A case of atypical course of femoral hernia, complicated by hydrocele.

Abstract. A hydrocele of femoral hernial sac is a casuistry in surgery. We describe a case of painless
course of femoral hernia with hydrocele mass in 31-year-old female. On preoperative sonography the
groin mass was identified, as a cystic mass, with homogenous contents and a cervix in central part,
which passed close to femoral artery. On magnetic resonance imaging (MRI) it was represented as a
cystic mass with a septums septa inside, it`s posteromedial boundary was directed to femoral vessels.
During surgery, the hernia sac was excised without significant difficulties and Bassini repair was done. It
was shown that despite of applying a highly informative diagnostic procedures – sonography and MRI -
final diagnosis was unclear until the surgery. Key words: femoral hernia, casuistry in surgery, hernia
repair, hydrocele. Why abstract mentioned again in the manuscript?

Hernia repair in general surgical departments is one of the most frequent operations [1]. Most of them
are performed on inguinal or umbilical hernias. Femoral ones are rare and represent only 2-5% of all
groin hernias [2]. According to the classical concepts, their clinical picture is very scanty due to small size
in most of cases [3]. They very seldom reach big size and very often the first symptoms are synchronous
with an episode of incarceration and strangulation, while painless course of disease is very scarce [4,5].
According to the number of publications formation of hydrocele in femoral hernia sac can be estimated
as casuistry. So far there were only 7 known described up until 2016 [6,7].

We present a case of hydrocele of left-side femoral hernia. A 31-year-old woman complained about a
tumor-like mass in groin area. She noticed this mass for the first time about 9 years ago, which gradually
increased in size. She had not ever felt any pain during movements, physical exertion, or long sitting
position. No episodes of constriction occurred. General condition was satisfactory. Cardiovascular,
pulmonary, abdominal, rectal, and vaginal examination were unremarkable.

Local examination. In left groin region – tumor-like fluctuating, movable, non-tender, smooth mass, with
intact skin over it. On local examination a tumor-like fluctuating, movable, non-tender, smooth mass,
with intact skin over it was felt in the left groin region. It was located along the inguinal ligament. Cough
impulse and bowel sounds over the mass are were absent. Laboratory investigations: were within
normal limits. Sonography – revealed no fluid in abdominal cavity, and in hypoderm – a cystic mass, with
homogenous contents, 115x28x54 mm, in central part – cervix 5x5 mm in diameter 9 mm in length, in
which the movement of hyperechoic tissue of 15 mm in length is was visible. Close to the cervix the
femoral vein is was visualized. Magnetic resonance imaging (MRI) – revealed in hypoderm of upper
third of left hip - a cystic mass 93x36x53 mm of irregular shape with septums septa inside. The inguinal
canal is was intact. The posteromedial boundary of cystic mass is was directed to femoral vessels (Fig.).

Under spinal anesthesia the incision along the inguinal ligament was performed. In the subcutaneous fat
thin-walled cystic mass with fluid inside was dissected easily. In lower medial part which spread to
direction of femoral vessels it was multilocular. In this place cyst surrounds surrounded the external
superior inferior epigastric artery and vein. Vessels were separated and preserved. In posteromedial
part cystic mass is was fixed, it`s wall is was thicker and forms formed a neck which passes passed under
the inguinal ligament medial to the femoral vein –as in femoral hernia. The sac was opened,. In in it`s
lumen - amber-colored fluid about 110 ml was present. On revision dissection of hernia sac, the lumen
of it`s neck is was narrow and passable only for mosquito clamp. Hernia sac was excised after ligation.
It`s stump was easily sunk in abdominal cavity. Because of tight femoral ring it was closed by Bassini
technique. Why Bassini’s technique was performed in femoral hernia? The wound was closed layer-by-
layer.

Treatment in postoperative period contained analgetics analgesics and low molecular weight heparin.
There were no complications. The patient was discharged of the 5th postoperative day. After 3 months
weren’t defined wasn’t detected any evidence of hernia recurrence.

Discussion. In this case a most singular phenomenon of painless long-lasting course of femoral hernia,
complicated by hydrocele formation, was shown. Such a cliniсal peculiarity could be due to tightness of
hernia ring that prevented permeation of peritoneal content to the hernia sac and simultaneously
evacuation of peritoneal fluid from it. This fact can explain absence of visualization of neck in hernia sac
during MRI. Therefore, the most informative method of instrumental visualization in such cases can be
sonography. How? It was not demonstrated in sonography also. Intraoperative assessment was best.