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9. Femoral hernia Flashcards

1
Q

Femoral Hernia

A
  • PATHOLOGY
  • CLINICAL PICTURE:
  • Differential Diagnosis
  • Investigations
  • TREATMENT
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2
Q

PATHOLOGY of Femoral Hernia

A
  • Defect
  • Sac
  • Contents
  • Coverings
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3
Q

Defect in PATHOLOGY of Femoral Hernia

A

Femoral ring.

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4
Q

Sac in PATHOLOGY of Femoral Hernia

A
  • The pathway
  • The reason it doesn’t continue inferiorly
  • The neck
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5
Q

The pathway Sac in PATHOLOGY of Femoral Hernia

A

The sac of the femoral hernia pass

  • downwards in the femoral canal

then

  • forwards stretching the cribriform fascia of the saphenous opening

then

  • upwards and laterally towards anterior superior iliac spine taking its retort shape.
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6
Q

The reason it doesn’t continue inferiorly in Sac in PATHOLOGY of Femoral Hernia

A
  • Wrong answer but said in lectures

* Right answer

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7
Q

Wrong answer but said in lectures in The reason it doesn’t continue inferiorly in Sac in PATHOLOGY of Femoral Hernia

A

Due to attachment of scarpas fascia to lower border of saphenous opening

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8
Q

Right answer of The reason it doesn’t continue inferiorly in Sac in PATHOLOGY of Femoral Hernia

A

because of the strong attachment & fusion

of the deep and superficial fascia of the thigh below the saphenous opening.

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9
Q

The neck in Sac in PATHOLOGY of Femoral Hernia

A
  • The neck of the sac is narrow

* so femoral hernia is more liable to irreducibility and strangulation

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10
Q

Contents in PATHOLOGY of Femoral Hernia

A
  • Omentum
  • Intestine
  • Only a part of the circumference of the intestine
    (Richter’s hernia).
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11
Q

Coverings in PATHOLOGY of Femoral Hernia

A
  1. Skin.
  2. Subcutaneous fat & Scarpa’s fascia.
  3. Stretched cribriform fascia.
  4. Anterior layer of the femoral sheath:
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12
Q

CLINICAL PICTURE of Femoral Hernia

A
  • Symptoms

* Examination

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13
Q

Symptoms in CLINICAL PICTURE of Femoral Hernia

A
  • Painless swelling in upper part of thigh ( femoral triangle)
  • Females are Commonly affected
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14
Q

The reason why Females are Commonly affected in Symptoms in CLINICAL PICTURE of Femoral Hernia

A
  1. Repeated pregnancy )> inc. abdominal pressure
  2. Small sized femoral vein )> Wide femoral ring
  3. wider pelvis
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15
Q

Examination in CLINICAL PICTURE of Femoral Hernia

A

A swelling with the following criteria

  • Site
  • Size
  • Shape
  • Edge
  • Surface
  • Consistency
  • Special character
  • Descent
  • Reduction
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16
Q

Site of the swelling in Examination in CLINICAL PICTURE of Femoral Hernia

A

Femoral triangle.

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17
Q

Size of the swelling in Examination in CLINICAL PICTURE of Femoral Hernia

A

Variable.

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18
Q

Shape of the swelling in Examination in CLINICAL PICTURE of Femoral Hernia

A

Early rounded & then retort

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19
Q

Edge of the swelling in Examination in CLINICAL PICTURE of Femoral Hernia

A

Well defined.

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20
Q

Surface of the swelling in Examination in CLINICAL PICTURE of Femoral Hernia

A

Usually smooth

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21
Q

Consistency of the swelling in Examination in CLINICAL PICTURE of Femoral Hernia

A

Soft or doughy

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22
Q

Special character of the swelling in Examination in CLINICAL PICTURE of Femoral Hernia

A
  • may give Expansile impulse on cough unless complicated

* Usually irreducible

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23
Q

Descent of the swelling in Examination in CLINICAL PICTURE of Femoral Hernia

A

Downwards, forwards and then upwards and laterally.

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24
Q

Reduction of the swelling in Examination in CLINICAL PICTURE of Femoral Hernia

A

Usually irreducible but early it can be reduced

backward and upward.

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25
Q

Differential Diagnosis of Femoral Hernia

A

1- Inguinal hernia.

2- Swellings of the femoral triangle

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26
Q

Inguinal hernia in Differential Diagnosis of Femoral Hernia

A

Inguinal hernia is above and medial to the pubic tubercle.

Femoral hernia is below and lateral to the pubic tubercle.

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27
Q

Swellings of the femoral triangle in Differential Diagnosis of Femoral Hernia

A

A. Reducible femoral hernia

B. Irreducible femoral hernia

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28
Q

Reducible femoral hernia in Swellings of the femoral triangle in Differential Diagnosis of Femoral Hernia

A
  • Saphena varix.
  • Femoral artery aneurysm.
  • Varicose aneurysm “A-V fistula”.
  • Psoas abscess.
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29
Q

Irreducible femoral hernia in Swellings of the femoral triangle in Differential Diagnosis of Femoral Hernia

A
  • Lipoma.
  • Ectopic testis
  • Inguinal lymph node.
  • Psoas bursa.
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30
Q

Investigations of Femoral Hernia

A

As inguinal hernia.

