Bilateral Secondary Femorocele in a Case of Ascites Due to Cardiac Cirrhosis Following Dual Valvular Replacement for Rheumatic Heart Disease.

Background: Fluid collection in a femoral hernia sac designated as a femorocele is an extremely uncommon surgical condition. Till date 9 cases of unilateral femorocele and one case of bilateral femorocele have been reported in English literature. Objective: Thus making the case presented the second case of bilateral femorocele in English literature. Case report: A case of bilateral femorocele in a patient suffering from rheumatic heat disease who had undergone dual valvular replacement with ascites due to cardiac cirrhosis is presented to highlight the surgical challenges in management of such a rare case. Discussion: Pathophysiology, clinical features, investigations and managemeny of femorocele are discussed. Conclusion: Contrast enhanced CT scan of the abdomen and scrotum is diagnostic. Open surgery in the form of dissection of sac with high ligation followed by obliteration of femoral ring is therapeutic. There is no scope of laparoscopy in such a case.

Is Histopathological Evaluation of Hernia Sacs Necessary?

BACKGROUND: Our aim was to investigate the pathologies in the hernia sac in adults, and the frequency of malignancy as well as to confirm the necessity of maintaining the current applications in histological examination of the hernia sac. METHODS: Patients who were operated for hernia in our clinic from 2013 to 2019 were included in the study. Patient data were evaluated retrospectively. We divided the patients into four groups, according to the type of hernia. We evaluated the demographic characteristics of the patients, the pathologies within the hernia sac, histopathological examination outcomes of the hernia sac and clinical features of malignancy in patients with malignancy. RESULTS: A total number of 556 adult patients underwent inguinal, femoral, umbilical or incisional hernia repair in our hospital. Nine patients (0.61%) had malignancy in the hernia sac. Three out of nine patients (33%) had no preoperative diagnosis of malignancy. Six patients (67%) had a known history of malignancy. Two tumors were located in the inguinal (22.0%), six tumors in the incisional (67%), and one in the umbilical (11%) hernia sacs. Among these, 56% were of gastrointestinal, 22% of gynecological, 11% of breast and 11% of epididymis origin. Most of the other pathologies found in the hernia sac were herniated bowel segments, lipomas and omentum. CONCLUSION: Since the hernia sac might be the first clue for an underlying cancer, if abnormal pathological findings are detected during surgery, histopathological examination should be performed to exclude malignancy. The purpose of histological examination is to detect a hidden malignancy.

Femoral Hernia Containing the Right Fallopian Tube: A Rare Finding.

Femoral hernias comprise a small proportion of all groin hernias. They are more common in women and have a high rate of incarceration and strangulation, leading to emergency repair. A 61-year-old female patient was admitted to the emergency department complaining of a 2-day painful lump in the right groin, that had become more intense in the last 24 hours. Physical examination suggested the presence of a strangulated femoral hernia, and the patient underwent emergency surgical repair. Intraoperatively, the right fallopian tube was observed in the hernia sac. Since there were no signs of ischemia, the tube was reduced back into the pelvic cavity and the hernia was repaired. The postoperative period was uneventful, and the patient was discharged without complications, 3 days after surgery.

As hérnias femorais representam uma pequena fração de todas as hérnia da região inguinal. Elas são mais comuns entre as mulheres e estão associadas a elevadas taxas de complicações, como encarceramento e estrangulamento, com necessidade de cirurgia urgente. Uma paciente do sexo feminino, de 61 anos, recorreu ao serviço de emergência por quadro de dor e tumefação da região inguinal direita com 2 dias de evolução e agravamento nas últimas 24 horas. O exame objetivo sugeria a presença de uma hérnia femoral encarcerada, e a paciente foi submetida a cirurgia urgente. Intraoperatoriamente, confirmou-se o diagnóstico de hérnia femoral encarcerada, que continha a trompa de falópio direita no interior do saco herniário. Uma vez que a que a trompa não apresentava sinais de isquemia, o conteúdo da hérnia foi reduzido, e procedeu-se à sua reparação. O período pós-operatório decorreu sem intercorrências, e a paciente teve alta no 3° dia após a cirurgia.

