Simultaneous Bilateral Femoral, Direct, and Indirect Inguinal Hernia in
a Single Patient: A Case Report
Authors: Hossein Torabi1, Kasra
Shirini2*, Rona Ghaffari3
- Assistant Professor, Department of General Surgery, Poursina Medical
and Educational Center, Guilan University of Medical Sciences, Rasht,
IRN.
Email: dr.torabi1367@yahoo.com
- MD, Department of General Surgery, Iran University of Medical Science,
Tehran, IRN. Email: Kasrashirini21@gmail.com
- MD, Department of General Surgery, Poursina Medical and Educational
Center, Guilan University of Medical Sciences, Rasht, IRN. Email:
dr.ghaffari1370@yahoo.com
*Correspondence author:
Kasra Shirini, MD
Department of General Surgery, Iran university of medical science,
Tehran, Iran
Telephone: +989112481500 Fax number: +982166879611
E-mail:
KasraShirini21@gmail.com
ORCID-ID: https://orcid.org/0000-0003-4104-7633
Acknowledgment: None
Disclosure of conflicts of interest: The authors certify that there is
no conflict of interest with any financial organization regarding the
material discussed in the manuscript. The patient has consented to the
submission of the case report for submission to the journal.
Funding: The authors report no involvement in the research by the
sponsor that could have influenced the outcome of this work.
Authors’ contributions: All authors contributed equally to the
manuscript and read and approved the final version of the manuscript.
Patient’s contest: Written informed consent was obtained from the
patient to publish this report in accordance with the journal’s patient
consent policy.
Key Clinical words: Concomitant bilateral direct, indirect, and femoral
inguinal hernia is a rare condition that can lead to complications such
as incarceration, strangulation, and postoperative recurrence. So, it is
important to choose the most useful diagnostic and treatment way.
Abstract:
Concomitant bilateral direct, indirect, and femoral inguinal hernia is a
rare condition that can lead to complications such as incarceration,
strangulation, and postoperative recurrence. So, it is important to
choose the most useful diagnostic and treatment way. In this article, a
patient with complaint of bilateral pain and bulging of inguinal areas
is being presented who was diagnosed with simultaneous bilateral direct,
indirect and femoral inguinal hernias during operation.
Keywords: Inguinal hernia, Femoral hernia, Lichtenstein, Ultrasonography
Introduction:
Inguinal hernia is a widespread problem and accounts for 75 % of
abdominal wall hernias, with an incidence probability of 27% in men and
3 % in
women [1].
On the other hand, the majority of femoral hernia is approximately 2-8%
in adults, and it is four times higher in women than in men as the
structure of the pelvis is wither in women. Femoral hernia accounts for
just 2-4 % of all groin hernias, and 10% of femoral hernias are found
bilaterally [2,3].
Inguinal hernias are more common than femoral hernias, but femoral
hernia is more associated with complications such as incarceration and
can lead to significant mortality and
morbidity [4].
More than three simultaneous bilateral inguinal and femoral hernia is a
very rare
condition [5].
The main treatment way is surgery. Choosing between different surgical
methods depends on various things, such as the surgical team preference
and patient’s condition, leading to selecting the best and most useful
way [1].
The main imaging method to diagnose this problem is ultrasonography, but
it is highly dependent on operator
experiences [6].
In this article, an old male presented with bilateral groin bulging and
pain with a diagnosis of bilateral inguinal herniation, which was
diagnosed with simultaneous bilateral direct and indirect inguinal
hernias and bilateral femoral hernias during operation.
Case presentation:
An 85-year-old patient presented to the surgical emergency department of
Poursina Hospital, Rasht, Iran, in January 2022, with a complaint of
bilateral pain and bulging of inguinal areas. The patient did not have
any underlying disease. He claimed that the pain started suddenly from
the past five days. He mentioned that the pain was moderate at first but
increased gradually, and it became unbearable when he presented to the
hospital. He did not have nausea, vomiting, urinary incontinence or
frequency, and fever. The pain had nothing to do with painkillers. He
also mentioned that he had normal defecation and gas passing. During the
physical examination, moderate to severe tenderness was detected in both
inguinal areas with a right-side predominance without erythema. Another
bilateral bulging was detected above and medial previous hernias during
the Valsalva maneuver. All vital signs were in the normal range. He was
asked to do abdominal and inguinal sonography. The results revealed
incarcerated bilateral inguinal hernias. He was admitted to the surgical
ward for more investigations. The blood test analysis showed white blood
cell count (WBC) = 4800 g/dL, Hemoglobin (Hb) = 11.3 g/dL and placate =
163000. So, the surgical team prepared an open surgery with the
diagnosis of bilateral inguinal herniation in Lichtenstein way.
