although inguinal hernias may contain small or large bowel , only 10% of them cause bowel obstruction or strangulation and in extremely rare cases malignant lesions are observed in their sacs . the most intrasaccular neoplasms are colonic , especially of the sigmoid colon and usually in a left inguinoscrotal hernia . we herein report an interesting and extremely rare case of a 91-year - old man who had a right inguinoscrotal hernia containing a sigmoid colon carcinoma . a 91-year - old man was admitted due to a right inguinoscrotal hernia [ figure 1 ] . his past medical history included triple aortocoronary bypass , chronic obstructive pulmonary disease , and prostate benign hypertrophy . digital examination of the rectum was negative for blood while the laboratory findings revealed anemia ( hemoglobin : 6.8 g / dl , hematocrit : 23.3% ) . the abdominal and pelvic computer tomography ( ct ) demonstrated a thick - walled segment of sigmoid colon in the inguinoscrotal hernia , which was suspicious of a tumour , dysomogeneous paricolonic fat , and small local lymph nodes [ figure 2 ] . the right inguinoscrotal hernia the abdominal computer tomography demonstrates the sigmoid carcinoma in the right inguinoscrotal hernia ( arrow ) during the operation , a consistent part of the sigmoid colon was localized within the hernia . a large tumor of the sigmoid colon ( 5 cm  9 cm in diameter ) was observed obstructing the lumen . a temporary end colostomy was fashioned , and the rectal stump was oversewn ( hartmann 's procedure ) [ figure 3 ] . the postoperative course was uneventful , and the patient was discharged the seventh postoperative day . the tumor in the resected specimen of the sigmoid colon ( arrow ) a percentance of 10% of inguinal hernias may become irreducible while malignancies in inguinoscrotal hernias are rare conditions and constitute < 0.5% of the existed sacs . they can be classified as intrasaccular or saccular : the first group includes primary neoplasms incarcerated into the hernias while the second one involves tumors with peritoneal metastasis ( mesothelioma , metastasis ) . a review performed by ruiz - tovar et al . the intrasaccular tumors are uncommon in comparison with saccular tumors , and most of them are discovered during surgery as an incidental finding . most of the cases involve the sigmoid colon , but malignancies involving caecum and ascending colon have also been described . we hypothesize that the most common side of this type of hernia is the left due to the length , the anatomic place , and the mobility of the sigmoid colon . signs and symptoms may be limited to the already commonly reported signs for the inguinal hernia . patients with history of intra - abdominal malignancy presented with a new inguinal hernia should always be investigated for a possible recurrence . additional findings such as loss of weight , changes in bowel habits and defecation , bleeding or anemia not otherwise attributed , and the contemporaneous presence of inguinal hernia should raise the suspicion of a herniated colonic neoplasm . according the question whether patients who present with inguinal hernias should have colon imaging as part of their initial workup , we strongly believe that if there are signs and symptoms of anemia and colonic obstruction or changes in bowel habits , a colonic investigation should be performed because partial colonic obstruction could be a precipitating factor in the development of a groin hernia . it is unclear whether the best surgical approach is via an abdominal or inguinal incision or both ; this will depend on the patient 's anatomy , the surgical findings and the surgeon 's experience . others authors were able to deliver the sigmoid colon through the internal ring , resected the sigmoid colon and the mesentery and repaired the hernia via the internal ring . we performed this technique in our reported case because we strongly believe that the selected procedure must achieve a resection based on oncological principles and ensure a secure hernia repair . this surgical approach has the advantage of allowing good access to both the left colon and inguinal canal . our clinical suspicion was mainly based on patient 's clinical ( sizable , hard , and irreducible groin hernia ) and laboratory findings ( anemia ) . the ct described the large bowel into the sac and the possibility of tumor while the colonoscopy confirmed the diagnosis . during the operation , we focused to perform an oncological procedure and at the same time to repair the hernia keeping always in mind our patient 's advanced age and his comorbidities . inguinal hernia containing colonic neoplasm should always be considered in patient with an irreducible mass in the inguinal region or with a mass with a steady increasing of volume . surgical approaches vary and depend on patient 's anatomy , surgical findings , and surgeons experience .
the inguinoscrotal hernia with colonic malignancy in the sac presents rare but severe consequence . 
 the most common side of this type of hernia is the left one while the most common part of the large bowel is the sigmoid colon . 
 the clinical picture can be easily confused with simple inguinoscrotal hernia unless the clinician is alert to the presence of certain sinister symptoms and signs . 
 we report an extremely rare case of a 91-year - old man presented with anemia who had a right inguinoscrotal hernia containing a sigmoid colon carcinoma .