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.