Femoral and direct inguinal hernias are very uncommon in infants and children, and management differs considerably from that of the more usual indirect inguinal hernias. In this series, there were 25 pediatric patients, 12 with a femoral hernia and 13 with a direct inguinal hernia; the correct preoperative diagnosis was made for only 8.
Four of the 13 patients with direct hernias had been subjected to previous inguinal explorations for hernia, and the direct hernia may have resulted from damage to the previously normal or tenuous transversalis fascia weakened during the inguinal exploration. The basic defect in both femoral and direct inguinal hernias is a weakness or absence of a portion of the posterior inguinal wall associated with increased intra-abdominal pressure. In contrast to indirect inguinal hernias in which simple high ligation of the sac may suffice to produce surgical cure, these infrequent lesions require fascial repair, even in infants and children. High ligation or inversion of the hernial sac followed by a Cooper's ligament repair is recommended for femoral hernias, A formal reconstruction of the transversalis fascia behind the spermatic cord will suffice for the direct lesion.
Fonkalsrud EW, deLorimier AA, Clatworthy HW. Femoral and Direct Inguinal Hernias in Infants and Children. JAMA. 1965;192(7):597-599. doi:10.1001/jama.1965.03080200015003