Femoral Hernia

Femoral canal

-       Empty of structures apart from fat, lymphatics and a lymph node (Cloquet’s or Rosenmueller’s node)

-       Allows expansion of the femoral vein?

-       Femoral ring

o   Entrance to the femoral canal

o   Bounded by the tissue of the femoral sheath

o   Anteriorly

§  Iliopubic tract, inguinal ligament

o   Medially

§  Iliopubic tract and lacunar ligament

o   Posteriorly

§  Pectineal ligament

o   Laterally

§  Femoral vein

o   Closed by a tenuous fascia layer

o   Only extraperitoneal fat between ring and peritoneum

-       When the ring is expanded e.g. hernia the more unyielding structures form its boundaries

-       Only 1 –2 cm long before its walls fuse

-       With a femoral hernia, it is initially deep to fascia lata

o   As it enlarges, it tends to protrude through the weakest area in the region (region of the LSV penetrating to the deep vein – fossa ovalis)

o   However the deep layers of the superficial fascia from the abdomen inserts into the distal margin of this fossa

o   Thus as a sac enlarges, this fascial attachment extends to prevent the downwards extension of the sac so it bulges up (large femoral hernia can give the appearance of being above the inguinal ligament)

-       Formed from the fascia adjacent to the iliac vessels as they exit under the inguinal ligament and become the femoral vessels

-       Posteriorly

o   Pectineal ligament

-       Below

o   Pectineus fascia

-       Fascia covering iliopsoas forms part of the posterior wall but is mainly the lateral relation

-       Anterior sheath

o   Arises from the iliopubic tract part of the transversalis fascia (also bounds the medial part of the opening into the femoral sheath)

-       Sheath descends with the vessels becoming progressively narrower and ending 4cm below inguinal ligament by fusing with the adventitia of the vessels

-       Anteroposterior running septa divide the femoral sheath into 3 compartments

-       Lateral compartment - femoral artery

-       Middle compartment – femoral vein

-       Medial compartment – femoral canal

Differential diagnosis

-       Inguinal hernia

-       Saphena varix

-       Enlarged femoral lymph node

-       Lipoma

-       Femoral artery aneurysm

-       Psoas abscess

-       Adductor longus rupture.

v Layers of femoral hernia

Femoral herniae

· Low approach –elective repair; suture or mesh plug

· High approach – NB exam approach to acute incarcerated femoral hernia

· femoral hernias may be repaired with interrupted sutures joining the inguinal ligament and

pectineal ligament placed either from inside the inguinal canal or from below the inguinal

ligament

High

GA. IV ABx Supine with arms tucked. IDC. IV Abx. Heparin. TEDS. SCD. Timeout. Sterile prep and drape so that the groin hernia and anterior abdominal wall are exposed.

· Transverse skin crease incision 3cm above pubic tubercle » 8 cm long to midline

· Ligate superficial epigastric veins

· Divide external oblique in line of fibres, extend onto anterior rectus sheath

· Sweep rectus medially using a Langenbach retractor

Retract the anterior abdominal tissues superiorly to visualize the posterior wall of the myopectineal orifice.

· Identify inferior epigastrics which generally do not need to be divided, unless obscuring vision

· Dissect down on peritoneum to femoral ring

The hernia sac appears as a funnel-shaped structure entering the crural canal.

· If the hernia sac is small it is easily reduced with taxis, pressure from below, keeping control of its contents with fingers

· 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

· Ensure contents inspected

· If contents of sac slip back into the peritoneal cavity, then make a laparotomy through the posterior wall of the incision and run bowel to ensure that it is not strangulated.

· Resection if necessary

Close the sac using 2/0 Vicryl purse string suture.

· Close femoral canal with 2-3 ethibond sutures, finger over femoral vein to protect

— Suture iliopubic tract to pectineal ligament

· Close Anterior rectus sheath with 1 vicryl. S/c 3-0 monocryl to skin

Low

· Groin crease incision »8 cm long

— over lump

· Dissect onto hernia

· Define neck of hernia under inguinal ligament

· Open sac, inspect contents

· Reduce contents

— If necessary enlarge ring, incise neck, or relaxing incision in inguinal ligament

· Define neck

· Transfix neck of sec & excise sac

· Close femoral canal with 2-3 ethibond sutures, finger over femoral vein to protect

— Suture iliopubic tract to pectineal ligament

—    Consider mesh plug if large prevascular hernia

· S/c 3-0 monocryl to skin

Femoral Hernia repair - additional notes

Indications/Presentation

-       Elderly female

-       Small bowel obstruction

-       Tender, irreducible groin lump

-       No cough impulse

Contraindications

Preoperative preparation

-       Oxygen per mask/nasal prongs

-       Intravenous access

o   Fluids

o   Antibiotics perioperatively

-       Indwelling catheter

-       Nasogastric tube

-       Consent

o   General risks of surgery

§  Anaesthesia

§  Sepsis

§  Wound infection

§  Haemorrhage

·      Haematoma

·      Blood transfusion

§  Infection

§  DVT/PTE

o   Specific risks

§  Risk of bowel resection

·      Anastomotic leak

·      Prolonged stay in hospital

·      Deep intra-abdominal collection

§  Hernia recurrence

-       Notify

o   Anaesthetist

o   Theatre

o   Patient’s next of kin

Anaesthesia

-       General anaesthesia

Position of the patient

-       Supine in an operating theatre.

Special equipment

Incision

-       High approach – 2cm above an incision for inguinal hernia repair (medial 2/3 of a line drawn between pubic tubercle and anterior superior iliac spine)

-       Advantages

o   Better exposure

o   Peritoneal cavity access

o   Control of accessory obturator artery

-       Disadvantages

o   Greater post-operative pain

o   Risk of incisional hernia

Exploration

-       Deepen incision to reach external oblique

-       Incise external oblique aponeurosis in line of fibres

-       Muscle split internal oblique muscle and transversus abdominis

-       If encounter inferior epigastric artery, ligate or sweep away

-       Reach the preperitoneal space

-       Follow down to inguinal ligament

-       Blunt dissect tissues overlying femoral ring

-       Approach hernia from infra-inguinal region, dissecting out the sac (tends to have an onion ring effect)

-       Try to reduce from below and above with gentle pressure and traction

-       Open peritoneum

o   Examine what is going into sac

o   Small bowel – one dilated and one deflated loop

o   Omentum

-       Try inserting little finger into medial aspect of the femoral ring

-       Apply gentle traction on bowel from above and sac from below

-       What is limiting reduction

o   Peritoneal covering

o   Femoral ring boundaries

-       Divide lacunar ligament medially, palpating for an accessory obturator artery

-       Dilate up the ring

-       Retract or divide inguinal ligament

-       Incise peritoneum longitudinally down to sac extracting hernia contents

-       Inspect contents

-       Return to abdominal cavity

-       2/0 prolene interrupted repair of hernia

o   Femoral vein is always lateral and visible

o   Care not to constrict vein – risk of thrombosis, thrombophlebitis

-       Re-examine contents

o   Non-viable

§  Segmental resection

§  End to end anastomosis

§  3/0 Maxon continuous

o   Viable

Drainage

-       Not routine

-       If large infra-inguinal space – redivac drain

Closure

-       PDS in layers

Dressing

-       Primapore dressing or Comfeel dressing

Post-operative instructions

-       Nil by mouth

-       Nasogastric tube on free drainage with 4^th hourly aspirates

-       IDC hourly urine output

-       Intravenous fluid

-       Oxygen

-       Chest physio

-       TEDS and s/c heparin

-       PCA or infusion