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A primary femorocele is an uncommon pathology wherein fluid accumulates within the sac of a femoral hernia due to occlusion of communication with the peritoneal cavity and in the absence of ascites. Here, we report the case of a primary femorocele in a 45‑year‑old female patient who presented to our hospital with right groin swelling. The diagnosis of a primary femorocele was only made on surgical exploration, which deferred from the initial preoperative diagnosis made using ultrasonography. Surgical excision and repair were undertaken with the use of a mesh plug. Keywords: Femorocele, groin swelling, hydrocele of femoral canal
| Introduction | |  |
A femoral hydrocele, also known as a femorocele, is an extremely rare occurrence whereby a fluid collection is found within the sac of a femoral hernia. It is an uncommon differential for groin swellings, and its diagnosis is difficult to make. The etiology of a femorocele is also still not fully understood. The present case is that of a primary femorocele which was diagnosed on surgical exploration. A comprehensive literature review is included as well as to summarize the clinical presentation, diagnostic evaluation, and treatment of femoroceles to date. For over a century, there have only been 13 cases of femoroceles reported, of which 11 were primary.
| Case Report | | |
A 45-year-old female, body mass index (BMI) of 27 and no significant medical comorbidities, presented with a slowly enlarging painless right groin swelling of 7 years duration. Examination of the right groin demonstrated a large irreducible firm swelling with negative cough impulse.
Ultrasonography of the right groin revealed a cystic mass with low level echoes in the right inguinal canal measuring 7.4 cm × 6.6 cm × 4.3 cm. An echogenic focus was noted medially, which was found to be more prominent on Valsalva and it was reported as a small right inguinal hernia [Figure 1]. The provisional diagnosis was that of a hydrocele of the canal of Nuck with a right inguinal hernia. | Figure 1: Ultrasound of right groin showing large cystic mass with low level echoes and an adjacent echogenic focus with increased prominence on straining
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Surgical exploration was undertaken through a right groin skin crease incision overlying the swelling. A large 8 cm translucent fluid-filled cystic mass was encountered [Figure 2]. After carefully dissecting the cyst wall from its surrounding adhesions up toward its neck, it was found to be arising from the femoral canal. No inguinal hernia was identified. The infrainguinal fluid-filled sac was then incised, and clear straw-colored fluid was drained. A small tongue of omentum that was found to be plugging the neck of the sac was dissected free and reduced, subsequently demonstrating communication with the peritoneal cavity. The sac was excised after suture transfixation at its neck. A mesh plug was created using a lightweight mesh (ULTRAPRO, Ethicon, Johnson and Johnson) and inserted within the femoral ring to completely occlude the femoral canal. Using nonabsorbable prolene sutures, the mesh plug was anchored anteriorly to the inferior edge of the inguinal ligament, posteriorly to the iliopectineal ligament, and medially to the lacunar ligament. | Figure 2: Intraoperative photograph showing a translucent fluid‑filled femorocele
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The patient recovered well with no immediate complications and was discharged home on the first postoperative day. There was no evidence of recurrence on clinical review at 1 month postoperatively. Histopathology of the cyst wall returned as benign inflamed mesothelial-lined fibroconnective tissue. Cytology from the cyst fluid showed scattered flat sheets of mesothelial cells and background inflammatory cells.
| Discussion | | |
Hydrocele of the femoral hernia sac was first described in 1884 by Sir Astley Cooper, referring to it as a hydatid tumor in the upper and inner part of the thigh. It is an extremely rare condition and there have been few cases reported in the literature over the last century and are summarized in [Table 1].[1],[2],[3],[4],[5],[6],[7],[8],[9],[10] Primary femoroceles occur when fluid accumulates in the sac of a femoral hernia due to occlusion of communication with the peritoneal cavity, with no evidence of ascites. This occlusion may be due to an omental plug or adhesions at the narrow femoral neck or it may be due to complete obliteration from traumatic or inflammatory causes whereby hemorrhage or inflammatory exudates cause the serous surfaces to fuse. Secondary femoroceles are associated with the presence of ascites and occur when peritoneal ascitic fluid forms a collection in the hernia sac. | Table 1: Clinical features and management of femoroceles[1],[2],[3],[4],[5],[6],[7],[8],[9],[10]
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The clinical presentation and demographics of patients that have a femorocele are almost similar to that of femoral hernia. These include women with lower BMI in the 4th–6th decades of their life, and there is increased predilection for a unilateral right-sided pathology. All reported cases of femoroceles thus far have occurred in female patients. The mean age of presentation of a femorocele was 41 years, and 85% of the patients were aged between 30 and 50 years old. All the previously described cases consist of irreducible groin swellings which were soft to firm in consistency with no cough impulse. These clinical findings make it difficult to exclude possible differentials of an incarcerated femoral hernia, hydrocele of the canal of Nuck, lipoma or hygroma.
