A 60 year old male presented to casualty with pain, swelling in the left groin since last 2 years with history irreducibility of swelling from past 1 day.

Swelling was initially of size 2x1cm which gradually progressed to the current size of 6x4 cms approximately as shown by patient’s hand gestures, swelling used to increase on standing and coughing and decreases on lying down which from past 1 day is irreducible.

Pain was insidious in onset gradually progressive, dull aching type, radiating to upper abdomen with no aggravating and relieving factors, but from past 1 day the pain over the swelling was increased.

• H/O on and off burning micturition with occasional history of hematuria
• No H/O Nausea and Vomiting
• No H/O Fever
• No H/O Constipation
• No H/O Chronic cough
• No significant past medical and surgical history.

• Patient conscious, oriented to time, place and person
• Vital parameters within normal range.
• Afebrile
• H/O bilateral pitting edema noted.

On Local Examination

A irreducible swelling of size 8cms x 6cms with regular surface, well defined margins,with medial border 2cms and lateral border 4cms lateral to pubic tubercle extending to mid of scrotum with tenderness over the swelling,doughy consistency and dull note on percussion.

Routine laboratory investigations were performed which showed deranged Creatinine (7.23mg/dl).

In view of the above examination features suggestive of irreducible inguinal hernia, Patient underwent USG ABDOMEN AND PELVIS which showed Bilateral Hydroureteronephrosis, Bilateral renal calculi, and features of Left irreducible inguinal hernia with content as Omentum.

Patient was taken up for Emergency Open Inguinal Exploration. Intra-operatively indirect hernia with Thickened sac and Thickened Omentum noted. Omentum which was forming the content along with sac was sent for Histopathological examination revealing Metastatic Poorly Differentiated Adenocarcinoma for which IHC was done which shows diffusely positive to PanCK,CK19 and patchy positive to CEA, showing those of undifferentiated cancer.

On POD 3 Patient underwent Bilateral DJ stenting in view of USG report showing Bilateral Renal Calculi with hydroureteronephrosis.

On POD 5 patient had multiple episodes of hematemesis and melena, and underwent UGI Scopy under local anaesthesia which showed prominent edematous mucosal folds, difficulty in inflating stomach and superficial mutiple erythematous ulcers. Biopsies were taken from ulcer on the stomach wall and sent for Histopathological examination which showed Poorly Differentiated Adenocarcinoma of Stomach.

CECT Abdomen and Pelvis but the procedure was abandoned due to patient’s deranged creatinine and risk of further worsening of renal function. Hence patient was taken up for USG Abdomen and Pelvis and Plain CT which showed Diffuse thickening of stomach wall (?Gastric Malignancy).

This highlights a rare case of a Gastric Cancer with tumor implants noted in the hernial sac and Omentum which presented as Irreducible Inguinal Hernia.

1. Saif MW, Siddiqui IA, Sohail MA. Management of ascites due to gastrointestinal malignancy. Ann Saudi Med. 2009; 29: 369-377.
2. Sangisetty SL, Miner TJ. Malignant ascites: A review of prognostic factors, pathophysiology and therapeutic measures. World J Gastrointest Surg. 2012; 4: 87-95.
3. Becker G. 33- Ascites. In: Davis MP, Feyer PC, Ortner P, Zimmermann C, Editors. Supportive Oncology. Saint Louis: WB Saunders. 2011; 362-368.
4. Rickard BP, Conrad C, Sorrin AJ, Ruhi MK, Reader JC, Huang SA, et al. Malignant ascites in ovarian cancer: cellular, acellular, and biophysical determinants of molecular characteristics and therapy response. Cancers (Basel). 2021; 13: 4318.
5. Kusamura S, Baratti D, Zaffaroni N, Villa R, Laterza B, Balestra MR, et al. Pathophysiology and biology of peritoneal carcinomatosis. World J Gastrointest Oncol. 2010; 2: 12-18.
6. Kanda M, Kodera Y. Molecular mechanisms of peritoneal dissemination in gastric cancer. World J Gastroenterol. 2016; 22: 6829-6840.
7. Sobhani R, Alsaeidi S, Mahmoudabadi A. Metastatic hernial sac tumor in a patient with FUO. Int J Surg Case Rep. 2011; 2: 97-99.
8. Yokoyama N, Shirai Y, Yamazaki H, Hatakeyama K. An inguinal hernia sac tumor of extrahepatic cholangiocarcinoma origin. World J Surg Oncol. 2006; 4: 13.
9. Lowenfels AB, Rohman M, Ahmed N, Lefkowitz M. Hernia-sac cancer. Lancet. 1969; 1: 651.
10. Nicholson CP, Donohue JH, Thompson GB, Lewis JE. A study of metastatic cancer found during inguinal hernia repair. Cancer. 1992; 69: 3008-3011.
11. Matthews SJ, McClelland HR. Saved by a hernia: an unusual presentation of ovarian cancer. Int J Clin Pract. 1998; 52: 127-128.
12. Brenner J, Sordillo PP, Magill GB. An unusual presentation of malignant mesothelioma: the incidental finding of tumor in the hernia sac during herniorrhaphy. J Surg Oncol. 1981; 18: 159-161.
13. Korn O, Moyano L, Cabello R, Csendes A. Incidental finding of inguinal hernia sac cancer. Rev Med Chil. 2002; 130: 91-95.
14. Oruc MT, Kulah B, Saylam B, Moran M, Albayrak L, Coskun F. An unusual presentation of metastatic gastric cancer found during inguinal hernia repair: case report and review of the literature. Hernia. 2002; 6: 88-90.
15. Takeuchi K, Tsuzuki Y, Ando T, Sekihara M, Hara T, Kori T, et al. Malignant mixed Mullerian tumor of the ovary growing into an inguinal hernia sac: report of a case. Surg Today. 2003; 33: 797-800.
16. Díaz-Montes TP, Jacene HA, Wahl RL, Bristow RE. Combined FDG-positron emission tomography and computed tomography for the detection of ovarian cancer recurrence in an inguinal hernia sac. Gynecol Oncol. 2005; 98: 510-512.
17. Qin R, Zhang Q, Weng J, Pu Y. Incidental finding of a malignant tumour in an inguinal hernia sac. Contemp Oncol (Pozn). 2014; 18: 130-133.
18. Nakayama Y, Miura T, Hakamada K. Successful resection of the peritoneal dissemination recurrence of colon cancer, including metastasis to the inguinal hernia sac-a case report. Gan to Kagaku Ryoho. 2015; 42: 1600-1602.
19. Wang T, Voogjarv H, Vajpeyi R. Incidental perivascular epithelioid cell tumor in an inguinal hernia sac. Pathol Res Pract. 2013; 209: 593-595.
20. Brimo Alsaman MZ, Lina G, Zeino Z, Alahmad Z, Attar M, Haboush S, et al. An inguinal hernia revealing an advanced stage gastric cancer in a young patient: a case report. Ann Med Surg (Lond). 2022; 79: 103974.
21. Han Y, Huang L, Tian X, Liu J. Rare form of metastasis: lung cancer metastases to inguinal hernia sac detected by 18F-FDG PET/CT. Jpn J Clin Oncol. 2022; 52: 1353-1354.
22. Gill-Wiehl GF, Veenstra B. Incidental diagnosis of metastatic prostate cancer post-inguinal hernia repair. Am Surg. 2022; 88: 552-553.