Case Report OCT 2016 vol. 01 iss. 03 | POCUS J | 15
Incarcerated femoral hernia containing ovary, unusual presentation of uncommon groin hernia
by Priyank Gupta, MD, FRCR1; Hadiel Kaiyasah, MRCS Glasgow2; Mahra AlSuwaidi, MRCS Glasgow2 (1) Dubai health authority, Rashid hospital, radiology department, UAE. (2) Dubai health authority, Rashid hospital, general surgery department, UAE.
f all groin hernias, femoral her examination. Initially a point of care Outcome and FollowUp: Patient Onias account for around 2–8%. ultrasound (POCUS) was done by was doing well postoperatively and They occur four to five times more the attending surgical doctor, who responded well to the planned man commonly in females than males was able to appreciate a localized agement. She had an uneventful re and have a peak incidence in those cystic swelling within the hernia sac. covery and was discharged home on between 30 and 60 years old [1,2]. A departmental Ultrasonography of the next day. Follow up after 6 In adult population, femoral hernias the right groin area was obtained to weeks revealed no complication. are more commonly found in pa confirm the findings of POCUS. It re Discussion: The anatomical loca tients with previous inguinal hernia vealed a welldefined rounded soft tion of the ovaries and fallopian tube repair [3]. We present an unusual tissue echogenicity lesion with a well at a level below femoral ring makes case of a 28 yearold woman who defined cystic component containing herniation of these structures presented to our institution with an no internal septations or mural nod through it unusual, particularly in incarcerated femoral hernia contain ules. The lesion was located subcu adults [4]. According to the most ac ing the right ovary & fallopian tube taneously anterior & medial to the ceptable theory, the primary cause occurring after inguinal hernia repair. femoral vein & reaching medially up for the formation of femoral hernia is The point of care ultrasound that to the level of pubic symphysis with a congenitally narrow posterior in was done in the emergency depart no obvious intraabdominal exten guinal wall attachment onto ment had helped in prompt diagnos sion (Figure 1A). The lesion was not Cooper’s ligament with a resultant is of the condition, hence sending reducible and did not change in the enlarged femoral ring, while the sec the patient to operation theatre for size on Valsalva maneuver or cough ondary aetiology is a state of pro urgent surgical intervention. impulse. No evidence of any peri longed and increased stalsis or free fluid noted within con intraabdominal pressure, which Case Presentation: A 28yearold tents of the swelling. Color Doppler female presented to the emergency forces preperitoneal fat into the con imaging revealed central branching genitally large femoral ring [1,5,6]. department with a sudden onset of pattern of vascularity consistent with abdominal pain in the right iliac However, it should be noted that in ovarian vasculature pattern (Figure younger ages with femoral hernias, fossa and suprapubic area. The pain 1B). The ultrasound findings were in was dull, mild to moderate in sever processes responsible for elevated keeping with right femoral hernia intraabdominal pressure are rarely ity with no radiation. Patient gave with the ovary within the hernia sac. history of chronic right groin swelling encountered. Due to the rigid liga that was reducible for the last 2 Treatment: The patient was admit mentous borders & relatively narrow months. Prior to presentation to ac ted under the care of the general lumen, incarceration occurs more cident & emergency department, surgery team with provisional dia frequently in femoral hernias than she developed an irreducible swell gnosis of an incarcerated right other abdominal hernias [7,8]. The ing. There was no associated vomit femoral hernia with a plan for urgent incidence of recurrent femoral hernia ing or constipation. Of note in her laparoscopic repair of the right occurring after inguinal herniorraphy surgical history was significant for femoral hernia. Intraoperatively, ex has been reported to be up to 35% Left inguinal hernia repair ten years ploration revealed no fluid in the ab [8]. The increased incidence of ago. She was normotensive and domen and no signs of bowel femoral hernia after inguinal hernior afebrile at presentation. Examination obstruction. A hernia sac was raphy may be due to an overlooked revealed a scar in the left inguinal present protruding down towards the hernia or a new spontaneous hernia region. Her abdomen was soft. femoral canal. The contents were due to weakening of the femoral re There was an irreducible firm tender reduced & found to be the ovary and gion caused by inguinal hernior lump palpated below the level of the fallopian tube (online Figure S1). raphy [8,9] right inguinal ligament and lateral to Both structures were looking viable. Femoral hernias typically present as the pubic tubercle. The anatomy of the area was clari a painless or painful groin lump, al fied and dissected reaching to the Investigations: All her laboratory though may present simply as groin pubic tubercle medially and the in pain or with features of their com tests were within normal limits. The guinal ligament superiorly and later patient was reviewed by the surgical plications such as obstruction. The ally. A prolene mesh was applied differential diagnoses include inguin oncall doctor who made the provi and fixed using endoscopic clips sional diagnosis of irreducible right al hernia, lipoma, saphena varix, en (takar). The peritoneum was closed larged lymph nodes, femoral artery femoral hernia based on the clinical and the abdomen deflated. 16 | POCUS J | OCT 2016 vol. 01 iss. 03
