The last time I read about femoral hernias was during my surgery internship. Up to recently, I have never seen an actual femoral hernia or heard of any of my colleagues seeing one.
So it was with surprise that I encountered my first one. This school-age boy initially presented with a groin lump, not fluctuating and not painful. At first glance, I thought it was a cord lipoma or an incarcerated hernia with omentum. Because of the atypical features, I decided to order an ultrasound.
The radiologist reported:
There is a 3.5 x 2.3 x 0.9 cm sized echogenic lesion within the right inguinal canal, unclear if this represents fat-containing inguinal hernia or lipoma.
The family elected to proceed with surgery given the possibility of a hernia. After opening Scarpa’s fascia, a fat-containing hernia held in a clear hernia sac was seen. The hernia, however, was in an atypical location, lateral and inferior to the inguinal ligament. We opened the inguinal canal to confirm the anatomy by finding vas and vessels –which in retrospect was not necessary.
The hernia sac was opened and the omentum was returned to the abdomen. The sac was then further dissected proximally, twisted and divided, just like with inguinal hernias. After that, we noticed there was a significant defect inferolateral to the inguinal ligament and medial to the femoral vessels:
I thought that the defect needed to be closed, possibly using mesh, to prevent a recurrence. A pediatric surgery colleague came to the rescue and instead of using mesh, she performed a relatively simple repair by approximating the inguinal ligament to the pectineal ligament, using interrupted non-absorbable sutures. (Before this repair, the inguinal canal was reconstructed).
Femoral hernias constitute less 0.3% of pediatric groin hernias.
Although the recommended closure involves the reduction of hernia contents, suture ligation of the sac, and ligament approximation to close the defect, I found an article where femoral hernias in children were repaired laparoscopically by only encircling the defect, with no ligament approximation. Some books describe these hernias as been prone to incarceration and strangulation, but I could not find data regarding those outcomes.
Femoral hernias in children are very rare (<1%) but when encountered, can be repaired easily by first reducing its contents and tying off the sac, followed by the closure of the defect with interrupted non-absorbable sutures approximated the inguinal ligament to the pectineal ligament.