30. Femoral hernia.

Question 1

Femoral hernia - Definition

Answer 1

A femoral hernia is a protrusion of peritoneum through the femoral canal.

Question 2

Femoral hernia - Sac

Answer 2

proceeds downwards in femoral canal – stretch cribiform fascia, then upwards and lat towards inguinal lig – neck is narrow thus strangulation can easily happen

Question 3

Femoral hernia - - Contents

Answer 3

May contain abdominal contents or extraperitoneal fat. Omentum bowel or part of circumference of bowel (richter’s hernia)

Question 4

Femoral hernia - Covering

Answer 4

stretched femoral septum, transversalis fascia, cribiform fascia, superficial fascia, skin

Question 5

Femoral hernia - Main Points

Answer 5

1/3 most common type of groin hernia, after indirect and direct inguinal hernias

Account for approximately 6 per cent of all abdominal wall hernias

Question 6

Overriding importance of Femoral hernias

Answer 6

They are themost liable to become strangulated.

More common on R than L

Question 7

Femoral hernia - Etiology

Answer 7

• Large femoral canal

increased intra-ab pressure

nulliparous women

previous groin injury for inguinal hernia repair

Question 8

Femoral hernia - Classification

Answer 8

Reducible

Irreducible

Strangulated

Question 9

Femoral hernia - Anatomy

Answer 9

Femoral canal occupies most medial compartment of femoral sheath – extends from femoral ring above to saphenous opening below – 1.25cm long + 1.25cm wide

Canal bounded by:

1. Anteriorly = inguinal lig
2. Posteriorly = pectineal lig (cooper’s lig), pubic bone
3. Medially = lacunar lig
4. Laterally = iliopsoas muscle

Divided into 2 compartments by the medial border of femoral vein. Medial compartment = femoral ring

Lateral compartment contains: F vein, artery, nerve, genitofemoral nerve

F artery + vein enclosed by femoral sheath – an extension of transversalis fascia

Question 10

Femoral Ring Anatomy

Answer 10

Femoral ring:

medial compartment of femoral canal (main site for femoral hernia)

• Contents: cloquet’s node + lymphatics
• Anteriorly: inguinal lig
• Posteriorly: pectineal lig (cooper’s) + pectineal muscle
• Medially: locunal lig
• Laterally: medial border of F vein

Question 11

Femoral hernia - Pathology

Answer 11

if hernia passes through saphenous hiatus – irreducible (incarcerated) – as it expands + no longer confined to inelastic wall of femoral canal

Question 12

Femoral hernia - Clinical Presentation

Answer 12

Rare before puberty

Occurs in females more than males

S+S less pronounced than inguinal hernias

Swelling more apparent on standing + straining

Mild pyrexia with localised discomfort suggests strangulated omentum within the hernial sac

Question 13

Femoral hernia - Diagnostic Investigations

Answer 13

Clinical dx.

US of Groin done when dx inconclusive.

Difficult to palpate in obese pts

Question 14

Femoral hernia - Rare Types

Answer 14

1. Hydrocele of femoral hernial sac: neck of sac becomes plugged with omentum or by adhesions + a hydrocele of the hernia sac results
2. Laugier’s femoral hernia: hernia through a gap in the lacunar lig – unusual medial position of a small hernia sac – nearly always strangulated
3. Narath’s femoral hernia: occurs only in pts with congenital dislocation of the hip + is the result of lateral displacement of the psoas muscle – hernia lies hidden behind the femoral vessels
4. Cloquet’s hernia: the sac lies under the fascia covering the pectineus muscle – strangulation is likely

Question 15

Femoral hernia - Treatment

Answer 15

Surgical not conservative treatments as there’s constant risk of strangulation

non tender lump may be reduced temporarily to decrease local tenderness. In this case op is mandatory.

Empty bladder before op

1. The low op (lockwood)
   a. Sac dissected out below inguinal lig via a groin crease incision.
   Essential to peel of anatomical layers that covers sac

.Neck of sac pulled down, ligated + allowed to retract through femoral canal.

Canal closed, suturing inguinal canal to iliopectineal line using 3 non-absorbable sutures

2. The high op (McEvedy) – vertical incision
   a. Vertical incision over femoral canal upwards above inguinal lig sac dissected out through lower part of incision.

Upper part of incision exposes inguinal lig + rectus sheath.

Sac delivered upward through canal, neck ligated.

Iliopectineal lig sutured to conjoined tendon.

Can also put mesh (polypropylene) over femoral canal orifice.

Anchoring mesh inferiorly to iliopectineal lig + medially to rectus sheath

i. Adv: if resection of intestine is required there is sufficient room
ii. Disadv: if infx occurs, incisional hernia may develop

3. Lotheissen’s op (inguinal approach)
   a. Inguinal canal opened like in inguinal herniorrhaphy.

T.fascia incised to medial side of epigastric vessels + opening enlarged.

Peritoneum now in view – it is incised – now can see if intraperitoneal structure is in sac or not.

If sac empty – it is withdrawn from f.canal.

If not empty follow technique for strangulation = open sac, stretch neck, remove contents, lift sack then canal.

Conjoint tendon sutured to ilio-pectineal line to form a shutter