Keywords
femoral hernia - fallopian tube - ovary - infertility
Palavras-chave
hérnia femoral - trompa de falópio - ovário - infertilidade
Introduction
Femoral hernias are relatively uncommon and account for ∼ 2% of all hernias and 2
to 8% of all groin hernias. They are mostly observed among adults (40–70 years), much
more common in women than in men, and are frequently associated with incarceration
and strangulation.[1]
[2]
[3] Increased intra-abdominal pressure, which occurs in certain conditions, such as
obesity, chronic cough, heavy exercise or lifting, and pregnancy, is usually implicated.[4]
[5]
[6] Different contents in the hernia sac have been described in the literature, but
exclusive herniation of the fallopian tube is extremely uncommon.[7]
[8] We present a rare case of a 61-year-old female with a femoral incarcerated hernia
containing a fallopian tube that required emergency surgical intervention at our institution.
Case Presentation
A 61-year-old female patient was admitted to the emergency department complaining
of a 2-day painful lump in the right groin, which gradually became tender to palpation
during the last 24 hours. She denied urinary symptoms, anorexia, nausea, or vomiting
and had regular bowel function. She had no significant past medical or surgical history.
On clinical examination, the patient was afebrile, her pulse rate was 83 bpm and blood
pressure 132/86 mmHg. Physical examination revealed a 3 × 4 cm tender mass in the
right groin, irreducible and non-pulsatile. Abdominal examination showed mild tenderness
in the right iliac fossa. The leucocyte count was 7,400/μl (neutrophils: 50%), and
C-reactive protein was 0.84 mg/dL. The patient underwent ultrasonography that showed
“signs compatible with right femoral hernia, non-reducible, containing intestine,
fat and fluid.” Abdominal and thorax X-rays were unremarkable.
Treatment
Clinical assessment suggested the presence of a strangulated femoral hernia, and the
patient underwent emergency surgery. We used a lower inguinal approach and carefully
exposed the femoral hernia sac. After opening the sac, we confirmed the diagnosis
of femoral hernia that unexpectedly contained the right fallopian tube ([Figs. 1] and [2]). The tube was congested, but showed no signs of ischemia and was reintroduced into
the pelvic cavity, without any difficulty. We excised the hernia's sac and repaired
the defect using a polypropylene mesh plug.
Fig. 1 The uterine tube with its mesosalpinx, while the right ovary lies within the abdominal
cavity.
Fig. 2 The uterine tube with its mesosalpinx, and the right ovary.
Outcome and Follow-Up
The postoperative period was uneventful, and the patient was discharged without complications
3 days after the surgery. No signs of hernia recurrence were noted at 1-, 3-, and
6-month follow-up appointments.
Discussion
Femoral hernias comprise a small proportion of all groin hernias, accounting for ∼
2 to 8% of cases.[2] They are 4-to-5-fold more common in women, generally occur in the elderly, and are
more frequent on the right side.[1]
[2]
[3]
[4]
[5]
[6] This specific type of hernia occurs when intraabdominal content protrudes through
the femoral ring into the femoral canal, beneath the inguinal ligament. Because of
their narrow neck and rigid ligamentous borders, they are prone to incarceration and
strangulation, leading to emergency surgery in many cases.[9]
[10] Femoral hernias usually contain preperitoneal fat or segments of the small bowel;
nonetheless, other contents, such as stomach, colon, appendix, bladder and Meckel
diverticulum have been described in the literature. Herniation of the fallopian tube
or ovary is an extremely rare condition, especially in adults, due to their normal
anatomical position, located at a lower level than the femoral ring.[11] Maylard[12] described one of the first cases of a femoral hernia containing the ipsilateral
fallopian tube, in 1892. Since then, a few of cases have been reported, and most of
them were found in the pediatric population. Typical femoral hernias present as a
tender, non-reducible groin lump, with no cough impulse, situated below and lateral
to the pubic tubercle. The diagnosis is generally done by physical examination; however,
in some patients, imaging exams, such as abdominal X-ray, ultrasonography, CT, or
MRI, may be useful in the diagnosis, especially because of the variety of possible
contents.[8]
[11] Preoperative diagnosis of a strangulated fallopian tube in a femoral hernia is extremely
difficult, as only one case is described in the literature.[13]
Early diagnosis and surgical treatment are key factors for the prognosis, since female
adnexa are particularly vulnerable to ischemia when entrapped, which may lead to an
infarcted and unsalvageable ovary or fallopian tube. Therefore, female adnexa should
always be considered as possible hernia contents to warrant a prompt assessment and
intervention, thus avoiding the necessity of resection and preserving fertility in
women of childbearing age.[11]
[14]
[15] Surgical approach of a femoral hernia containing female adnexa follows the same
principles of any other femoral hernia treatment. There are many different repair
techniques that can be divided in two main groups: tension-free mesh techniques (open
or laparoscopic), or non-mesh techniques. In our case, we have decided to do a tension-free
repair using a polypropylene mesh plug, known to have lower recurrence rates and associated
to less short-term pain and discomfort, allowing for a faster recovery and rapid return
to normal activities.[1]