Femoral hernia containing the right fallopian tube: a rare finding / Hérnia femoral contendo a trompa de falópio direita: um achado raro

Abstract Femoral hernias comprise a small proportion of all groin hernias. They are more common in women and have a high rate of incarceration and strangulation, leading to emergency repair. A 61-year-old female patient was admitted to the emergency department complaining of a 2-day painful lump in the right groin, that had become more intense in the last 24 hours. Physical examination suggested the presence of a strangulated femoral hernia, and the patient underwent emergency surgical repair. Intraoperatively, the right fallopian tube was observed in the hernia sac. Since there were no signs of ischemia, the tube was reduced back into the pelvic cavity and the hernia was repaired. The postoperative period was uneventful, and the patient was discharged without complications, 3 days after surgery.

Resumo As hérnias femorais representamuma pequena fração de todas as hérnia da região inguinal. Elas são mais comuns entre as mulheres e estão associadas a elevadas taxas de complicações, como encarceramento e estrangulamento, com necessidade de cirurgia urgente. Uma paciente do sexo feminino, de 61 anos, recorreu ao serviço de emergência por quadro de dor e tumefação da região inguinal direita com 2 dias de evolução e agravamento nas últimas 24 horas. O exame objetivo sugeria a presença de uma hérnia femoral encarcerada, e a paciente foi submetida a cirurgia urgente. Intraoperatoriamente, confirmou-se o diagnóstico de hérnia femoral encarcerada, que continha a trompa de falópio direita no interior do saco herniário. Uma vez que a que a trompa não apresentava sinais de isquemia, o conteúdo da hérnia foi reduzido, e procedeu-se à sua reparação. O período pós-operatório decorreu sem intercorrências, e a paciente teve alta no 3° dia após a cirurgia.

Combined Littre and Richter's femoral hernia: an extremely rare intra-operative finding.

Littre hernia is defined as the herniation of a Meckel's diverticulum, while Richter's hernia is the herniation of a portion of the bowel wall. An extremely rare case of a combined Littre and Richter's femoral hernia is reported. An 82-year-old male presented at the emergency department with a painful golf ball-like mass at the right inguinofemoral region. With the diagnosis of incarcerated femoral hernia, he was urgently taken to the operating room. Intraoperatively, an incarcerated Littre, as well as a Richter's hernia were revealed. Enterectomy and side-to-side small bowel anastomosis were performed. The patient made an uneventful recovery. To the best of our knowledge, the present is the first report of a combined Littre and Richter's femoral hernia. Such findings should be reported to raise the awareness of surgeons for complicated cases. It is of utmost importance to have a high suspicion index for strangulated hernias, to minimize the time between admission and surgery.

Midline Extraperitoneal Approach for Obturator Hernia Repair.

Obturator hernia (OH) is a rare condition that accounts for 0.073-1% of abdominal hernias and 0.48% of bowel obstructions. OH frequently occurs in elderly women, with an incidence that increases with age. The only treatment for OH is surgical intervention, and the approaches used vary greatly. Consequently, a well-defined consensus has not yet emerged. We assessed the efficiency and safety of the midline extraperitoneal approach for OH. Six patients with OH repaired using the midline extraperitoneal approach at KKR Sapporo Medical Center between April 2011 and January 2016 were included in the study. We retrospectively evaluated the patient characteristics, intraoperative findings, and the postoperative course. All patients were elderly women [median age, 90 (range, 79-92) years], with a median body mass index of 17.0 (range, 15.6-18.3) kg/m2 at presentation. All had symptoms associated with bowel obstruction: two patients presenting with leg pain had the Howship-Romberg sign. In two patients, bowel resection was required because of irreversible ischemic changes. Five patients had coexisting femoral and inguinal hernias that were repaired by bilateral mesh repair. One patient had aspiration pneumonia as a postoperative complication. All patients were discharged alive, without infection or recurrence. OH can be efficiently and safely repaired using the midline extraperitoneal approach. This approach establishes the diagnosis of OH, avoids injuring obturator vessels, gives improved exposure of the obturator canal, enables identification and simultaneous repair of other pelvic hernias, and facilitates bowel resection. This approach reduces the risk of mesh infection in patients undergoing bowel resection.

[A Case of Endometrioid Adenocarcinoma in the Sac of a Femoral Hernia].

A 74-year-old woman presented to our institution with right inguinal swelling. The swelling had appeared 1 year previously and exhibited a tendency to increase in size. Physical examination revealed a thumb tip-sized swelling in the right inguinal region. Computed tomography revealed a right femoral hernia and fluid accumulation, resulting in the diagnosis of a right femoral hernia. Using the anterior approach, we completely removed the cystic nodule and repaired the femoral hernia. The hernia sac contained elastic nodules, and pathological examination led to the diagnosis of endometrioid adenocarcinoma. Although postoperative positron emission tomography-computed tomography and magnetic resonance imaging revealed no tumor residue, systemic chemotherapy was selected after consultation with the obstetrics and gynecology department. In summary, we herein report a case of an endometrioid adenocarcinoma that occurred in the sac of a femoral hernia.