Even with the aid of ultrasound or computed tomography imaging, making a preoperative diagnosis of a femorocele remains uncertain. The identification of a cystic groin mass on imaging tends to point toward the comparatively less rare diagnosis of a canal of Nuck hydrocele. This case highlights the difficulty in diagnosing a femorocele using clinical and radiological evaluation. To date, all cases have been diagnosed after surgical exploration.
Surgical repair of the femorocele is the treatment of choice to prevent its recurrence and future development of a femoral hernia. In cases where there is occlusion at the neck by an omental plug or adhesions, it is important to deal with this possible underlying etiology and dissect the tissue free from the femoral ring to be either reduced or excised. Subsequently, the sac of the femorocele should be obliterated as closed to its neck as possible. Majority of the case reports in the literature describe performing a tension-free primary repair using nonabsorbable suture to approximate the inguinal ligament and iliopectineal ligament. Bakshi described a case of an infected femorocele, and in such cases, primary suture repair is the preferred method due to the risk of mesh infection.[8] Surgical repair has also been successfully performed with the use of a mesh plug,[9] and we believe that the use of mesh is safe with low risk of complications when used in the case of an uncomplicated femorocele. Mesh repair through a preperitoneal approach is also effective and has been shown to have lower rates of recurrence and postoperative pain compared to using mesh plugs in femoral hernia repairs. Makawana described an open preperitoneal repair of bilateral femoroceles through a pfannenstiel incision.[10] Perhaps, with greater experience in diagnosing and managing this condition in the future, endo-laparoscopic preperitoneal approach may even be considered. Visualization of the femoral opening from within could give a better perspective and understanding of femoroceles and its etiology.
| Conclusion | | |
More likely than not, femoroceles will remain an intraoperative rather than a preoperative diagnosis. In general, it is a benign pathology and does not warrant unnecessary diagnostic preoperative evaluation. Despite this, femoroceles should not be an overlooked differential. Surgical repair is the mainstay of treatment to prevent any unnecessary recurrence and the potential development of complicated femoral hernias in future.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Marcy HO. The Anatomy and Surgical Treatment of Hernia. New York: Appleton and Co; 1892. p. I26.  |
| 2. | Bailey H. Hydrocele of a femoral hernia sac. Br J Surg 1927;15:166. |
| 3. | Rives JD. Femoral hydrocele. Ann Surg 1934;99:989-92. |
| 4. | McCorkle H, Bell H. Hydrocele of the femoral hernia sac. Ann Surg 1941;133:264-6. |
| 5. | Mote DG, Chakravarty KB. Hydrocele of a femoral hernia sac. World J Hernia Abdom Surg 2009;13:657-8. |
| 6. | Abdellah AA, Musa AM, Bashier OH. Hydrocele of a femoral hernia in a young woman. S Afr J Surg 2010;48:1. |
| 7. | Madhivanan S, Jain RK. Hydrocele of femoral hernia sac. Indian J Surg 2016;78:235-7. |
| 8. | Bakshi S. Infected femorocele: Case report of an extremely rare surgical condition in a middle-aged lady suffering from a painful inguinal swelling. Surg Case Rep 2019;5:153. |
| 9. | Mimery A, Munugani S, Al-Askari M. Femoroceles – A Rare differential for the irreducible groin lump: A case report and literature review. Indian J Surg 2019;82:430-2. |
| 10. | Makwana RA. Bilateral femoral hydrocele – First case in the medical literature. Int J Sci Res 2020;9:245-4. |
Correspondence Address:
Tiffany Jian Ying Lye,
Dr. Tiffany Jian Ying Lye, Outram Road, Singapore 169608
Singapore
 Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1] |
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