Complete uterine and bilateral adnexal herniation in a female infant: a late-presenting case report

Introduction and Importance: Indirect inguinal hernias in female infants infrequently involve reproductive organs beyond the ovary and fallopian tube. Herniation of the uterus (hernia uteri inguinalis) is exceptionally rare, with only 73 pediatric cases documented. This case is unique due to its presentation of complete bilateral adnexal herniation (uterus, ovaries, and tubes) in a reducible, non-incarcerated hernia diagnosed in a 1-year-old, highlighting the need for heightened clinical suspicion regardless of patient age or symptom severity. It critically underscores the indispensable role of preoperative imaging to prevent diagnostic omissions and guide surgical planning. Case Presentation: A 1-year-old female infant presented electively with a left inguinal mass, noted since early infancy, that was spontaneously reducible. The mass was non-tender with no history of incarceration or systemic symptoms. No preoperative imaging was obtained. Intraoperative exploration revealed the hernia sac contained the viable uterus, bilateral ovaries, and fallopian tubes without evidence of torsion or ischemia. The organs were meticulously reduced, and a high ligation of the hernia sac was performed successfully. Clinical Discussion: Uterine herniation with concomitant bilateral adnexal involvement is scarcely reported, representing only 18.2% of known cases. This patient’s asymptomatic presentation contrasts with the literature, where 37.5% of cases present with incarceration. The pathophysiology is attributed to a patent processus vaginalis (canal of Nuck), with contributing factors including laxity of the uterine ligaments. The omission of preoperative ultrasound in this case represents a critical learning point, as it has a near-100% sensitivity for identifying reproductive organ content in reducible hernias. Surgical management prioritizes gentle reduction to preserve future fertility, and laparoscopic approaches may offer advantages in reducing the risk of iatrogenic injury. Conclusion: This case demonstrates that complex reproductive organ herniation, including the uterus and bilateral adnexa, can occur in reducible hernias and can present beyond early infancy, even in the absence of alarming symptoms. A high index of suspicion is necessary, and routine preoperative ultrasonography should be strongly considered for all female infants with inguinal hernias to ensure accurate diagnosis and optimal surgical management focused on fertility preservation.