Femoral Hernia

Section: Abdominal wall and retroperitoneum Sub-section: Hernias Curriculum: Curriculum, page 2

Definition

• A hernia that passes into the Femoral canal

Incidence

• 7% of abdominal wall hernias are femoral
• But in both sexes, femoral hernia is less common than inguinal (1:25)
• More common in female
  • Elderly, associated with weight loss/changes in fat distribution
  • Esp. women who have borne children
• Account for ≈ 1/3 of groin hernias in women
• 2% in men
• More common on RHS (2:1)
• Bilateral in up to 20%?

Classification

• Classical – through femoral canal
• Pre-vascular
  • Under inguinal ligament, in front of femoral artery and vein
  • Wide, flattened neck
  • Difficult to repair
  • May need mesh plug

Aetiology

• Predisposing factors:
  • Female pelvic anatomy
  • Obesity
  • Pregnancy
  • Increased intra-abdo pressure
    • Chronic cough, straining / constipation

Clinical

• Mostly asymptomatic until incarcerated/strangulated
• Present as an irreducible swelling at the femoral triangle
  • Can be indistinguishable from a node or a synovial cyst
• Usually appear irreducible, even with an empty sac, because of associated fat and nodes
• Rarely they can be fully eliminated with manipulation, in which case they can be confused with a saphenous varix (dilation of great saphenous vein at junction with femoral vein)
• Richter’s type femoral hernias
  • May present late with minimal local signs and bowel obstruction/infarction
• De Garengeot Hernia – Appendix in femoral hernia sac

Pathology

• Preperitoneal fat is forced out of the canal, followed by adherent peritoneum
• Femoral ring wider in women, as the iliopubic tract inserts into Cooper’s ligament
• M+M due to toxaemia that results from strangulation

Management

• Operative Technique
  • Three classical approaches to the femoral canal have been described
    • Low (Lockwood) - Elective
    • Transinguinal (Lotheissen)
    • High (McEvedy) – Incarcerated/strangulated
• Key operative steps:
  • Dissection of the sac
  • Reduction / inspection of the contents
  • Ligation of the sac
  • Approximation of the inguinal and pectineal ligaments

Modified McEvedy - High Approach

• Incision
  • Transverse skin crease incision 3cm above pubic tubercle
  • 8 cm long to midline
  • Ligate Superficial Epigastric Veins
• Entry
  • Divide the rectus sheath a few cm from its lateral boarder
  • Sweep rectus medially
  • Divide the transversalis fascia
  • Identify inferior epigastrics, ligate if necessary
  • Dissect down on peritoneum to femoral ring
• Management of the hernia
  • If incarcerated, I would routinely open the peritoneum to control spillage with the use of soft bowel clamps before reducing
  • Reduce hernia with pressure from below
    • If doesn’t reduce easily
    • Follow external oblique inferiorly, dissect out inguinal ligament
  • Dissect out sac, open & inspect contents
  • Reduce or incise neck
  • If need to incise ring then relaxing incision in inguinal ligament
    • Lacunar ligament incision runs the risk of bleeding from Aberrant Obturator Artery
  • Ensure contents inspected
  • Bowel resection if necessary
• Repair
  • Close femoral canal with 2-3 ethibond /PDS sutures
  • Finger over femoral vein to protect (not retracting just overlying so as not to narrow vein)
  • Suture iliopubic tract to pectineal ligament
• Closure
  • Close Anterior rectus sheath with 0 maxon. S/c 3-0 monocryl to skin

Lockwood - Low Approach

• Incision
  • Groin crease incision below the medial half of the inguinal ligament
  • 5 cm long over lump
• Dissection
  • Dissect onto hernia
  • Define neck of hernia under inguinal ligament
• Hernia
  • Open sac, inspect contents
  • Reduce contents
  • If necessary, enlarge ring, incise neck, or relaxing incision in inguinal ligament
  • Define neck
  • Transfix neck of sac & excise sac
• Repair
  • Close femoral canal with 2-3 Nylon or Ethibond sutures
    • Interuppted
    • Check the vein is not occluded before tying
  • Finger over Femoral Vein to protect
  • Suture inguinal ligament to the pectineal ligament
  • Consider mesh plug as an alternative
• Closure
  • S/C 3-0 monocryl to skin

If the femoral vein is torn, control the bleeding with pressure from gauze packs for 5 minutes. Meanwhile, order blood, arterial sutures, tapes, bulldog clamps and heparin solution, and summon assistance. Expose the vein; do not hesitate to approach it from above and below the inguinal ligament. Apply bulldog clamps and tapes above and below the damaged segment. Insert fine 5/0 sutures set 1 mm apart, 1 mm from the torn edges, to evert them and close the hole. Flush with heparin at intervals. Release, then remove the clamps and tapes

Lothiesen - transinguinal approach

• Advantage of both inguinal and femoral
• Entry
  • As per inguinal hernia
  • Incside transveralis fascia
• Hernia
  • Identify sac and external iliac vein
  • Gently reduce
  • Transfix and ligate
• Repair
  • Close the femoral canal with 2-0 non- absorbable suture
• Closure
  • Either close the transversalis fascia with non-absorbable suture or perform a mesh repair