes

NS

II

4

Lookanoffa

1960

M

67

Left

Sigmoid

Yes

NS

NS

5

Griffiths [16]

1964

M

74

Left

Sigmoid

No

Yes

NS

6

Lees [7]

1966

M

68

Left

Sigmoid

Yes

No

II or III

7

Silberman [17]

1968

M

62

Right

Cecum

Yes

Yes

II

8

Dross [18]

1973

M

76

Right

Cecum

Yes

Yes

IV

9

Gross [19]

1980

M

86

Right

Ascending

Yes

NS

NS

10

  

M

73

Left

Sigmoid

NS

NS

NS

11

Javors [20]

1981

M

77

Left

Sigmoid

No

Yes

II or III

12

  

M

84

Left

Sigmoid

Yes

NS

IV

13

Kanzer [21]

1983

M

70

Left

Sigmoid

Yes

NS

NS

14

Sriram [22]

1986

M

63

Left

Sigmoid

Yes

No

III

15

  

M

85

Right

Cecum

Yes

No

NS

16

Pappas [23]

1987

M

80

Left

Sigmoid

No

Yes

II or III

17

Lafferty [24]

1989

M

86

Left

Sigmoid

No

Yes

III

18

  

M

75

Left

Sigmoid

No

No

II

19

  

M

66

Left

Sigmoid

No

Yes

NS

20

Knecht [25]

1990

M

95

Left

Sigmoid

Yes

NS

NS

21

Hale [26]

1991

M

85

Left

Sigmoid

No

Yes

II

22

Tan GY [8]

2003

M

62

Left

Sigmoid

Yes

Yes

III

23

Koulaklis [9]

2003

M

79

Left

Sigmoid

No

Yes

III

24

Boormans [27]

2006

M

44

Right

Sigmoid

No

Yes

II

25

Tan SP [28]

2007

M

69

Left

Transverse

Yes

Yes

II

26

Slater [4]

2008

M

66

Left

Sigmoid

No

Yes

III

27

  

M

73

Left

Sigmoid

No

Yes

III

28

Ruiz-Tovar [6]

2009

M

67

Left

Sigmoid

Yes

No

III

29

Ko [29]

2010

M

84

Left

Sigmoid

Yes

Yes

II or III

30

Mai [30]

2010

M

83

Left

Sigmoid

Yes

Yes

NS

31

Pernazza [5]

2011

M

70

Right

Cecum

Yes

No

II

NS not stated

aReported by William Lees et al.

bDukes and Astler and Coller staging were replaced by AJCC (American Joint Committee on Cancer) staging

Carcinoma within an inguinal sac is often difficult to diagnose. In fact, intrasaccular malignancies were not diagnosed preoperatively in 14 (45 %) of the 31 cases reviewed. Up until about 10 years ago, barium enema was used for the diagnosis, but now colonoscopy and CT scans are used to detect carcinomas in the hernia sac.

Emergency operations were performed for obstruction or perforation in 17 (55 %) patients and exploration of the inguinal canal of incarcerated hernia occasionally identified the presence of colon carcinoma in the sac. Because the postoperative course was not always described, it is unclear whether there was a difference in survival between the groups. Postoperative events were documented in only 19 cases. Of the 14 patients who underwent emergency surgery, 3 died soon after the procedure and two suffered abdominal abscess postoperatively. On the other hand, all five patients who underwent elective surgery had a good postoperative course. Thus, emergency surgery could be associated with higher mortality and morbidity.

After colon resection, radical resection of the remaining colon and mesocolon was performed through another incision. While these two-phase operations are necessary to complete carcinoma resection and hernia repair, they can extend the operation time and be invasive to critically ill patients. We consider that a preoperative diagnosis of carcinoma is important to plan the best approach for definitive cancer surgery and hernia repair. Further preoperative workup is necessary when a patient presents with a combination of certain physical findings indicative of malignancy, such as long-standing incarcerated hernia, general fatigue, weight loss, anemia, or an irreducible inguinal mass.

Surgical management also differed among the preoperatively diagnosed cases. In the majority of such cases, colon resection and hernia repair were performed through separate incisions. However, some reports suggested that a single incision allowed the conduct of these two procedures. Lees [7] completed the operation through a left paramedian incision, whereas others reported that an approach through the transverse left iliac fossa incision provided good access to the descending colon and inguinal region [8]. In the case presented by Kouraklis et al. [9], the sigmoid colon was resected and double-barrel colostomy was performed through the inguinal incision. To the best of our knowledge, Pernazza et al. [5] were the first group to report the laparoscopic resection of primary colon carcinoma incarcerated within an inguinal hernia.

We adopted the laparoscopic approach based on its advantages, such as minimal operative trauma and perioperative recovery. The findings of several randomized controlled trials indicate that laparoscopic surgery is associated with minimal blood loss, earlier recovery of bowel function, less need for analgesics, and a shorter hospital stay than open surgery [10, 11]. Moreover, the rates of intra- and post-operative complications, hospital readmission, reoperation, and cancer recurrence were similar between the two groups [1013]. Since our patient did not have any symptoms of obstruction or strangulation, there was no indication for emergency open surgery. Moreover, the diagnosis was confirmed preoperatively; hence, laparoscopy-assisted surgery was the preferred option. We performed lymph node dissection and then reduced the hernia before colon resection. The resection and anastomosis were carried out through a 4-cm midline incision. Retrospectively, the alternative approach would have been resection of the sigmoid colon through the inguinal incision without reduction, after lymphadenectomy and a lateral approach, whereby a midline incision would have been avoided, allowing for less invasive surgery. We performed high ligation alone for the inguinal hernia in the first operation and although we considered hernioplasty at the second operation, the hernia did not recur after the high ligation and it is possible that it might remain reduced. After obtaining fully informed consent, we performed only the mastectomy, as hernioplasty can be carried out when the hernia recurs in the future.

In conclusion, when a patient presents with irreducible swelling of the scrotum accompanied by symptoms indicative of malignancy, surgeons should consider carcinoma within the hernia and initiate investigations. We planned the surgical approach based on minimal invasiveness and radical treatment of the malignancy, performing laparoscopy-assisted surgery for the incarcerated sigmoid colon cancer and inguinal hernia, with a good postoperative outcome.

Conflict of interest

T. Kanemura and co-authors have no conflict of interest.

Copyright information

© Springer Japan 2013