A Rare, Complicated Busoga Hernia

Inguinal herniae are the most common herniae encountered in the Surgical OPD or even the emergency setting. The indirect variety has a higher rate of bowel obstruction due to the constriction of the sac at the super�cial ring. Direct herniae, owing to the larger defect, are relatively safe from complications. Busoga hernia (1) is a rare subtype, which is prone to strangulation of contents, owing to the extremely narrow neck under continual tension within a tough fascial sling.


Introduction
Busoga Hernia is a funicular direct inguinal hernia (1) .It is indigenous to the Busoga province of Uganda, Southern Sudan and Ghana, where it is common in women.It usually contains pre-vesical fat and sometimes a part of the urinary bladder, but not often bowel.The hernia protrudes through a narrow defect in the medial part of conjoint tendon or transversalis fascia cranial to the pubic tubercle.Since it has a tight neck within the fascial sling, it is prone to strangulation.Also, the neck of the sac being small, it does not often allow a large loop of bowel to completely herniate, so that when strangulation occurs, often only part of the circumference of the gut is involved causing what is known as a Richter's hernia.This hernia is also known as Gill-Ogilvie's Hernia in Europe.Statistical data regarding this subtype of hernia and its complication rates is anecdotal, at best.We describe a classical presentation of this rare hernia in a middle aged Indian lady.

Case Report
A 43 year old lady presented with sudden onset severe pain abdomen that started in the lower abdomen and rapidly worsened.The pain was particularly severe in the left groin where a hernia had been noted 2 years ago, progressively increasing in size.On examination, she had an irreducible, tender left inguinal hernia with signs of bowel strangulation.She was taken up for emergency exploration under G.A., after due resuscitation and with the proper informed consent.
A left inguinal crease incision was given, and deepened further.On separating the external oblique aps, a medially placed large sac, tensely distended with altered blood, was identi ed.No indirect sac could be separately identi ed.The posterior wall seemed relatively intact, except for a 1x1cm tight defect in the medial aspect of the conjoined tendon, just cephalad and to the left of the pubic tubercle.The sac was incised and the uid was drained.A 10cm segment of ileum was identi ed within the sac, having undergone gangrene and partly retracted back within the peritoneal cavity.There was faecal contamination within the peritoneal cavity.
Hence, a formal laparotomy, segmental ileal resection and end-end anastomosis was performed.The round ligament was excised and the deep ring suture-closed.The posterior wall was strengthened by darning, including the defect.
No mesh was placed in view of the gangrenous nature of contents and the presence of signi cant e uent at the surgical site.She recovered well and was discharged on the 5 th postoperative day.

Discussion
Busoga herniae are anecdotal in their occurrence.The diagnosis is most often made intraoperatively.
They may confuse the unwary novice surgeon: the herniated loop of the bowel may migrate under the skin and simulate other conditions.Ogilvie and Gill (2,3) felt that this type of hernia is probably acquired and that its cause differs from that of the diffuse bulge of the fascia transversalis usually seen in direct inguinal herniae.It is likely that the fascia transversalis defect is traumatic in origin and, because its margins are strong, the sac tends to be tubular and its neck small.Strangulation of contents is the most fearful complication, and resection anastomosis is required in those cases.The key lies in the identi cation of the sac and careful dissection to prevent inadvertent injury to the contents.The management is otherwise similar to other inguinal herniae.We have not come across any other case report of this hernia in an Indian origin woman, and hence, the importance of reporting the case.

Conclusion
It is important to look thoroughly for trapped bowel.Excision of the sac and identifying a Richter or Maydl's type strangulation is of paramount importance.Addition of a diagnostic laparoscopy or laparotomy is advisable in dubious cases.Repair with or without mesh is likely to have similar outcomes, though data is scarce.Intraoperative photo revealing the cord structures inferiorly and the sac with gangrenous ileum craniomedially.