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362 Inguinal and Femoral Hernias and Hydroceles Inguinal and Femoral Hernias and Hydroceles
363 Inguinal and Femoral Hernias and Hydroceles 363
Treatment
For uncomplicated femoral hernias, the treatment is surgical repair of the
femoral defect as soon as the diagnosis is made. There are three methods
of approaching the femoral canal for the repair of a femoral hernia:
1. a high or suprainguinal (transperitoneal or extraperitoneal) approach;
2. an inguinal approach; and
3. a low infrainguinal approach.
Irrespective of the method of approach used, the procedure is as follows:
1. The hernia sac is dissected free and opened to inspect the contents,
which are then reduced back to the peritoneal cavity, if present.
2. The sac is then suture-ligated and the inguinal ligament is approximated
to the pectineal ligament, thus effectively eliminating the defect. (A)
Caution should be exercised not to strangulate the femoral vein,
which will lead to compromised venous return, resulting in the swelling
of the lower limb on the affected side. In an incarcerated femoral
hernia, the transperitoneal approach may come in handy if there is the
need to resect gangrenous bowel.
Femoral hernias can also be repaired laparoscopically.
Complications
Complications include recurrence of femoral hernia (mainly reported
in patients who underwent simple herniotomy without any attempt to
close the defect in the femoral canal), trauma to the femoral vessels,
oedema of the lower limb, haemorrhage leading to haematoma forma-
tion, and wound infection.
Hydrocele
A hydrocele is an abnormal collection of fluid in the layers of the tunica (B)
vaginalis, the persistently patent processus vaginalis surrounding the Figure 58.7: A communicating hydrocele in a 6-year-old boy: (A) in a standing
position, fluid fills the tunica vaginalis and the hydrocele is apparent; (B) in a lying
testis. Hydroceles are common in infants. The PPV is found in about position, the fluid trickles back into the peritoneal cavity and the hydrocele empties.
90% of term babies at birth. This incidence rate will gradually decrease
to about 40% at 2 years of age and then to about 10% in adulthood. A
clinically apparent hydrocele is present in only 6% of term male chil-
dren beyond the neonatal period.
Aetiology
In infants, hydroceles, which are mostly congenital, can be commu-
nicating or noncommunicating. A communicating hydrocele (Figure
58.7A) occurs when the proximal portion of the PV remains patent,
allowing fluid from the abdominal cavity to trickle down its narrow
neck into the scrotal sac, or tunica vaginalis. A communicating hydro-
cele fluctuates in size and is usually larger in ambulatory patients at the
end of the day. It becomes small as the child lies down supine and the
fluid trickles back into the peritoneal cavity (Figure 58.7B).
In the case of noncommunicating hydroceles (Figure 58.8), the
PV is obliterated proximally with a collection of fluid distally in the Figure 58.8: A vaginal (scrotal) hydrocele in a 10-year-old boy. The PV was
completely obliterated above the hydrocele at operation.
tunica vaginalis alone or the tunica vaginalis and part of the PPV
proximal to it. Thus, one can have (1) a vaginal (scrotal) hydrocele
in which the whole PV is obliterated and there is fluid collection in
the tunica vaginalis; (2) an infantile hydrocele, in which part of the
PV proximal to the tunica vaginalis is still patent, and can sometimes hydrocele of the cord
extend into the inguinal canal as far as the internal inguinal ring; or (3)
an encysted hydrocele of the spermatic cord (or, simply, hydrocele of
the spermatic cord), in which there is a collection of fluid in a portion
of PV somewhere along its length between the external inguinal ring left testis
and the testis. Most often, the cyst does not communicate with either
the peritoneal cavity above or the tunica vaginalis below, and even may
be considered as a third testis by the uninitiated (Figure 58.9). In the
case of girls, the inguinal swelling filled with fluid is referred to as a
hydrocele of the canal of Nuck.
Acquired hydroceles can be due to viral infection, trauma (called
posttraumatic hydroceles), or testicular neoplasia. Figure 58.9: Encysted hydrocele of the left spermatic cord. Notice that the mass
Clinically, hydroceles are soft nontender masses within the above the left testis transilluminates light brightly and is separate from the testis
below it. Intraoperatively, the PV was found to be completely obliterated above
hemiscrotum. The testis can usually be felt at the posterior aspect of and below the cyst.