Introduction Inguinal hernia often presents as an emergency with obstruction and subsequent strangulation. We report an interesting case where an inguino-scrotal sliding type hernia contained the hepatic flexure as its lead point, resulting in acute colonic obstruction and caecal wall perforation.

Aims/Background A 63-year-old gentleman admitted with abdominal distension and vomiting had a large, tense irreducible inguino-scrotal hernia on the right side which was non-tender, with concomitant tenderness in the left iliac fossa. Radiographic findings were of acute colonic distension.

Method At laparotomy the hepatic flexure on an abnormally long mesentery, formed the lead point of an inguino-scrotal hernia bringing with it the greater omentum, distal ascending and proximal transverse colon. The dilated caecum was found in the left iliac fossa, within its wall an ischaemic serosal tear and a single ‘pistol shot’ perforation laterally, with surrounding faecal contamination. A right hemicolectomy with side-to-side stapled anastomosis was performed an the patient made an uncomplicated recovery.

Results This is an extremely rare variant of the complete inguino-scrotal sliding type hernia. A detailed anatomical sketch of the encountered pathology is included, with correlation to the plain radiographic imaging.

Conclusion Acute presentation of an inguinal hernia with intestinal obstruction requires emergency surgery with a mid-line laparotomy incision most appropriate. When confronted with a patient who has colonic obstruction and abdominal tenderness, proceeding to emergency laparotomy is prudent.