The Duari hernia and recognition of the femoral vein compression sign.

Femoral hernias can be difficult to diagnose and are at high risk of strangulation. This report is of a rare case of an irreducible femoral hernia containing caecum and appendix presenting as an emergency. To the authors' knowledge, there have only been three cases reported, the first described by Duari. This case was incorrectly diagnosed preoperatively as an inguinal hernia, so the CT diagnosis of femoral hernias is reviewed, in particular demonstrating the radiological use of the femoral vein compression sign.

Pattern of abdominal wall herniae in females: a retrospective analysis.

BACKGROUND: Gender differences are expected to influence the pattern and outcome of management of abdominal wall hernias. Some of these are left to speculations with few published articles on hernias in females. OBJECTIVES: To describe the clinical pattern of abdominal wall hernias in females. METHOD: A 5 year retrospective review. RESULT: There were 181 female patients with 184 hernias representing 27.9% of the total number of hernia patients operated. Mean age was 41.66±24.46 years with a bimodal peak in the 1(st) and 7(th) decades. Inguinal hernia accounted for majority (50.5%) but incisional hernia predominated in the 30-49 age group, while only inguinal and umbilical hernias were seen in the first two decades (p=0.04). There was no side predilection in the cases of inguinal hernia. There were 12 (6.6%) emergency presentations, most of which occurred in the 6th decade and above and none below 30 years (p=0.02). Umbilical (4 cases) and femoral hernias (3cases) accounted for most of these cases. Incisional hernia was the commonest cause of recurrent hernias. CONCLUSION: Inguinal hernia is the commonest hernia type in females followed by incisional hernias which also accounteds for most recurrent cases. Age appears to be a risk factor for developing complications.

Type 4 appendiceal diverticulum within a de Garengeot hernia.

A de Garengeot hernia is defined as an incarcerated femoral hernia containing the vermiform appendix. We describe the case of a patient with a type 4 appendiceal diverticulum within a de Garengeot hernia and delineate valuable learning points. A 76-year-old woman presented with a 2-week history of a non-reducible painless femoral mass. Outpatient ultrasonography demonstrated a 36mm × 20mm smooth walled, multiloculated, partially cystic lesion anterior to the right inguinal ligament in keeping with an incarcerated femoral hernia. Intraoperatively, the appendix was found to be incarcerated in the sac of the femoral hernia and appendicectomy was performed. Histopathology demonstrated no evidence of inflammation in the appendix. However, an incidental appendiceal diverticulum was identified. It is widely recognised that a de Garengeot hernia may present with concomitant appendicitis, secondary to raised intraluminal pressure in the incarcerated appendix. Appendiceal diverticulosis is also believed to develop in response to raised pressure in the appendix and may therefore develop secondary to incarceration in a de Garengeot hernia. To our knowledge, only one such case has been described in the literature. A de Garengeot hernia is a rare entity, which poses significant diagnostic challenges. A high index of clinical suspicion is necessary as these hernias are at particularly high risk of perforation and so prompt surgical management is paramount.

Prevascular femoral hernia and its relation with inferior epigastric vessels: a rare presentation of the femoral hernia sac.

A 61-year-old man presented to the emergency department, with a 2-week history of a painful lump on his right groin. A diagnosis of an irreducible right femoral hernia was made. As such, an urgent operation was carried out on the same day, and the patient was found to have a rare prevascular femoral hernia in which the sac was lying over the femoral vessels and split by the inferior epigastric vessels into 2 components resembling 2 trouser limbs. The hernia sac presented in a different and challenging way that necessitated meticulous dissection and full orientation of the anatomy of the femoral triangle. Complete dissection and control of the inferior epigastric vessels, and complete reduction of the sac followed by repair with a prosthetic mesh plug were performed successfully. The patient was discharged home the next day.

Femoral hernia, a rare complication following deep inguinal lymph node dissection.

