Unsuspected femoral hernia in patients with a preoperative diagnosis of recurrent inguinal hernia.

PURPOSE: Small femoral hernias may be difficult to diagnose by physical examination and are sometimes identified unexpectedly by laparoscopy. The aim of this study was to examine the incidence of unsuspected femoral hernia discovered during laparoscopic inguinal hernia repair in two well-defined patient groups.
METHODS: Patients undergoing laparoscopic transabdominal preperitoneal inguinal hernia repair from April 2000 until December 2009 (n = 561) were prospectively registered including data on previous hernia operations and identified type of hernia during surgery. We included patients whose preoperative diagnosis was either bilateral primary inguinal hernia (Primary Group) or recurrent inguinal hernia (Recurrent Group).
RESULTS: Four hundred and sixty-one (82.2 %) patients were included in the study, of whom 211 (45.8 %) was in the Primary Group and 250 (54.2 %) in the Recurrent Group. The incidence of unsuspected femoral hernia in the Recurrent Group [23/250, 9.2 % (95 % CI 5.9-13.5 %)] was significantly higher than in the Primary Group [8/211, 3.8 % (95 % CI 1.7-7.3 %)], p = 0.02. Furthermore, 38.1 % of women operated on for a recurrent inguinal hernia, presented with an unsuspected femoral hernia at surgery as opposed to 6.6 % of the men, p = 0.003.
CONCLUSION: Unsuspected femoral hernias are more prevalent in patients with recurrent hernia than in patients with primary hernia in the inguinal region. Femoral hernias may be unrecognized at the primary inguinal hernia operation, or the previous inguinal hernia operation may facilitate the formation of a femoral hernia. Unsuspected femoral hernias are especially frequent in women with recurrent inguinal hernia. In women with a groin hernia, a femoral hernia should always be excluded by laparoscopy or by open exploration of the preperitoneal space.