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362 Inguinal and Femoral Hernias and Hydroceles Inguinal and Femoral Hernias and Hydroceles
363
• testicular atrophy as a result of transection of the vessels during the
operation or, in the case of children presenting with incarcerated her-
nias, with evidence of infarction of the testis at operation;
• infarction of the ovary and fallopian tube (rare because there is usu-
ally no obstruction to the blood supply of these organs);
• subfertility or infertility if injury to the vas deferens is bilateral or is
to the vas deferens of a solitary testis; and
• numbness of the inguinal region as a result of injury to the ileoin-
guinal nerve.
Femoral Hernia
Femoral hernia is an unusual hernia in the paediatric age group. A
Source: By kind permission of the African Journal of Paediatric Surgery. femoral hernia presents as a mass located lateral to and below the
Figure 58.6: Amyand’s hernia in a 5-year-old boy. Note the oedematous and pubic tubercle, inferior and posterior to the inguinal ligament and
shiny nature of the scrotum. Intraoperatively, an inflamed appendix was found. medial to the femoral pulse. It occurs in about 0.5% of all groin hernias
in children. The diagnosis of a femoral hernia is challenging, and the
correct preoperative diagnosis is usually not made in many children.
finger of the left hand are placed on either side of the external inguinal
Most often, it is misdiagnosed, and only during surgery for a suspected
ring (where the mass is usually obstructed) over the pubic tubercle.
inguinal hernia is the precise diagnosis made. Note that a diagnosis of a
The fingers of the right hand compress the fundus of the hernia gently
missed femoral hernia or a direct inguinal hernia should be considered
but firmly. The pressure should be gentle, firm, and sustained.
if any child returns with an early recurrence of a groin bulge after an
2. Meanwhile, the thumb and the index finger of the left hand attempt
adequate herniotomy, as recurrent indirect inguinal hernias are rare. In
to disimpact the neck of the hernia from the narrow external inguinal
the literature, some femoral hernias are reported to have occurred after
ring and also prevent the contents of the sac from spreading to the
an inguinal canal exploration or even as a result of iatrogenic disruption
sides and outwards.
of the femoral canal. Most paediatric surgeons know of the existence of
3. When reduction is successful, the whole bowel is felt to return to the this entity but have not encountered it in their practice due to its rarity.
peritoneal cavity suddenly and with a gurgle or gush.
Aetiology
4. After successfully reducing an incarcerated hernia, the child is kept The aetiology of femoral hernias remains elusive. It is suggested that
in hospital for at least 24 hours for observation, and herniotomy is it may be due to either (1) a congenital narrow posterior inguinal wall
planned for the next available elective list. attachment to Cooper’s ligament with a resulting enlarged femoral ring
Other surgical methods available for repair of inguinal hernias in (this is the anatomic aspect accepted by many paediatric surgeons); or
children consist of the different techniques of laparoscopic surgery. (2) an acquired genesis related to increased intraabdominal pressure.
These include percutaneous internal ring suturing, laparoscopic flip- Anatomy
flap technique, and others.
The anatomy of the femoral canal, which occupies the most medial
Postoperative Complications compartment of the femoral sheath and extends from the femoral
Complications of herniotomy can be immediate, early, or late. The ring above to the saphenous opening below, has the medial border as
immediate complications will include anaesthetic complications, such the lacunar (Gimbernat’s) ligament, posterior border as the pectineal
as nausea, vomiting, and laryngeal spasm or oedema. Other immediate (Cooper’s) ligament, the lateral border as the femoral vein, and the
complications are haemorrhage (which should be rare if haemostasis is anterior border as the inguinal ligament. It is usual to have a lymph
meticulous) and haematoma formation in the wound. node (Cloquet) within the canal.
If the vas deferens is transected intraoperatively and this is noticed, In the available series of childhood femoral hernias, 60–65% are
then it should be repaired by using fine monofilament sutures. found on the right side, 25–30% on the left, and 10–15% are bilateral.
The early complications comprise Presentation
• haematoma formation in the wound or scrotum; such a haematoma The clinical signs and symptoms of a femoral hernia are a bulge below
will slowly resolve in 3–5 weeks if there is no superimposed infection;
the inguinal ligament and lateral to the pubic tubercle; the mass appears
• wound infection, which may occur as a result of anaemia and malnu- on straining or coughing, and reduces in size or disappears when the
trition in patients and especially after repair of incarcerated hernias; patient lies supine; and there may be a cough impulse. A femoral hernia
can remain unnoticed for a long period until it incarcerates, drawing the
• abscess formation in the wound or scrotal haematoma;
attention of the patient to the problem for the first time. Incarceration of
• intestinal obstruction; and paediatric femoral hernias is a very rare occurrence, however.
• faecal or urinary incontinence as a result of iatrogenic trauma to the Diagnosis
bowel or urinary bladder. The diagnosis of a femoral hernia is mainly clinical or at operation.
Late complications comprise: For the diagnosis to be made preoperatively, the surgeon must consider
it in the differentials of groin hernias. There are no known investiga-
• stitch abscess, associated with the use of nonabsorbable sutures;
tions to help confirm the diagnosis of a femoral hernia. The advent of
• undescended testis or high testis due to the fact that the surgeon did laparoscopic surgery definitely helps with the diagnosis and repair of
not make sure the testis was replaced in the scrotum when closing such hernias.
the inguinal incision; The differential diagnosis of a femoral hernia include inguinal
• recurrence of the inguinal hernia (causes of recurrence include infec- hernia, ectopic testis, femoral aneurysm, sahpena varix, enlarged
tion and missing the hernia sac during the first operation); femoral lymph nodes, lymphadenitis, lipoma, psoas abscess, and
lymphangioma.
• hydrocele, which may resolve spontaneously or may require surgery;