3 DISCUSSION
Groin hernias are common disorders, with a wide range of variations, and
they may be difficult to diagnose preoperatively. As a result, the
nature and numbers of hernias observed in surgery may differ from those
identified at diagnosis. Of note, subclinical contralateral groin
hernias and unsuspected femoral hernias in patients undergoing
laparoscopic inguinal hernia repair are reported in
8%-28%4-7 and 7.2%-11.1% of patients,
respectively.8, 9 In the present case, a right
inguinal hernia was diagnosed, but a subclinical hernia was also found
on the left side during laparoscopy. If an anterior approach had been
performed, the left side hernia may not have been observed,
necessitating repair at a later date. The present case was an extremely
rare one as simultaneous bilateral inguinal and femoral hernias were
observed. Reports of three or more simultaneous hernias are very
few,10, 11, 12 and to the best of our knowledge, this
is the first report of both bilateral inguinal and femoral hernias.
Strangulation or incarceration is the chief complaint for femoral
hernias.13 In the present case, the right inguinal
region was incarcerated, but the inguinal ligament protruded from the
cranial side, and CT did not detect this complication in the femoral
hernia. Data suggest that femoral hernias are more common in women over
the age of 50,14 which would have made it extremely
difficult to suspect femoral hernias in the present case.
Laparoscopic surgery is the standard procedure for inguinal hernia
repair and its advantages include a good view of the surgical field,
reduction in wound pain, and, the most remarkable aspect, easy
observation, diagnosis, and repair of subclinical and contralateral
groin hernias.15, 16, 17 In this case, three
additional hernias that could not be detected preoperatively, were
successfully detected during laparoscopic surgery. The presence of a
femoral hernia does not change the repair procedure. As in the case of
the initial hernia, the repair operation is performed so that the
preperitoneal space is removed, including the inner inguinal ring,
Hesselbach’s triangle, and thigh ring. The mesh is placed in a manner
same as that used during as the repair of the non-coexisting type
hernia, and the largest possible mesh is used. The wound is also similar
to that incurred when repairing the non-coexisting type hernia and
postoperative pain does not increase. We conclude that laparoscopic
surgery offers a superior means of repairing groin hernias to the
anterior approach, although the anterior approach may be the better
method if solid adhesion of the preperitoneal cavity is anticipated,
such as after prostate surgery. In these cases, performing a
prone-position CT scan before surgery is advisable as studies have shown
that occult hernias are easier to detect with prone-position CT than
with supine position CT.18