Management of Ovarian Hernia in Children , in Teaching Hospital of Bouaké , Côte d ’ Ivoire Prise en Charge des Hernies de l ’ ovaire de l ’ enfant au CHU de Bouaké , Côte d ’ Ivoire

Objective: To analyze our experience in the management of ovarian hernia in children. Methods: It was a retrospective study about 11 cases treated in pediatric surgery unit of the Teaching Hospital of Bouaké, in 2 years period. Results: Ovarian hernia represented 7.69% of the hernias and 73.33% of the hernia cases in girls. The mean age was 4 years and the median 36 months. The main reason for consultation was inguinal swelling (45.45%) following by swelling of the labia majora (36.36%), and a round mass of labia majora palpated by parents while bathing the child (18.18%). Nine (9) patients had been operated on; we realize the closure of peritoneo-vaginal canal, associated in 66.66% cases with a routine surgical exploration of the contralateral side. Average age of these children with contralateral hernia was 20 months. The mean follow up was 6 months (15 days 15 months). We noticed an appearance of contralateral ovarian hernia in a girl operated on at 3 years old without routine surgical exploration. Conclusion: We recommend early management with a systematic surgical exploration of the contralateral side in young female child. A preoperative ultrasonography could be a routine in case of strangulated hernia, if available.


Introduction
Hernia containing ovary is a rare congenital disease with a risk of severe complications: strangulated hernia, ovarian torsion, infertility [1] [2] [3].The aim of this study was to report our experience of the management of inguinal hernia containing ovary in children.

Methods
It was a retrospective study about eleven (11) records of female patients managed in pediatric surgery unit of the Teaching hospital of Bouake during a 2 years period (02 May 2014 au 30th April 2016).Where included in this study, all female child age from 0 day to 15 years presented with ovarian hernia.Exclusion criteria where: all female child age from 0 day to 15 years with other cause of labia majora or inguinal swelling, incomplete records, operated ovarian hernia.We analyzed the age, the gestational age, symptoms, clinical presentation, the hernia site, associated lesions, management, and the outcome.Data where recorded with software word and excel, from charts and operative reports.The median was calculated with Epi info 7.5.
All parents gave their informed consent prior to their inclusion in the study.Additional informed consent was obtained from all individual parent of participant for whom images are included in this article.
The consent of local ethics committee was obtained.

Demographic Aspects
The frequency of hernia containing ovary was 5.5 per year.The prevalence was represented 7, 69% of hernia in children and 73.33% of female child hernia.The average age was 4 years (6 months -13 years).The median was 36 months with the interquartile range from 20 months to 48 months.There was none preterm patient.

Diagnosis
The clinical presentation was a swelling of groin (45.45%) or a swelling of labia majora (36.36%).At Physical examination, we noticed a swelling of labia majora (Figure 1(a)), a round palpable, painless and movable mass (100%).The left side was involved in 54.54% and the right side in 45.45%.Associated lesions were: 7cases of umbilical hernia (Figure 1(a)), 1 case of inguinal hernia (Figure 2).No preoperative radiological investigation had been done.

Treatment
We performed surgery in 9 patients.The 2 others did not come for surgery.The herniotomy was done under general anesthesia, through an incision in abdominal inferior wall.At routine contralateral surgical exploration realized in 6 cases (66.66%), we noticed a contralateral hernia containing ovary (Figure 1  in all these patients whom average age was 1year 8 months (6 months to 2 years).
The follow up of the patients with routine contralateral exploration was uneventful in all 6 cases; there was no recurrence.In the 3 patients without routine contralateral exploration, we observed no contralateral hernia in 2 cases (11 years/13 years old) after 12 months and 15 months follow up.The third one operated at 3 years old, had a contralateral hernia, after a 7 months follow up (Table 1).

Comments
Embryology: Hernia containing ovary is a congenital disease.It results from an incomplete obliteration of processus vaginalis (PV) developed at around the 6th month of fetal development and passes through the inguinal canal up to the labium majora.It is usually obliterated by 8 months of gestations [4] [5]; these conditions explain the high risk of hernia in preterm [4].Ovarian herniation through the patent Processus vaginalis named the canal of Nuck, results in an inguinal hernia containing ovary.However, Bowel, omental fat, fluid, fallopian tube, rarely uterus and urinary bladder can also herniate though this [5] [6] and lead to a problem of differential diagnosis.
Socio-demographic aspects: Hernia containing ovary is rare.The prevalence was 7.69% of children's hernia in our series.Huang reported 4.48% (26 ovarian hernia out of 580 female inguinal hernia cases admitted in Chang Gung Children's Hospital, Taiwan from 1997 to 2002) [7].Ovarian hernia is the most frequent inguinal hernia in a female child in our series where it represented 73.33% of female child hernia.Osifo also reported a predominance ovarian hernia with or without fallopian tube (71%) [8] This disease is congenital and can be diagnosed at any age in the childhood [5] [9] [10].
Diagnosis: The clinical aspect is usually, as observed in our experience, an asymptomatic palpable movable mass in the groin or over the labium majora, painless in absence of incarceration.We did not do pre-operative sonography unlike in literature [1]; it could help to identify the content of hernia and explore the contra lateral side.It is an easy accurate pre-operative diagnosis procedure [7], has ability to evaluate ovary and differentiate hernia containing ovary among hydrocele in the canal of Nuck, a bowel containing hernia, an enlarged lymph node [5] [11].Oudesluys-Murphy suggests routine ultrasonography mostly in preterm infant girls with an inguinal hernia [12].
Treatment: The treatment of hernia containing ovary is surgery.Hernia containing ovary should be repair promptly but not in emergency [4].There is no possibility of spontaneous regression unlike hernia containing bowel [12].For hernia repair, all the hernia sacs had been opened in our series (Figure 1(b)).
Osifo et al. in Nigeria also advised to open hernia sac in female with inguinal hernia to prevent the injury of ovary [8].In case of strangulated hernia containing ovary, Authors advised a pre operative ultrasonography followed by reduction of hernia and delayed surgery if ovary is normal [2].If there is a poor vitality of ovary (ultrasonography) or if ultrasonography is not available in emergency, hernia should be emergently repair.Surgeons performed routine open contralateral inguinal exploration to identify a patent processus vaginalis in all children or in selected population like former preterm infants, or children younger than 2 years [13].However, Open surgery contralateral exploration is decreasing with the use of Laparoscopy which is [13] an alternative increasingly use for treatment of the hernia containing ovary and contra lateral exploration [14] [15].
In this case, laparoscopy through umbilicus is recommended [4], but laparoscopy through hernia sac can also be use for contralateral exploration even in infants [4] [16] with less scars and it is cost effective [16] evaluation [17].In low income countries routine pre operative ultrasonography is still a great alternative for patients whose parents cannot afford to pay for laparoscopy.

Conclusion
Health care givers should be aware of the necessity of early surgery and routine contra lateral exploration in young female child with inguinal hernia.Preoperative ultrasonography could be a routine assessment in our practice where pediatric laparoscopy is currently unavailable.

Communicated
This study has been communicated (oral presentation) at 57 th Conference of West African College of Surgeons (WACS), 26 -4 March 2017, Ouagadougou, Burkina Faso.

Figure 1 .
Figure 1.(a) Two years old patient with right hernia containing ovary associated with umbilical hernia; (b) Right hernia containing ovary with a big hernia sac, opened for exploration; (c) The same patient with patent left processus vaginalis (PV) with a hernia containing ovary discovered at routine contralateral surgical exploration.

Figure 2 .
Figure 2. Left hernia containing ovary associated with a big right hernia containing bowel.