Journal of Pediatric Surgery Case Reports Femoral hernias occur in both genders

Femoral her nias are un com mon in chil dren, due to the un fa mil iar ity it is an of ten mis di ag nosed con di tion. In this ar ti cle, we pre sent a 6 - year old male pa tient and a 14 - year old fe male pa tient. Ini tially the pa tients were di ag nosed with a in guinal her nia and a hy dro cele of the canal of Nuck, re spec tively. In the first case the pa - tient re turned af ter the first surgery with a re cur ring bulging, dur ing the sur gi cal ex plo ration of the sec ond surgery a femoral her nia was found. In the sec ond case a femoral her nia was ob served dur ing surgery in stead of a hy dro cele of the canal of Nuck. With the aim of pre vent ing mis di ag no sis, clin i cians must be aware of femoral her ni a tion in chil dren, es pe cially when clin i cal pre sen ta tion is not typ i cal.


. Introduction
The in ci dence of in guinal her nias in chil dren is 1 -5%. On the other hand, a femoral her nia is a rare clin i cal con di tion in chil dren. Less than 1% of all groin her nias in chil dren are due to femoral hernias [ 1 ]. Most sur geons have lim ited ex pe ri ence with this type of hernia in chil dren. The un fa mil iar ity with this rare her nia and its clin i cal pre sen ta tion in chil dren may re sult in an in cor rect or de layed di ag nosis [ 1 ]. In this re port we pre sent two cases of chil dren (6 and 14 -year) with a pri mary mis di ag nosed femoral her nia.

. Case reports
A 6 -year -old male pa tient was re ferred to our sur gi cal out pa tient clinic with a pain less, re ducible swelling in his right in guinal re gion, ob served by his par ents for sev eral weeks. On phys i cal ex am i na tion, no bulging was ob served af ter val salva ma neu ver and both tes ti cles were de scended into the scro tum. The ul tra sound showed a small inguinal her nia and the her nial sac con tained mesen teric fat. As a right in guinal her nia was sus pected, it was de cided to ex plore the right groin. Dur ing surgery, a preperi toneal lipoma was found and removed. An ev i dent her nial sac was not iden ti fied. The re cov ery from surgery was un event ful. Dur ing the 2 -weeks fol low -up there were no com plains and no bulging was ob served dur ing val salva ma neu ver. Af ter eleven months, the boy re turned with a re cur ring bulging in the right in guinal re gion. On phys i cal ex am i na tion, a bulging was ob -served dis tal to the in guinal scar. It was de cided to per form a sec ond ex plo ration of the groin un der sus pi cion of a re cur rence in guinal hernia. Dur ing surgery the her nial sac could not be iden ti fied in the inguinal canal. Ex plo ration cau dal to Poupart's lig a ment, a her nial sac was found in the la cuna va so rum match ing with a femoral her nia. The her nial sac (with out con tent) was re moved and oblit er ated and the femoral canal was nar rowed. Post -operative there were no com pli cations and at the fol low -up at 3 weeks no sing of re cur rence re vealed. The pa tient re sumed nor mal ac tiv ity.
The sec ond case is a 14 -year -old fe male pa tient, re ferred to the emer gency de part ment with com plains of a painful swelling in her left in guinal re gion. The swelling first ap peared one year ago and had become larger, was in ter mit tently painful, mostly dur ing the evening. On ex am i na tion, a pain less, re ducible, 5 cm large swelling was palpated in the left in guinal re gion. On ul tra sound, most likely a ar te riove nous mal for ma tion was ob served. Sub se quently a mag netic res onance an giog ra phy of the pelvis and lower ex trem i ties was per formed. This showed a cys tic le sion, but, more likely a hy dro cele of the canal of Nuck ( Fig. 1 An ax ial im age of the pelvis most likely show ing a hydro cele of the canal of Nuck). Sur gi cal or non -surgical ther apy was dis cussed with the pa tient and her par ents who opted for surgery. Dur ing surgery a her nia sac in the femoral canal was ob served. The her nia sac was opened and con tained omen tal fat which was re sected. Af ter re sect ing the fat, the her nial sac was closed and repo si tioned intra -abdominal. Poupart's lig a ment was at tached to Coop er's lig a ment to close the an nu lus femoris. The re cov ery was un event ful and at the fol low -up af ter 3,5 weeks there were no sing of re cur rence. The patient re sumed nor mal ac tiv ity.