A 72-year-old woman underwent complete deep inguinal lymph node dissection on her right side subsequent to metastasis from malignant melanoma. On the second postoperative day, the patient reported of nausea and vomiting. She presented with a mass in the resected area that gradually increased in size to approximately 15×20 cm. The wound was opened a few hours after onset of symptoms and a large femoral hernia with 40 cm of small intestine was immediately revealed protruding in the groin. Prophylactic suturing of the inguinal ligament and Coopers ligament can reduce the risk of postoperative femoral hernia. Further, the authors argue that drainage for seroma and haematoma should be performed with utmost care, considering other possible causes and, if necessary, guided by ultrasonography.

Preperitoneal femoral hernioplasty: an "umbrella" technique.

INTRODUCTION: Tension-free inguinal mesh-plug hernioplasty is well established. However, femoral hernia repair remains challenging and controversial. We aimed to evaluate a preperitoneal approach of tension-free hernioplasty for femoral hernia upon the anatomy rationality. METHODS: A prospective study of 62 patients between October 1999 and June 2011 received femoral hernioplasty in our hospital. This repair method involved a preperitoneal approach accomplished under regional or local anesthesia with mesh and plug; the emphasis was put on fulfilling the abdominal defect, i.e., the myopectineal orifice, with the plug flattened like an "umbrella", above the femoral ring but not to fill the femoral ring. RESULTS: All cases receiving preperitoneal tension-free hernioplasty had a smooth recovery. There were no severe complications, and no recurrences were detected within a 0.5- to 4-year follow-up. No specific restrictions with regard to activity were placed on the patients after surgery. All cases were able to return to normal life, including work, within 2 weeks. CONCLUSIONS: The preperitoneal tension-free hernioplasty may be a more effective method of femoral hernia repair; meanwhile, we must re-understand the anatomy of femoral hernia correctly so as to restore the anatomic and physiologic functions at this region optimally.

The necessity of routine histologic examination of hernia sac, revisited.

PURPOSE: To validate the need of continuing the current practice of histologic examination of hernia sacs (HS). METHODS: All HS received by our laboratory over 15 years were reviewed for any pathological findings. Cases harboring these results were selectively re-examined histologically by a pathologist and their charts were reviewed by a surgeon checking for clinical significance. Moreover, previous studies were analyzed to reach a final conclusion. RESULTS: Pathological findings were noted in only 13.7 and 12.8% of adults and kids HS, respectively. None of these had significant impact on patient care. CONCLUSIONS: Serious pathologies reported in HS in the literature are rare. This, coupled with our data, suggest that the current practice of routine microscopic examination of HS is not justified. Criteria are proposed for categorizing cases as eligible for histologic evaluation. This will significantly reduce the workload and contain the cost.

[Connective tissue dysplasia as a reason of recurrent inguinal hernia].

The examination results of 78 patients with recurrent inguinal hernia revealed presence of systemic connective tissue abnormalities in addition to dysplasia of posterior wall of inguinal canal in 48 (61.6%) patients. Hernial disease was observed in 37 (47.4%) patients including umbilical hernia in 12 cases, femoral hernia in 8 patients, hiatal hernia in 3 patients and bilateral inguinal hernia in 14 cases. Group of other diseases included varicose veins of lower limbs in 15 (19.2%) patients, mitral valve prolapse in 3 (3.8%) patients, violation of skin elasticity (striae) in 6 (7.7%) cases, diverticulum of bladder in 2 (2.6%) patients, diverticulum of esophagus in 1 (1.3%) patient, diverticulosis of small intestine in 2 (2.6%) cases. Our data prove that inguinal hernia is local manifestation of systemic disease.

The epidemiology and risk factors for recurrence after inguinal hernia surgery.