1) Investigations to detect underlying cause of increased abdominal pressure:
2) Routine preoperative investigations

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31
Q

Investigations to detect underlying cause of increased abdominal pressure in Investigations of Femoral Hernia

A

a. Chest x-ray & pulmonary function test.
b. Abdominal U.S.
c. Trans-rectal U.S

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32
Q

Abdominal U.S in Investigations to detect underlying cause of increased abdominal pressure in Investigations of Femoral Hernia

A

may show

  • Ascites
  • splenomegaly
33
Q

Trans-rectal U.S in Investigations to detect underlying cause of increased abdominal pressure in Investigations of Femoral Hernia

A

to detect B.P.H.

34
Q

Routine preoperative investigations in Investigations of Femoral Hernia

A

a. Blood picture “CBC”
b. Blood chemistry.
c. P.T & P.T.T.
d. ECG.

35
Q

TREATMENT of Femoral Hernia

A
  • Surgery is the only line of treatment

* Approaches

36
Q

Approaches of TREATMENT of Femoral Hernia

A

1- Low approach

2- High approach

3- The pre-peritoneal approach

  • Hernioplasty can be done via any of these 3 approaches instead of repair
37
Q

Low approach in Approaches of TREATMENT of Femoral Hernia

A
  • Alternative names
  • Operative details
  • Disadvantage
38
Q

Alternative names for Low approach in Approaches of TREATMENT of Femoral Hernia

A
  • Femoral approach

* Lockwood approach

39
Q

Operative details of Low approach in Approaches of TREATMENT of Femoral Hernia

A
  • Incision

* Steps

40
Q

Incision in Operative details of Low approach in Approaches of TREATMENT of Femoral Hernia

A

1 inch below & parallel to the medial 2/3 of the inguinal ligament

41
Q

Steps in Operative details of Low approach in Approaches of TREATMENT of Femoral Hernia

A
  1. The coverings are divided to expose the sac.
  2. Manipulation of the sac
  3. Repair of the defect
42
Q

Manipulation of the sac in Steps in Operative details of Low approach in Approaches of TREATMENT of Femoral Hernia

A
  1. The sac is dissected up to the femoral ring.
  2. The sac is opened at the fundus
  3. Contents are reduced
  4. Finally the sac is transfixed.
43
Q

Repair of the defect in Steps in Operative details of Low approach in Approaches of TREATMENT of Femoral Hernia

A

Done by suturing the inguinal ligament to the pectineal ligament.

44
Q

Disadvantage of Low approach in Approaches of TREATMENT of Femoral Hernia

A

a. Low transfixion of the sac.

b. If the bowel was strangulated, resection is difficult
to be done from this approach.

c. Injury to the abnormal obturator artery

45
Q

abnormal obturator artery in Disadvantage of Low approach in Approaches of TREATMENT of Femoral Hernia

A

Normal anatomy

Abnormal anatomy

46
Q

Normal anatomy in abnormal obturator artery in Disadvantage of Low approach in Approaches of TREATMENT of Femoral Hernia

A

Usually the obturator artery and the inferior epigastric artery each gives a small pubic branch which anastomose at the back of the pubis

47
Q

Abnormal anatomy in abnormal obturator artery in Disadvantage of Low approach in Approaches of TREATMENT of Femoral Hernia

A

In 30% of people the pubic branch of the inferior epigastric is very large taking the place of the obturator artery and is known as the abnormal obturator artery which passes down in relation to the femoral ring to reach the obturator foramen as follows

(a) Safe position
(b) Dangerous position

48
Q

Safe position of Abnormal anatomy in abnormal obturator artery in Disadvantage of Low approach in Approaches of TREATMENT of Femoral Hernia

A

stick to the side of the femoral vein

49
Q

Dangerous position of Abnormal anatomy in abnormal obturator artery in Disadvantage of Low approach in Approaches of TREATMENT of Femoral Hernia

A

pass along the free edge of lacunar ligament only in 10% (i.e. in 3%) of all cases (dangerous position) as it may be injured during
the low approach

50
Q

High approach in Approaches of TREATMENT of Femoral Hernia

A
  • Alternative names
  • Operative details
  • Advantages
  • Disadvantages
51
Q

Alternative names for High approach in Approaches of TREATMENT of Femoral Hernia

A
  • Inguinal approach

* Lotheissen’s approach

52
Q

Operative details of High approach in Approaches of TREATMENT of Femoral Hernia

A
  • Incision

* Steps

53
Q

Incision in Operative details of High approach in Approaches of TREATMENT of Femoral Hernia

A
  • similar to that of inguinal hernia

* 1 inch above & parallel to the medial 2/3 of the inguinal ligament

54
Q

Steps in Operative details of High approach in Approaches of TREATMENT of Femoral Hernia

A
  1. The external oblique aponeurosis is incised & the cord is drawn aside
  2. Incision of Transversalis fascia
  3. Manipulation of the sac
  4. Repair of the defect
55
Q

