Editor-in-ChiefClinical Case ReportsJune 5,2025Dear Editor-in-Chief,We would like to submit our manuscript entitled “Neglected inguinal hernia with endometriosis: A case report” for publication as a case report in Clinical Case Reports.Inguinal hernia with endometriosis is a rare and misdiagnosed situation in clinical practices. In this study, we report an unusual case of neglected inguinal hernia with endometriosis, presenting as a reversible mass in the right inguinal region without painful during menstruation. This case shows that caution must be exercised when diagnosing a groin mass in child-bearing period female, ultrasound and CT are useful for assessing lesions, and MRI can also help identify specific patterns.We believe this case will be of great interest to clinicians. As the premier international journal devoted to publish scientifically accurate and valuable research, Clinical Case Reports represents the perfect platform for us to share this case with the international research community.We confirm that this manuscript has not been published elsewhere and is not under consideration by another journal. All authors have approved the manuscript and agree with submission to Clinical Case Reports . The authors have no conflicts of interest to declare.Please address all correspondence to: Tao Yang, Department of Gastroenterology, Shaoxing People’s Hospital, Shaoxing 312000, China. taoyang2017@zju.edu.cn. Telephone: +86-15757193769We look forward to hearing from you at your earliest convenience.Yours sincerely,Tao Yang.Title pageCase ReportTitle ：Neglected inguinal hernia with endometriosis: A case reportJing-Jing Feng1, Li-Xin Li1, Tao Yang2*1Department of Gynecology, Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing,Zhejiang, China.2Department of Gastroenterology, Shaoxing People’s Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing,Zhejiang, China.*Correspondence addressed: Department of Gastroenterology, Shaoxing People’s Hospital, Shaoxing 312000, China.Tel: +86-15757193769E-mail: taoyang2017@zju.edu.cnCONFLICT OF INTEREST:Authors declared no conflict of interest.ConsentThe patient’s written consent for the publication of this case report was obtained.Case ReportTitle ：Neglected inguinal hernia with endometriosis: A case reportKeywords: Inguinal hernia, endometriosis, round uterine ligament, cutaneous endometriosisKCMA 42-year-old female, gravida 3, para 1 (G3P1), presented to our general surgery department with a reversible mass in the right inguinal region for one month. She underwent tension-free repair for groin hernia, removing the uterine round ligament and the mass. The pathology result of mass was round uterine ligament endometriosis. The patient was followed up in gynecology outpatient clinic and received hormone therapy.1 | IntroductionEndometriosis(EMs) is a chronic gynecologic condition affecting around 10% in reproductive-aged women[1]. It is described as the presence of endometrial epithelial and stromal cells outside the uterus, frequently associated with infertility, dysmenorrhea, dyspareunia, chronic pelvic pain and urinary tract symptoms. The most common sites of EMs are ovaries, pelvic peritoneum, broad ligaments and uterosacral ligaments, can also occur in bladder, rectum, abdominal incision or umbilical cord [2]. However, cutaneous endometriosis is considered a rare form of EMs, the incidence of cutaneous endometriosis is approximately 5%[3]. Inguinal endometriosis (IEM) is a rare and misdiagnosed situation in clinical practice. Patients usually present with periodic distention pain. It is easily misdiagnosed as other diseases such as femoral hernia, inguinal leiomyoma, cysts and soft tissue tumors[4]. Patients with IEM were divided based on the site of occurrence. In type I, endometriosis exists at a hernia sac or hydrocele of Nuck’s canal. In type II, endometriosis originates in the round ligament. In type III, endometriosis locates in the subcutaneous area[5]. Here, we report an unusual case of inguinal hernia with endometriosis without clinical symptoms or surgical history.2 | Case Presentation2.1 | Case History and ExaminationA 42-year-old female, gravida 3, para 1 (G3P1), presented to our general surgery department with a reversible mass in the right inguinal region for one month. The patient had regular menstrual cycles and denied dysmenorrhea history. Physical examination revealed a 2*2cm, soft and no tenderness in the right inguinal region. The patient denied a history of pain and the VAS pain scores was 0. The patient’s tumor marker CA125 was 26.61U/ml, within normal range. Blood routine, hepatitis B, preoperative infectious disease examination, biochemical routine and so on were within the normal range. The mass disappeared after the patient was supine and the transmittance test was negative. Computed tomography (CT) of the hypogastric region revealed the inguinal region was widened, part of the abdominal cavity contents herniated, an 18*15mm nodular density shadow was seen in the left ovary(Figure 1).2.2 | Investigations and TreatmentComplete excision of both tumor tissue and round ligament is performed for pathological analysis. The hernia sac is identified and opened, hemostasis at its distal end is maintained while leaving it in situ, followed by detachment of its proximal segment up to the internal ring, where a high ligation at this site is executed. After thorough hemostasis, suturing of the transversus abdominis muscle layer occurs, with subsequent repair utilizing a 6*8 cm biological mesh patch secured to both the conjoint tendon and inguinal ligament as well as to the anterior sheath of rectus abdominis. The patient was in