we present a case illustrating the diagnostic and treatment difficulties that arise when these two common conditions co - exist . a 78 year old man was referred to surgical outpatients with a hypochromic , microcytic anaemia ( hb 7.4  g / dl mcv 68  fl , ferritin 8  g / l ) of unknown cause having initially presented with fatigue . colonoscopy was technically difficult and abandoned after reaching the ascending colon . at this point , no bowel lesions were visually identified to this point . to evaluate the non visualised proximal colon , ct colonography was performed showing a large right sliding inguinoscrotal hernia containing a caecal tumour and a large inguinoscrotal hernia containing loops of small bowel ( fig . 2 ) . completion of staging with standard contrast enhanced ct of the thorax , abdomen and pelvis showed a number of bulky mixed attenuation lymph nodes , suspicious for involvement with tumour extending from the right groin proximally along the ileocolic vascular arcade for 12  cm ( fig . intra - operatively , the left sided hernia was reduced but the right side was irreducible . histological examination of the specimen revealed a 70  mm moderately differentiated adenocarcinoma with 9 of 20 resected lymph nodes containing metastases including the apical node ( fig . follow up , the patient remains well with a performance status of one , good weight gain and no clinical or radiological evidence of metastases or hernia recurrence . the uk , national institute for clinical excellence guidelines recommend urgent referral for men of any age with unexplained iron - deficiency anaemia ( ida ) . this recommendation is based on the knowledge that ida without evidence of obvious bleeding is a feature of colorectal or oesophagogastric cancer and is especially suggestive of caecal tumours . hamilton calculated the likelihood ratio of having colorectal cancer in men with unexplained anaemia < 9  g / dl to be 27 . historically , microscopic evidence of neoplasia was found in fewer than 0.4% of excised hernia tissue . they can be classified based on the tumour 's relation to the hernial sac as intra - saccular , saccular or extrasaccular . saccular tumours involve the peritoneum and can be primary such as mesothelioma or metastatic deposits . many asymptomatic inguinal hernias are ignored by patients and can be present for many years . as many as a fifth of all male patients with colorectal cancer have concurrent inguinal hernia or have had a repair of an inguinal hernia 12 years prior to cancer diagnosis . most reported cases of intrasaccular tumours are sigmoid cancers within sliding left indirect inguinal hernias which often become incarcerated . they can be found by surprise or even mis - diagnosed during routine hernia repair or present as an emergency which risks suboptimal treatment . to date , treatment of intrasaccular cancer has not been standardised and optimal surgical management of intrascrotal colonic cancer is unclear . twenty lymph nodes were harvested suggesting acceptable mesentery resection , pathological staging and overall compatibility with surgical oncology principles . the use of mesh in the primary repair of an inguinal hernia reduces the incidence of recurrence . however , in the context of bowel resection there is a contaminated surgical field which risks infection of the mesh . combined with the risk of tumour seeding and local recurrence we performed a shouldice repair . a cochrane review found shouldice type repairs to be superior to other non mesh open inguinal hernia repair techniques . the chance of hernia recurrence is increased in this case due to the size of the hernia and damage of the inguinal fascia transversalis by surgical resection . to our knowledge , there are no reports of trans - scrotal colonic resection and only two case reports of laparoscopic resection of intrasaccular tumours . in locally advanced tumours , manual or surgical reduction carries a theoretical risk of tumour cell implantation in the inguinal canal and peritoneal cavity . in clinical suspicion of an intra - abdominal tumour , changes in hernias should be awarded due attention and a thorough investigation for neoplasia undertaken . written informed consent was obtained from the patient for publication of this case report and accompanying images . a copy of the written consent is available for review by the editor - in - chief of this journal on request . mm and sm created the figures . nc created the manuscript which was critically revised by all authors.key learning pointslarge hernias can alter presentation.intrasaccular tumours may impact upon standard investigations.surgical strategy must be adapted when resecting herniated tumours or viscera . large hernias can alter presentation.intrasaccular tumours may impact upon standard investigations.surgical strategy must be adapted when resecting herniated tumours or viscera .
introductioncolorectal cancer and inguinal hernias are both common surgical pathologies in the elderly but rarely co - exist . where the conditions overlap , there can be difficulties in both diagnosis and treatment.presentation of casea 78 year old man with unexplained iron deficiency anaemia was investigated for gastrointestinal cancer . 
 he was found to have enlarging bilateral inguinoscrotal hernias . 
 ct colonoscopy revealed a herniated caecal carcinoma contained within the scrotum . 
 an open excision was performed.discussioniron deficiency anaemia without obvious bleeding is associated with colorectal cancer and should be thoroughly investigated . 
 asymptomatic inguinal hernias are often ignored by patients . however , a change in an existing hernia may be associated with neoplasia.conclusiondual pathology raises new difficulties in assessment , investigation and management of colorectal cancer .