. Discussion
A femoral her nia is a pro tru sion of ab dom i nal con tents trough the an u lus femoralis, bounded an te ri orly by the in guinal lig a ment (Poupart's lig a ment), pos te ri orly by the pectineal lig a ment (Coop er's lig a ment), me di ally by the la cu nar lig a ment (Gim ber nat's lig a ment) and lat er ally by the femoral vein. The femoral her nial sac is lo cated dis tal to the in guinal lig a ment [ 2 ]. The eti ol ogy of the femoral her nia is still de bat able, but most clin i cians be lieve Mc Vay's hy poth e sis is the most likely [ 1 , 2 ]. This hy poth e sis im plies that an en larged an u lus femoralis is caused by a con gen i tally nar row pos te rior wall at tachment onto the pectineal lig a ment. This could con tribute to the risk of de vel op ing a femoral her nia [ 2 ].
In both cases the her nia was re paired by an open tech nique. Diverse tech niques have been de scribed for femoral her nia re pair. Commonly used tech niques are the Coop er's lig a ment (Mc Vay) re pair and the Bassini re pair, both an open an te rior re pair. Dur ing these pro cedures the first step is open ing the aponeu ro sis of the ex ter nal oblique mus cle and ex pose the sper matic cord, then the trans ver salis fas cia will be opened and the her nial sac can be re sected. For Coop er's approach the con joined ten don (trans ver sus ab do minis and in ter nal oblique) is su tured to Coop er's lig a ment to close the femoral canal. For the Bassini re pair Poupart's lig a ment is su tured to Coop er's lig ament [ 1 -3 ].
A femoral her nia is mainly seen in adults. A large epi demi o logic study of Bur charth et al. shows that in guinal her nias com prise the vast ma jor ity of the groin her nia re pair. Only a small part in cludes the femoral her nia re pair, and this preva lence is ex pand ing through out life with a peak -prevalence at the age of 80 -90 years [ 4 ].
Femoral her nia are much less com mon in chil dren. Al -Shanafey et al. de scribed 17 pa tients <15 years (mean age of 6.5 years) di agnosed with a femoral her nia (in ci dence 0.33%) over a pe riod of 20 years. Six of these pa tients were di ag nosed cor rectly be fore surgery, all other pa tients were ini tially di ag nosed as in guinal her nia. In compar i son, dur ing the same pe riod 5175 chil dren were di ag nosed with an in guinal her nia [ 1 ]. De Caluwe et al. de scribed over a 21 -year period, 38 chil dren (mean age 6 years) who un der went femoral her nia re pair. Twenty of these pa tients were di ag nosed cor rectly with a femoral her nia, but 11 pa tients were di ag nosed dur ing neg a tive ex ploration for in guinal her nia and 7 were di ag nosed af ter their pri mary ex plo ration for a pre sumed in guinal her nia [ 3 ]. Aneiros Cas tro iden tified 16 femoral her nias, out of 687 with groin her nias (2.3%). In 50% the di ag no sis was cor rectly per formed pre op er a tively, the other 50% was di ag nosed as a in guinal her nia ini tially [ 5 ]. Temiz et al. de scribed 3 cases, 2 were di rectly di ag nosed as an femoral her nia, but the other case was pre vi ously di ag nosed and treated as an in guinal her nia, however, dur ing surgery no her nial sac was found. Sec ondary surgery was per formed, un der sus pi cion of a femoral her nia and a her nial sac could be re moved [ 2 ].
Asymp to matic femoral her nias in chil dren are most of ten mis di agnosed as an in guinal her nia. In lit er a ture a range of 25 -75% of di agnos tic ac cu racy has been re ported [ 1 , 2 ]. The di ag no sis of groin hernias is most of ten a clin i cal di ag no sis, based on his tory and phys i cal ex am i na tion. In case of doubt a groin ul tra sound may be help ful. Aneiros Cas tro et al. pre sumed that care ful ex am i na tion and ul trasound could be the best di ag nos tic ap proach to avoid mis di ag no sis of femoral her nias in chil dren. Strik ing is the fact that in our sec ond case we per formed an ul tra sound, and this still led to a mis di ag no sis. In order to per form a CT -scan or MRI, to get a bet ter di ag no sis, chil dren of ten have to un dergo anes the sia and there fore are not rec om mended [ 5 ]. Po ten tial ben e fits from a la paro scopic ap proach in femoral hernias in chil dren, which could give bet ter as sess ment of the ab dom i nal wall anatomy, is not known and re search has to be con ducted [ 2 , 5 ].

. Conclusion
In con clu sion, pe di atric femoral her nias can oc cur in both gen ders, but it is an are rare and of ten mis di ag nosed con di tion. This can re sult in de layed di ag no sis, fre quently due to in con clu sive in guinal ex ploration. Clin i cians must be aware of femoral her ni a tion in chil dren and con sider this di ag no sis more of ten, es pe cially when clin i cal pre sen tation is not typ i cal com pared to nor mal in guinal her ni a tion.

Patient consent
The par ents have con sented to the sub mis sion of the case re port to the jour nal.

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Declaration of competing interest
The au thors de clare that they have no known com pet ing fi nan cial in ter ests or per sonal re la tion ships that could have ap peared to in fluence the work re ported in this pa per.