Presentation
Left inguinal swelling since birth.
Patient Data
Left inguinal region and ovary:
- herniated left ovary through internal inguinal ring, which is mildly enlarged with preserved arterial and venous flow, showing average velocities, however there is thickened left ovarian pedicle and high resistive waveform of the ovarian arteries which is suggestive of partial torsion. No ischemic changes are noted regarding parenchymal echopattern or ovarian edematous changes. (Note that the Doppler sampling is perpendicular to the ovarian pedicle which is incorrect, repeated sampling, not saved, shows decreased or absent diastolic flow)
- no other herniated contents
- few small reactive inguinal lymph nodes
Right inguinal region:
- small collapsed hernial sac is noted, extending at the proximal right canal of Nuck
- no hernial contents noted on cring and on standing position
- few small reactive lymph ndoes are noted
Right ovary:
- is located at right iliac fossa and of average size
- no evidence of torsion, cysts or masses with normal pedicle.
Opinion
- left canal of Nuck hernia, transmitting the left ovary, with partial torsion
- small right hernial sac with no identified herniated contents
Case Discussion
Ultrasound features are consistent with a left canal of Nuck hernia transmitting the left ovary. Canal of Nuck hernias are rare and can transmit the ovary in females. It has a high risk of vascular compromise and torsion of the herniated ovary.
Early signs of vascular compromise to the ovary or partial torsion include thickening of the ovarian pedicle and absent diastolic flow on Doppler study. Correction of the Doppler steer angel along the vascular stalk of the ovary and repeated sampling is important to exclude false-positive results. It is also important to examine the other ovary and confirm its location.
It is important to examine the other side in all cases of inguinal hernia. In pediatrics, the examination should be done while crying, on standing (lifted by the parent) or with the aid of abdominal compression so as to exclude hernia on the other side, so as to be done at the same surgical setting. Even small hernial sac should be searched for.
Other common abnormalities of the canal of Nuck include bowel hernia, hydrocele and endometriosis.
Inguinal lymph nodes are normal in pediatrics and usual finding and often confused with inguinal hernia and undescended testis in males.