|Year : 2015 | Volume
| Issue : 6 | Page : 833-835
Hernia of canal of nuck: Some considerations
Mirat Dholakia, Gurjit Singh, Rishikesh Kore, Iqbal Ali
Department of Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Web Publication||19-Nov-2015|
Department of General Surgery, Padmashree Dr. D. Y. Patil Medical College, Pimpri, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Hernia of canal of Nuck is an extension of peritoneal fold through the inguinal canal up to the labia majora. Defective obliteration of this peritoneal fold leads to herniation of abdominal content into the inguinal canal. Incidence of ovary and fallopian tube as contents of henia is rare overall and very rare in middle age women. This hernia would require surgical intervention once diagnosed, but type of intervention may vary. Although mesh repair is acceptable worldwide with low recurrence rate, nonmesh repair still has a place specifically in developing countries wherein cost consideration without significantly affecting outcome will be an important factor. Two cases treated with nonmesh repair are reported.
Keywords: Abdominal wall, groin, hernia, inguinal, inguinal canal
|How to cite this article:|
Dholakia M, Singh G, Kore R, Ali I. Hernia of canal of nuck: Some considerations. Med J DY Patil Univ 2015;8:833-5
| Introduction|| |
The canal of Nuck is a peritoneal fold extending to labia majora in women through the inguinal canal, which accompanies round ligament of uterus. It is analogous to processus vaginalis in males. The extension of this peritoneal fold obliterates into the fibrous cord in 1 st year of life.  When this fails to obliterate, it can result in inguinal hernia or hydrocele both in male and female. This defect causing a hernia of ovary into the canal of Nuck simulates the normal descent of the testis in males.
Inguinal hernia is more among men as compared to females. Male to female ratio was 7:1 according to a study from India. 
We report 2 cases of hernia of canal of Nuck managed by us.
| Case Reports|| |
A 50-year-old female (G4P4) farmer by occupation presented with a nontender palpable swelling in the right inguinal region of 2 years duration. She was healthy without any past medial or surgical history. A 4 cm × 3 cm pyriform shaped swelling exhibiting cough impulse was detected in right inguinal region, which was soft, nontender, and reducible. A diagnosis of right indirect inguinal hernia was made. Ultrasound of the abdomen suggested tubular structure and a mass likely to be ovary as the content and intra operative finding corroborated ultrasound findings. Contents reduced at herniotomy [Figure 1] and [Figure 2] and modified Bassini's repair was performed.
An 11-year-old female patient came with complaints of nontender palpable swelling since birth. A 4 cm × 3 cm pyriform shaped swelling, exhibiting cough impulse was present in right inguinal region, which was soft, nontender, and reducible. A diagnosis of right indirect inguinal was made. Ultrasound of the abdomen showed a defect of size 2.2 cm. Homogenous hyperechoic, noncalcified lesion was seen which was suggestive of omental fat as sac content. At herniotomy, content was confirmed to be omentum, which was reduced. Sac was excised after transfixation at its neck. Wound was closed without any repair.
| Discussion|| |
The canal of Nuck is a small protrusion of peritoneum, which corresponds to the processus vaginalis in male. It usually gets obliterated during 1 st year of life and failure or incomplete obliteration leads to hernia or hydrocele of canal of Nuck.  Hernial sac may contains peritoneal fluid, omental fat, bowel loops, ovary, fallopian tube, urinary bladder in the inguinal canal. All inguinal hernias in females occur as indirect protrusion, and many of these are in fact sliding hernias containing genital structures such as ovaries, fallopian tubes or even the uterus. Risk factors like positive family history and obstipation are associated with inguinal hernia. Small musculo-pectineal orifice of Fruchaud in female is a weak spot from where hernia can occur, which can be strengthened with controlled strenuous activity. Sports activity and obesity are protective for inguinal hernia. 
Simons et al. stated that women account for 8-9% of all inguinal and femoral hernia operations performed. 
According to one study, out of 23 cases, 17 cases were having hernia on right side and most common in first decade of life and in all the cases sac were anterior to the round ligament emerging from deep ring.  In our study, both the patients had right sided inguinal hernia with sac anterior to round ligament.
Ovary alone or fallopian tube along with ovary is seen in 15-20% cases.  In our study, fallopian tube along with ovary was present in case 1, and omental fat with peritoneal fluid in the other.
Ovary containing hernias of canal of Nuck and incarceration of hernial contents are most common in children, so once the diagnosis of the inguinal hernia in female is made, repair should be carried out promptly as chances of incarceration of hernia content during 1 st year of life is more. Incarceration of ovary leading to torsion has been reported. 
The most common differential diagnosis of the hernia of canal of Nuck is the hydrocele of canal of Nuck. Both can co-exist in about one-third of cases. Other differential diagnosis would be lipoma, lymphadenopathy, cold abscess, bartholin's cyst, posttraumatic hematoma, rarely cystic lymphangioma, neuroblastoma metastasis to groin and ganglion. 
The diagnosis of hernia of canal of Nuck is primarily based on the clinical presentation and physical findings and is obvious in the majority of cases. On ultrasonography, mass may be hypoechoic cystic (hydrocele of canal of Nuck) or homogenous hyperechoic (omental fat). Computed tomography scan and color Doppler studies may be required to know the exact nature of contents in case ultrasonography findings are inconclusive.  In our series nature and contents of swelling in both the cases were correctly identified as fallopian tube and ovary in 1 case and peritoneal fluid and omental fat in the other.
Many surgical treatment modalities are available these days like tension free prosthetic repairs, laparoscopic repair (totally extraperitoneal/transabdominal preperitoneal) and tissue suture repair such as Bassini and Shouldice technique. Nonmesh repair is justifiable in female patients as transversalis fascia is strong compared to men. 
Bassini and Shouldice techniques are tension repairs. Chances of recurrence are more but still these repairs have been done in developing countries. Still these repairs are done in developing world as these techniques require less surgical skill than laparoscopic repair and are cost effective. In developed countries, these techniques are used in the majority of cases. In our series, Bassini's repair was done in case 1 and herniotomy with primary closure was done in the other.
| Conclusion|| |
Ovary and fallopian tube containing hernia sac in middle age women is a rare entity. Ultrasound is helpful in assessing the contents. Even without the signs of any complication this type of hernia should be managed promptly with early surgical intervention. Optimal surgical approach is still remains controversial. Surgeons at least in developing countries must consider "No Mesh" repair among such patients in view of nonaffordability of mesh and possibility of increase incidence of infection.
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[Figure 1], [Figure 2]