stable condition after surgery.2.3 | Outcome and Follow-UpFollow-up and outcomes: the round ligament of the uterus mass was sent for pathology department. The pathological result was round uterine ligament endometriosis, we considered this IEM was type II(Figure 2). She was counseled to our gynecology outpatient clinic review. The patient completed transvaginal ultrasonography finding no lesions and VAS pain scores was 0. Considering that the patient had no obvious symptoms and no indication for laparoscopic surgery, the ASRM table score could not be performed. Endometriosis was prone to recurrence, and 3 injections of GNRH were performed after surgery (Figure 3).3 | Discussion and ConclusionThis study discussed a patient with a right groin mass who underwent surgery at a surgical clinic with a pathological indication of IEM and was subsequently treated at an outpatient clinic. In a meta-analysis of 133 patients with inguinal endometriosis, the mean age of onset was 36 years, about half of the patients presented with a right inguinal mass, and 54.1% of the study patients presented with periodic inguinal pain[6]. However, CA125 is not elevated in all patients with IEM, in one study of 8 patients, 2 patients had above-normal levels[7]. In our case, CA125 was within the normal range, indicating that this indicator was not specific in IEM cases.According to the guidelines for the diagnosis and treatment of endometriosis, it can be divided into the following types: peritoneal endometriosis, ovarian endometriosis, deep infiltrating endometriosis (DIE), and other endometriosis (bladder, lung, umbilical, inguinal, appendix, rectum, nasal, breast), inguinal endometriosis is rare in domestic and foreign cases, the most typical manifestation is a mass in the groin area associated with menstruation[8]. At present, the pathogenesis of inguinal endometriosis is not clear. According to literature reports, the pathogenesis may be as follows: (1) endometrial reverse tubal implantation; (2) static transmission; (3) embryonic cells of the Mullerian canal are activated by hormones; (4) metaplasia of mesenchymal cells; (5) Adjacent pelvic lesions spread directly along the round ligament, the main principle is based on the theory of countercurrent implantation of menstrual blood and supracoelom metaplasia. IEM occurs in the extraperitoneal part of the round ligament, which may be related to the obstruction of the left sigmoid colon, gravity and clockwise peritoneal movement. The characteristic of the disease is the non-retrievable lump of the inguinal in the extraperitoneal part of the round ligament, the mass becomes large and painful during menstruation, often occurring in the right[9].The inguinal endometriosis is easily misdiagnosed as inguinal hernia or round ligament cyst. Imaging examinations such as ultrasound, computed tomography or magnetic resonance imaging (MRI) have a certain significance for diagnosis and evaluation[10]. However, the final diagnosis is based on histology and immunohistochemistry. Complete surgical resection must include the mass and the round ligament[11]. General surgeon surgery discovered significant hernial sac wall thickening, adhesion, sac with blood, cylindrical or peritoneal ligaments apparent thickening, should consider inguinal endometriosis. The surgeon should conduct intraoperative gynecological consultation when encountering such patients. For infertile patients, laparoscopic pelvic examination is necessary. In this case, the patient refused to undergo laparoscopy, Considering that it was easy to relapse after surgery, GnRHa was given for 3 cycles after surgery, there was no recurrence after surgery and further treatment follow-up is still under way. Due to the rarity of inguinal endometriosis, the number of cases is small, we cannot discuss the efficacy of postoperative hormone therapy in preventing recurrence. Therefore, more cases are needed for further statistical analysis of the effectiveness of surgical treatment and postoperative hormone therapy[12].In conclusion, inguinal endometriosis is a rare disease usually seen with menstrual cycle pain. However, caution must be exercised when diagnosing a groin mass. Ultrasound and CT are useful for assessing lesions, and MRI can also help identify specific patterns. Surgical is the primary treatment and recurrence is rare after surgical resection. When patients with pelvic endometriosis are combined, individualized treatment can be selected according to the patient’s age, fertility requirements, and lesion degree.Author ContributionsJingjing Feng: data curation, project administration, writing – re-view and editing. Li-Xin Li: data curation, investigation, writing– original draft, writing – review and editing. Tao Yang: investigation, writing – original draftAcknowledgmentsThe authors have nothing to report.ConsentThe patient’s written consent for the publication of this case report was obtained.Conflicts of InterestThe authors declare no conflicts of interest.Data Availability StatementThe data that support the findings of this study are available from the corresponding author upon reasonable requestReference[1]Zondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J Med.2020;382(13):1244-56[2]Chapron C, Marcellin L, Borghese B, Santulli P. Rethinking mechanisms, diagnosis and management of endometriosis. Nat Rev Endocrinol 2019;15(11):666e82.[3]Raffi L, Suresh R, McCalmont TH, et al. Cutaneous endometriosis. Int J Womens Dermatol 2019;5:384–6[4]Basnayake O, Jayarajah U, Seneviratne SA. Endometriosis of the inguinal canal mimicking a hydrocele of the canal of nuck. 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