Pediatric femoral hernia in the laparoscopic era

Femoral hernia in pediatric population: a diagnostic and surgical challenge

PURPOSE

Femoral hernia (FH) is a rare and often misdiagnosed pathology in pediatric population. The aim of our study was to describe the experience of a Tertiary Center in children with FH, underlying diagnostic and surgical details that could improve its management.

METHODS

A retrospective study of pediatric patients who underwent FH repair from January 2010 to June 2023 at our Institution was performed.

RESULTS

In the analyzed period, 31 patients underwent surgical procedure for FH at our institution, of whom 16 (51.6%) were female. The mean age at time of surgery was 5.8 years (range 0.5-17.1 years). The rate of pre-operative misdiagnosis was 35.5% and open approach was adopted in all cases (16.1% with mesh application). Only two patients (6.4%) experienced surgical complications: one recurrence (repaired six months later) and one post-operative hematoma (treated successfully with conservative method).

CONCLUSION

Due to the high rate of misdiagnosis, the variety of surgical approaches proposed, and the potential for intraoperative complications, FH poses a challenge for pediatric surgeons and urologists, as confirmed by the literature. It is essential to underline the importance of a proper clinical examination in order to correctly diagnose FH, make the best surgical plan for the patient and prevent post-operative complications.

Laparoscopic Repair of Pediatric Femoral Hernias

Background: Current rates of reported pediatric femoral hernias remain exceedingly low, with their incidence reported to be <1%. The mainstay of repair has traditionally been through an open approach, and pediatric surgeons remain reluctant to repair otherwise. Owing to its rarity, consensus regarding management remains absent. Because of this, we present a scoping review on the use of laparoscopy and minimally invasive techniques to repair pediatric femoral hernias. Methods: A scoping literature review was performed using PubMed, Embase, Scopus, and Web of Science for related articles (keywords). Full-text articles and abstracts were then reviewed for relevance using inclusion and exclusion criteria with data extracted from each piece. Results: The search identified 268 articles published from 1992 to 2023. Eleven articles met our inclusion criteria. After reviewing their content, a total of 87 patients were identified. Of these, 42 laparoscopic repairs were reported. Three primary laparoscopic surgical techniques were described, with no recurrence reported. Conclusion: Laparoscopy remains a viable tool in diagnosing and managing femoral hernias. Various technically feasible options for laparoscopy and minimally invasive techniques have been described with excellent results and limited recurrence. However, given the quality of the data, further studies are needed to investigate the long-term durability of such repairs.

Laparoscopic identification of combined pediatric femoral hernia and ruptured abdominal cyst of the canal of Nuck: A report of an extremely rare case

A 7-year-old girl was referred to our hospital with a suspected right-sided indirect inguinal hernia. An egg-sized elastic, non-painful mass was palpated in the right inguinal region. Preoperative CT demonstrated a 30-mm simple cystic mass in the right internal inguinal canal, which we diagnosed as an abdominal cyst of the canal of Nuck. Laparoscopy revealed that the abdominal cystic component was ruptured, so we performed Pott's procedure. However, the patient's right groin swelled on postoperative day 3, necessitating re-operation. The patient's symptoms recurred again after 3 months, despite having had two surgical repairs. In the third operation, a right-sided femoral hernia was confirmed and repaired via external and laparoscopic approaches. To the best of our knowledge, there have been no reports on the combination of femoral hernia and cyst of the canal of Nuck in children. A laparoscopic approach was useful for obtaining a definitive diagnosis and conducting a safe and secure surgical repair.

Femoral hernias: A paediatric surgical enigma

PURPOSE

In the paediatric population, femoral hernia (FH) represents an uncommon and often misdiagnosed pathology. This study aimed to review our experience with the management of FH in children.

METHODS

Medical records were retrospectively reviewed for all patients presenting to the paediatric surgical service in Ireland over a 15-year period (2004-2019), who were operated on for FH. Collected data included demographics, preoperative diagnosis, operative details, complications and follow-up.

RESULTS

During the study period, n = 26 patients (n = 18 males) underwent FH repair, with a median age at surgery 6.9 years (range 3-16 years). During the same period n = 5693 patients underwent inguinal herniotomy, resulting in a FH to inguinal hernia (IH) ratio of 1:219 and a FH incidence of 0.45% of all groin hernias. The right side was affected in n = 18 (69.2%) cases and all cases were unilateral. A correct preoperative diagnosis was established in n = 16 (61.5%) cases, n = 8 (30.8%) cases were misdiagnosed as IH and the diagnosis was equivocal in 2 cases (7.7%). All operations were performed on an elective basis. In 3 patients from the misdiagnosed group, FH was found at first operation following negative groin exploration for IH. The remaining 5 patients underwent previous groin exploration for suspected IH and represented with clinical picture of groin hernia recurrence. All patients with a correct preoperative diagnosis underwent a FH repair via an inguinal or infra-inguinal approach. The content of the hernia sac was preperitoneal fat in n = 18 cases, lymph nodes in n = 2 cases, omentum in n = 1 and an empty sac in n = 1. There were no postoperative complications or recurrences. Median follow-up time was 6 weeks (range 0-2.5 years).

CONCLUSION

In the paediatric population, FH is a rare pathology and can be a challenging diagnosis. FH is commonly misdiagnosed as IH and may require more than one operation to correctly identify and treat. A high index of suspicion of FH should be maintained in patients who have a negative groin exploration for IH in the setting of a clear pre-operative diagnosis of a groin hernia. FH should also be considered in the differential diagnosis when an IH appears to recur.

Percutaneous hernia repair in children: Safe to introduce

BACKGROUND AND OBJECTIVE

In 2014 we introduced percutaneous internal ring suture as an alternative to open surgery for the treatment of inguinal hernia. This study aims to evaluate the introduction of the procedure at our institution.

METHODS

In total, 100 consecutive patients operated with percutaneous internal ring suture were compared with 100 consecutive patients operated with open surgery. The patients were operated from August 2014 until November 2017. Patient demographics, clinical history, operative time, time in theater, and postoperative complications were extracted from charts.

RESULTS

The mean operative time for percutaneous internal ring suture was 26.54 min and for open surgery 39.94 min, P < 0.0001. The total mean operative theater time for percutaneous internal ring suture was 108.95 min and for open surgery 118.4 min, P = 0.0343. During follow-up, two percutaneous internal ring sutures were operated for recurrent hernia. In the open surgery-group, three patients were operated for recurrent hernia, three for secondary testicular retention, and three for metachronous contralateral hernia.

CONCLUSIONS

Even when established as a new technique, the percutaneous internal ring suture procedure is safe and results in shorter operative time and shorter theater time compared to open surgery.