Bilateral incisions were performed on both inguinal areas. The fascia,
external oblique muscle, and external rings were opened bilaterally.
Direct and indirect herniations were seen in the right inguinal canal,
and an indirect herniation was seen in the left inguinal canal, as can
be seen in
Figures 1 and
2, and 3. All those three herniations were repaired by mesh suturing.
More bilateral exploration in femoral areas revealed simultaneous
bilateral femoral herniations, as can be seen in
Figures 4 and
5. The right femoral herniation included a big sac of preperitoneal
omental fat, and the left one included omental fat without any color
changing in the tissue appearance. After returning the hernias to their
original position, they were repaired by mesh suturing too. The
incisions were closed. After an uneventful recovery, the patient was
transferred to the surgical ward and discharged after two days.
Discussion:
Groin hernia, which means ”viscera or adipose tissue protrusions through
the inguinal or femoral canal,” is one of the most common surgical
pathologies that can occur in 27%-43% of men and 3%-6% of women
during their
lifetime [7].
There are different types of inguinal hernia such as direct hernia,
indirect hernia, scrotal or giant hernia, femoral hernia, and others
called rare
hernia [8].
Direct hernia means the tissue passes through an abdominal wall weakness
and is inferior and medial to the deep ring. Indirect hernia, which
means the tissue passes through the inguinal ring, and the femoral
hernia, which passes below and lateral to the pubic tubercle.
Consequently, it is understandable that inguinal hernias will be seen
above and medial to the femoral hernia if they happen
simultaneously [6].
Inguinal hernia is more common in men than women, but femoral hernia,
which occurs approximately 2-4% in adults, is more common in women and
occurs three to four times more than men. Studies show that the
prevalence incidence of bilateral inguinal hernia varies from 5% to
22% in different
studies [9,10].
On the other hand, just 10 % of femoral hernias are found
bilaterally [2,3].
Consequently, the incidence of bilateral direct and indirect and femoral
hernia is very rare and could lead to misdiagnosis as it can cause no
symptoms. Furthermore, as the femoral hernia is more associated with
complications such as incarceration and strangulation, and the
incarceration or strangulation rate is 44-86%, it can subsequently lead
to more mortality and
morbidity [9,10].
So, it is crucial to diagnose and treat this life-threatening condition
accurately and
immediately [3].
The main diagnostic way for this condition is findings during the
physical examination and imaging methods. Inguinal hernia and femoral
hernia present with a bulging in the groin area that disappears
temporarily with minimal pressure or when the patient is lying down.
Although it should be considered that inguinal hernias are typically
located above and medial to the pubic tubercle, femoral hernias are
typically located below and lateral to the pubic tubercle, so inguinal
hernia will appear above and medial to the femoral hernia during
physical
examination [1,6].
There are different types of imaging methods that can be used to
diagnose this condition as a helpful method, such as ultrasonography,
magnetic resonance imaging (MRI), computed tomography (CT) scan, and
herniography [11].
The main and the most useful imaging method is ultrasonography, but this
method highly depends on operator
experiences [6].
Some risk factors can increase the occurrence probability of groin
hernia divided into two general categories: patients’ risk factors and
external risk
factors [12].
Patient risk factors include male gender, old age, systemic connecting
tissue disorders, and low body mass
index [12,13].
External risk factors include high intra-abdominal pressure and smoking,
especially for recurrent
hernias [12,14].
The definitive treatment method for symptomatic hernia is surgery. There
are different methods of surgery available that choosing the best and
the most useful method depends on many factors such as patient’s
condition, surgical team preferences, and recurrences probability.
Although many studies showed the laparoscopic method has some positive
advantages like lower postoperative pain, fewer bound infections, and
quick return to daily activities, the Lichtenstein method has
significant features such as shorter operation time, fewer recurrences
probability, lower cost, and lower incidence of seroma
formation [15].
In this case, the surgical team performed an open operation as the
anesthesiologist advised to choose a method with lower operation time
because of the patient’s age.
Conclusion:
One of the most common abdominal wall hernias is an inguinal hernia that
can present with pain and bulging in groin areas. The inguinal hernia
has different types: direct, indirect, femoral, etc. They could appear
just on one side or occur bilaterally. The prevalence incidence of
simultaneous bilateral direct, indirect and femoral hernia is a very
rare condition. Strangulation and incarceration are the most
complications of groin hernias, especially femoral hernia. So, it is
crucial to diagnose and treat this condition most effectively. Choosing
the best surgical method between various methods depends on different
factors. In This case, based on the patient’s condition and the surgical
team preference, an open operation was performed in the Lichtenstein way
for the patient, and the hernias were repaired by mesh.
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