Figure 1. Transverse view of the ultrasound scan of the groin swelling revealed ovary lying anterior & medial to the femoral vein
aneurysm, sarcoma, obturator her imaging with CT may be similarly hernia. Ann Surg 1961; 154(6):2532. nia, psoas abscess, psoas bursa, beneficial in identifying a groin her 7. Ichinokawa M, Okada T, Sasaki F. Incarcerated femoral hernia with ovary and and in males, ectopic testis [4,10]. nia containing an ovary provided it fallopian tube torsion in an infant: a rare Different contents in femoral hernias causes no delay in the timing of sur occurrence. Pediatr Surg Int 2008; have been reported in the literature, gery [17]. 24:1149–51. such as small intestine, omentum, 8. Ludington LG. Femoral Hernia and Its Operative management of an incar bladder, cecum, colon, appendix Management: With Particular Reference to Its cerated femoral hernia containing an Occurrence Following Inguinal Herniorrhaphy. (what is known as De Garengeot’s ovary follows the same surgical prin Ann Surg 1958; 148(5):823826. hernia), Meckel’s diverticulum (Littre ciples for femoral hernia repair. In 9. Glassow F. Recurrent inguinal and femoral hernia), testis, ovary, and even hernia. Brit Med J 1970; 1(5690):215216. traoperative Reduction of the sac stomach or kidney [11,12]. 10. Alzaraa A. Unusual contents of the femoral content should be attempted in re hernia. ISRN Obstet Gynecol 2011; The preoperative diagnosis of productive young woman and chil 2011:717924. femoral hernia is a challenging is dren without any ovarian and tubal 11. Zacharakis E. An unusual presentation of sue. In previous reports, the clinical abnormalities [18], provided that any Meckel diverticulum as strangulated femoral diagnostic accuracy ranged from lifethreatening complication such as hernia. South Med J 2008; 101:9698. 12. Marioni P. Metastatic carcinoma with small 25% to 40% [13]. The ovary is quite acute salpingitis does not exist [19]. intestine in a femoral hernia. Can Med Assoc J sensitive to ischemia [14,15]. Should If the ovary can't be preserved due 1960; 82:10811082. it tort or become incarcerated in a to inviability, a salpingooophorec 13. AlShanafey S, Giacomantonio M. Femoral femoral hernia sac, a delay in dia tomy is to be undertaken. Hernia re hernia in children. J Pediatr Surg 1999; gnosis may necessitate its resection pair could be done via mesh plug 34:11041106. 14. Anders JF, Powell EC. Urgency of [16]. Imaging studies could prove to repair, which is considered to have evaluation and outcome of acute ovarian be a valuable preoperative investig the lowest recurrence rate [1]. torsion in pediatric patients. Arch Pediatr ation in women of childbearing age Adolesc Med 2005; 159:53255. Conclusion: Incarcerated femoral presenting with femoral hernia. 15. Yamashita Y, Sowter M, Ueki M, et al. hernia containing ovary, is an un Nowadays POCUS is a valuable tool Adnexal torsion. Aust N Z J Obstet Gynaecol usual presentation of uncommon 1999; 39:1747. in the initial assessment of irredu groin hernia. The point of care ultra 16. Gurer A, Ozdogan M, Ozlem N, et al. cible hernia cases, whether per sound that was done in the emer Uncommon content in groin hernia sac. Hernia formed by the emergency physician 2006; 10:1525. gency department had helped in or the attending surgeon. The most 17. Suzuki S, Furui S, Okinaga K, et al. prompt bedside clinical diagnosis of important points to keep in mind Differentiation of femoral versus inguinal the condition, hence early urgent hernia: CT findings. AJR Am J Roentgenol while performing POCUS are: surgical intervention & better out 2007; 189:W78–83. • Femoral hernia is visualized as a come. 18. Amarin ZO, Hart DM. Inguinal ovary and fallopian tube—an unusual hernia. Int J subcutaneous swelling in contact Gynaecol Obstet 1988; 27:141143. References: with the femoral vein. 19. Roth CG, Varma JD, Tello R. 1. Hachisuka T. Femoral hernia repair. Surg • Assess the contents of hernia sac, Gastrointestinal/genitourinary case of the day. Clin North Am 2003; 83:1189–205. Incarcerated inguinal hernia of the left fallopian whether loop of bowel within or a 2. Lytle WJ. Inguinal anatomy. J Anat 1979; tube and ovary. AJR Am J Roentgenol 1999; cystic swelling (e,g ovary like in our 128(Pt 3):581–94. 173:787, 791792. case). 3. Mikkelsen T, Bay Nielsen M, Kehlet H. Risk of Femoral hernia after inguinal Visit the online article to view additional • In cases where bowel loops are herniorrhaphy. Br J Surg 2002; 89:486488. content from this case: within a hernia sac, observe for 4. King R. Congenital, strangulated femoral pocusjournal.com/article/20160103p15 signs of strangulation, such as oed hernia in an infant aged six months containing 16 the ovary and fallopian tube. Br J Clin Pract ematous bowel wall or absent peri 1978; 32(7):209–210. stalsis. 5. Dahlstrand U, Wollert S, Nordin P, et al. Doppler ultrasound may identify re Emergency femoral hernia repair: a study based on a national register. Ann Surg 2009; duced blood flow in ovaries suggest 249(4):672–676. ive of torsion. Crosssectional 6. McVay CB, Savage LE. Etiology of femoral