BACKGROUND: Recurrence after inguinal hernia surgery is a considerable clinical problem, and several risk factors of recurrence such as surgical technique, re-recurrence, and family history have been identified. Non-technical patient related factors that influence the risk of recurrence after inguinal hernia surgery are sparsely studied. The purpose of the studies included in this PhD thesis, was to describe the epidemiologic characteristics of inguinal hernia occurrence and recurrence, as well as investigating the patient related risk factors leading to recurrence after inguinal hernia surgery. Four studies were included in this thesis. METHODS AND RESULTS: Study 1: The study was a nationwide register-based study combining the Civil Registration System and the Danish National Hospital Register during a five-year period. We included a total of 46,717 persons operated for a groin hernia from the population of 5,639,885 people (2,799,105 males, 2,008,780 females). We found that 97% of all groin hernia repairs were inguinal hernias and 3% femoral hernias. Data showed that inguinal hernia surgery peaked during childhood and old age, whereas femoral hernia surgery increased throughout life. Study 2: Using data from the Danish Hernia Database (DHDB), we included all male patients operated for elective primary inguinal hernia during a 15-year period (n = 85,314). The overall inguinal hernia reoperation rate was 3.8%, and subdivided into indirect inguinal hernias and direct inguinal hernias, the reoperation rates were 2.7% and 5.2%, respectively (p <0.001, chi-square). In the multivariate Cox proportional hazards analysis of factors predicting reoperation, we found that a direct inguinal hernia at primary operation was a substantial risk factor for recurrence with a Hazard ratio of 1,90 (CI 95% 1.77-2.04) compared with an indirect inguinal hernia at primary operation (p < 0.001). We found that there was a significant relationship between the type of hernia at the primary operation and reoperation, when controlling for the effect of the operation method, r = 0.45 (p < 0.001). This corresponded to odds ratios (OR) of 7.1 (CI 95% 6.0-8.4) of being reoperated for a direct inguinal hernia if the hernia at the primary operation was a direct inguinal hernia, and an OR of 3.0 (CI 95% 2.7-3.3) of being reoperated for an indirect inguinal hernia if the primary operation was for an indirect inguinal hernia. As subsequent findings, we saw that the frequency of laparoscopic hernia repair increased during the study period and that the laparoscopic repair of indirect inguinal hernias recurred more often than indirect inguinal hernias operated by Lichtenstein's technique (p < 0.001). Study 3: Using data from the DHDB, we included all female patients operated for elective primary inguinal hernia during a 15-year period (n = 5,893). Of those, a total of 305 operations for recurrences were registered (61 % inguinal recurrences, 38 % femoral recurrences, 1 % no hernial), which corresponded to an overall crude reoperation rate of 5.2%. A noticeable difference was found in reoperation rates after primary operation for direct inguinal hernias (DIH), indirect inguinal hernias (IIH) and combined IIH+DIH of 11.0%, 3.0%, and 0.007% respectively (p < 0.001, chi-square). In the multivariate Cox proportional hazards analysis of factors predicting reoperation, we found that a direct inguinal hernia at primary operation was a substantial risk factor for recurrence with a Hazard ratio of 3.1 (CI 95% 2.4-3.9) compared with an indirect inguinal hernia at primary operation (p < 0.001). Laparoscopic operation was found to give a lower risk of recurrence with a Hazard ratio of 0.57 (CI 95% 0.43-0.75) compared with Lichtenstein's technique (p < 0.001). We found that all femoral recurrences (n = 116) occurred after Lichtenstein's procedure and none occurred after laparoscopic operation (p < 0.001, Log Rank test). Study 4: This study was a systematic review and meta-analysis of non-technical patient-related risk factors for recurrence after inguinal hernia surgery. From a total of 5,061 potentially relevant records we included 40 studies in the review covering 719,901 procedures in 714,167 patients and of those 14 studies covering 378,824 procedures in 375,620 patients were included into meta-analysis of eight risk factors (gender, age, hernia type, hernia size, re-recurrence, bilaterality, mode of admission and smoking). We found that female gender (RR 1.38, 95% CI 1.28-1.48, I2 = 0%), direct inguinal hernias at primary procedure (RR 1.91, 95% CI 1.62-2.26, I2 = 10%), operation for a recurrent inguinal hernia (RR 2.2, 95% CI 2.0-2.42, I2 = 6%), and smoking (OR 2.53, 95% CI 1.43-4.47, I2 = 0%) were risk factors for recurrence after inguinal hernia surgery. Furthermore, emergency admission; connective tissue composition and degradation; and positive family history were found to have an impact on the risk of recurrence, while post-operative convalescence and age had no impact on the risk of recurrence. CONCLUSION: The studies included in the thesis have studies the natural history of groin hernias on a nationwide basis; have identified the epidemiologic distribution of groin hernias and the non-technical risk factors associated with recurrence. Data showed that non-technical patient-related risk factors have great impact on the risk of recurrence after inguinal hernia surgery. The reason to why inguinal hernias recur is most likely multifactorial and lies in the span of technical and non-technical patient-related risk factors and it is possible that the different groin hernia subtypes have different pathophysiology. This knowledge should be implemented into clinical practice in order to reduce the risk of recurrence and in future research design examining recurrence after inguinal hernia surgery as outcome.