Incision of Transversalis fascia in Steps in Operative details of High approach in Approaches of TREATMENT of Femoral Hernia

A
  • in the floor of the canal medial to the inferior epigastric vessels
  • Exposing the peritoneum and the neck of the sac.
56
Q

Manipulation of the sac in Steps in Operative details of High approach in Approaches of TREATMENT of Femoral Hernia

A
  1. The sac is opened at the fundus
  2. Contents are reduced
  3. Finally the sac is transfixed.
57
Q

Repair of the defect in Steps in Operative details of High approach in Approaches of TREATMENT of Femoral Hernia

A
  • Done by suturing the conjoint tendon to the pectineal ligament
  • Then suturing the pectineal ligament to the inguinal ligament
  • “C-C & P-P”.
58
Q

Advantages of High approach in Approaches of TREATMENT of Femoral Hernia

A
  • High transfixion of the sac at its neck proper.
  • If the bowel was strangulated, resection can be done from this approach.
  • If the hernia is strangulated or irreducible, the lacunar ligament can be divided under vision and an abnormal obturator artery can be ligated under vision.
  • Associated inguinal hernia can be dealt with
59
Q

Disadvantages of High approach in Approaches of TREATMENT of Femoral Hernia

A

Weakens the inguinal canal.

60
Q

The pre-peritoneal approach in Approaches of TREATMENT of Femoral Hernia

A
  • Alternative name
  • Operative details
  • Advantages
  • Disadvantages
61
Q

Alternative name for The pre-peritoneal approach in Approaches of TREATMENT of Femoral Hernia

A

McEvedy’s approach

62
Q

Operative details of The pre-peritoneal approach in Approaches of TREATMENT of Femoral Hernia

A
  • Incision

* Steps

63
Q

Incision in Operative details of The pre-peritoneal approach in Approaches of TREATMENT of Femoral Hernia

A

A vertical incision is made just over the femoral hernia to a point about 8 cm above the inguinal ligament.

64
Q

Steps in Operative details of The pre-peritoneal approach in Approaches of TREATMENT of Femoral Hernia

A
  1. Reaching to the fascia transversalis
  2. Incision of The fascia transversalis and dissection
  3. Identification of The hernial sac
  4. Herniotomy
  5. Repair of the defect.
65
Q

Reaching to the fascia transversalis in Steps in Operative details of The pre-peritoneal approach in Approaches of TREATMENT of Femoral Hernia

A
  1. Skin is retracted & the anterior rectus sheath is exposed
  2. The sheath is incised 1 cm medial to the lower 1/4 of linea semilunaris.
  3. The rectus muscle is retracted medially exposing fascia transversalis
66
Q

Incision of The fascia transversalis in Steps in Operative details of The pre-peritoneal approach in Approaches of TREATMENT of Femoral Hernia

A

The fascia transversalis is incised and dissection is carried down between the fascia transversalis infront & the peritoneum behind.

67
Q

Identification of The hernial sac in Steps in Operative details of The pre-peritoneal approach in Approaches of TREATMENT of Femoral Hernia

A

Identified as a funnel shaped protrusion of the peritoneum entering the femoral canal.

68
Q

Herniotomy in Steps in Operative details of The pre-peritoneal approach in Approaches of TREATMENT of Femoral Hernia

A
  1. The sac is opened at the fundus
  2. Contents are reduced
  3. Finally the sac is transfixed.
69
Q

Repair of the defect in Steps in Operative details of The pre-peritoneal approach in Approaches of TREATMENT of Femoral Hernia

A
  • Done by suturing the conjoint tendon to the pectineal ligament
  • Then suturing the pectineal ligament to the inguinal ligament
  • “C-C & P-P”.
70
Q

Advantages of The pre-peritoneal approach in Approaches of TREATMENT of Femoral Hernia

A
  • Avoids opening of the inguinal canal.
  • High transfixion of the sac at its neck proper.
  • If the bowel was strangulated, resection can be done from this approach.
  • If the hernia is strangulated or irreducible, the lacunar ligament can be divided under vision and an abnormal obturator artery can be ligated under
    vision.
71
Q

Disadvantages of The pre-peritoneal approach in Approaches of TREATMENT of Femoral Hernia

A

Retraction of the rectus muscle medially carries the risk of injury of its nerve supply leading to incisional hernia

72
Q

Nyhus classification of groin hernia

A
  • Type 1
  • Type 2
  • Type 3a
  • Type 3b
  • Type 3c
  • Type 4
73
Q

Type 1 in Nyhus classification of groin hernia

A

Indirect hernia without dilatation of the internal ring

74
Q

Type 2 in Nyhus classification of groin hernia

A

Indirect hernia with dilated internal ring

75
Q

Type 3a in Nyhus classification of groin hernia

A

Direct hernia with posterior wall defect

76
Q

Type 3b in Nyhus classification of groin hernia

A

Indirect hernia with posterior wall defect (combined hemia)

77
Q

Type 3c in Nyhus classification of groin hernia

A

Femoral hernia

78
Q

Type 4 in Nyhus classification of groin hernia

A

Recurrent hernia

Surgery.(General 1).Hernia (13 decks)

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