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Subacute Torsioned Femoral Hernia.

Introduction

The abdominal cavity is almost entirely surrounded by musculofascial layers. Abdominal hernias may be described as protrusions of any abdominal organ or tissue within the abdominal cavity through a natural or acquired opening in the abdominal wall that surrounds the organ or tissue. Of all abdominal wall hernias, 80% are groin hernias (1). Groin hernias can be generally classified as direct inguinal, indirect inguinal and femoral hernia. Of the all groin hernias, 2-8% are femoral hernias (2). Femoral hernias are acquired hernias, and infrequent during the childhood. It occurs at the median age of 4070 (peak 50) years (3). Although inguinal hernias present a significant prevalence among male patients, femoral hernias are more common among female patients. In addition, 80-90% of femoral hernia cases are females and show a right-side dominance (2, 4, 5). Inguinal, femoral, or extraperitoneal approaches can be used for femoral hernia reparation (6).

Case Presentation

A 36-year-old female patient with right inguinal swelling and pain complaints that suddenly appeared 2 months ago and showed minimal reduction in size in the 2 months was admitted to our clinic. Physical examination revealed an irreductible nonpulsatile soft tissue mass measuring 10 x 13 cm in the right inguinal region, extending to the left inguinal region over the symphysis pubis. Abdominal findings revealed no gastrointestinal symptoms. All laboratory tests were normal. A 135 x 90 x 75 mm sized highly intense cystic mass localized in the right inguinal region, extending to the femoral region was detected in the ultrasonographic examination. The patient underwent operation with a right inguinal transverse incision. During inguinal exploration, a 12-cm in diameter cystic mass was observed in the right inguinal region. The lesion was localized between the subcutaneous fascia and aponeurosis of the external oblique muscle (Figure 1). There was a femoral extension of the inguinal cystic mass, showing gradual narrowing underneath the inguinal ligament. This inguinal cystic mass was emerged because of the torsion of the femoral hernia along the sac neck, and the patient was diagnosed as having subacute torsioned femoral hernia. When the sac was dissected, a connection between the cystic mass and peritoneal cavity through the femoral canal via a wide torsioned neck was observed (Figure 2). There was no abdominal content within the sac. When the cystic mass was detorsioned, cystic fluid was emptied into the abdominal cavity. The fluid present in the peritoneal cavity was aspirated. McVay herniorrhaphy was performed after the neck of the hernial sac was ligatured. The postoperative period was uneventful, and the patient was discharged on postoperative day 2.

Discussion

Femoral hernias have higher complication ratios and urgent surgical requirements than other groin hernias, and have higher mortality and morbidity ratios (7). Strangulation and incarceration are the main acute complications of femoral hernias, which require urgent surgical intervention, and 40-60% of femoral hernia refer to a phycian because of incarceration and strangulation (8). Some types of incarcerated or strangulated femoral hernias are entitled with special nomenclature according to the abdominal content such as appendix, Meckel's diverticula, small bowel, or Fallopian tube. In our case, there was a subacute femoral hernia torsion, which might be assessed as a subacute complication other than acute complications that require urgent surgical intervention. The urgent surgical treatment of incarcerated or strangulated femoral hernias should be performed within a few hours or at least within a couple of days. The period between the onset of the complaints and the definitive treatment in our case was approximately 2 months, making us consider our case as a subacute complication.

Conclusion

As femoral hernia may mimic any mass lesion, which might appear in inguinal area, it should be considered in the differential diagnosis of every case of mass lesion in the inguinal region.

Informed Consent: Written informed consent was obtained from patient who participated in this case.

Peer-review: Externally peer-reviewed.

Conflict of Interest: No conflict of interest was declared by the author.

Financial Disclosure: The author declared that this study has received no financial support.

References

(1.) Richards AT, Quinn TH, Fitzgibbons RJ. Abdominal wall hernias. Surgery 3 rd ed. Philadelphia, PA.

(2.) Glassow F. Femoral hernia. Review of 2105 repairs in a 17 year period. Am J Surg. 1985; 150: 353-6.

(3.) Keith A. On the origin and nature of hernia. Br J Surg. 1923; 11: 455-75.

(4.) Waddington RT. Femoral hernia: a recent appraisal. Brit J Surg. 1971; 58: 920-2.

(5.) Suzuki S, Furui S, Okinaga K, Sakamoto T, Murata J, Furukawa A, et al. Differentiation of femoral versus inguinal hernia: CT findings. AJR Am J Roentgenol. 2007; 189: 78-83.

(6.) Hachisuka T. Femoral hernia repair. Surg Clin N Am. 2003; 83: 1189-205.

(7.) Naude GP, Ocon S, Bongard F. Femoral hernia: the dire consequences of a misseddiagnosis. Am J Emerg Med. 1997; 15: 680-2.

(8.) Kingnorths A, Bennet DH. Hernias, umblikus, abdominal wall. In:Russel RCG, Williams NS, Bulstrde CJK. Bailey@Lovee's short practice of surgery. 232rd ed. London England. Arnold publishers 2000: 1143-62.

Ali Naki Yucesoy

Clinic of General Surgery, Bati Bahat Hospital, Istanbul, Turkey

Corresponding Author: Ali Naki Yucesoy e-mail: alinakiyucesoy@gmail.com

Received: 17.04.2017 * Accepted: 25.04.2017 * Available Online Date: 09.08.2017

DOI: 10.5152/eajem.2017.80774

Caption: Figure 1. A 12-cm diameter cystic mass that was observed via the right inguinal transverse approach

Caption: Figure 2. The detorsioned femoral hernial sac
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Title Annotation:Case Report
Author:Yucesoy, Ali Naki
Publication:Eurasian Journal of Emergency Medicine
Article Type:Case study
Date:Jun 1, 2018
Words:890
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