Peritoneal cyst mimicking a femoral hernia

Abstract

Dear Editor, I read with great interest two papers published in the same issue of Hernia [vol 13(6) December 2009]: the Wrst from J.D. Ryan et al. (Haematoma in a hydrocele of the canal of Nuck mimicking a Richter’s hernia [1]), and the second by D.G. Mote (Hydrocoele of a femoral hernia sac [2]). These papers can be compared from a physiological perspective but diVer from an anatomical point of view. I had the opportunity to operate on two similar cases recently. I would like to congratulate J.D. Ryan et al. for their rare report and their incidental Wndings, which provide the opportunity to precise what is well know in males (processus vaginalis) but often not really known or understood in females. In fact, as the authors note in their paper, exactly the same process occurs during embryology, and if the canal of Nuck is not complete obliterated a cyst might form. I operated on a 35-year-old woman with a bulge palpated in the right upper-lateral area of the pubic tubercle—just the place where a direct hernia can occur, and indeed that was our preoperative diagnosis. By an inguinal direct approach we found that the transversalis fascia was correct and, above it, we found a cyst inside a Nuck canal. It was located inside the lacunar ligament (epigastric vessels). A resection of the hydrocele was easily performed; there was no communication with the abdominal cavity. The patient recovered well and was back home at day 1. So I agree with the conclusion of J.D. Ryan, and Benjamin [3]: resection of the sac and treatment of simultaneous inguinal hernia if present. Congratulations also to D.G. Mote for their exceptional case report. As they note, “hydrocoele of the femoral hernia sac is very rare” [4]. If we compare these two papers, we can make two kinds of comments. In both cases, a cyst appears in a peritoneal pouch, without communication with the abdominal cavity: a Nuck canal in the Wrst case (which is a peritoneal structure), and the peritoneal sac in the second. On the other hand, from an anatomical point of view they are located in two opposing places. The Nuck cyst corresponds to an indirect hernia in the inguinal canal, above the transversalis fascia, and is the result of a congenital problem. The peritoneal cyst inside the femoral canal is a direct acquired kind of hernia, of course below the transversalis fascia. So it is interesting to compare these two papers, and to be reminded, as the authors note, of the anatomical basis for understanding. I also recently operated such a peritoneal cyst mimicking a femoral hernia. A 63-year-old woman presented with a bulge in the upper part of the root of the right thigh, not really painful but causing some discomfort. It appeared some months ago, and we discovered that at the same time she had lost weight due to family problems. The examination showed that the bulge was not reducible and the inguinal area was normal, as was the left side. She had no history of previous hernia, even in childhood. Our idea was that part of the greatum omentum was strangulated in the femoral ring. An abdominal X-ray was not helpful and her laboratory Wndings were normal. By an inguinal approach we conWrmed that the inguinal canal was normal and, after opening the transversalis fascia, we saw the peritoneum strangulated in the femoral ring. It was necessary to open the inguinal ligament a little bit to O. Armstrong (&) CCDE, Hotel-Dieu, Centre Hospitalier Universitaire, Place Alexis Ricordeau, 44093 Nantes Cedex 1, France e-mail: Olivier.armstrong@chu-nantes.fr