Femoral Hernia Repair

Published on 16/04/2015 by admin

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Last modified 22/04/2025

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Chapter 30

Femoral Hernia Repair

Introduction

A femoral hernia is a type of groin hernia in which the hernia sac is located below the inguinal ligament. It can often be difficult to differentiate between femoral and inguinal hernias clinically, and thus the surgeon sometimes cannot distinguish between them preoperatively. Femoral hernias are much more common in women than in men (4 : 1) but are still less common than other types of inguinal hernias; they constitute only one third of all groin hernias in women and about 2% in men. Compared with inguinal hernias, femoral hernias are much more likely to become incarcerated or strangulated because of its anatomic location and rigid boundaries. For this reason, elective repair of femoral hernias is highly recommended to avoid the complications associated with incarceration or strangulation.

Clinical Presentation

The femoral hernia often is seen as an asymptomatic bulge inferior to the inguinal ligament, and as it enlarges, the sac can extend onto the thigh (Fig. 30-1, B). The hernia may or may not be reducible, and patients often report a sensation of fullness. Patients who have incarceration or strangulation often report significant pain, and they may also have evidence of a small bowel obstruction.

Open Surgical Repair

If a patient has signs of incarceration or strangulation, urgent repair is warranted. If the diagnosis of a femoral hernia is confirmed preoperatively, the incision can be placed below the inguinal ligament on the upper thigh. If the etiology of the hernia is uncertain, a standard inguinal hernia incision can be made, with plans to divide the transversalis fascia to expose the femoral space. The dissection can be completed from above the inguinal ligament or below (Fig. 30-2).

If the hernia sac cannot be reduced, the lacunar (Gimbernat’s) ligament can be divided. In rare circumstances in which the contents still cannot be reduced, the inguinal ligament can be transected. The hernia sac can be reduced through the femoral defect to transition it into an inguinal defect. If the hernia sac is opened during reduction of the hernia contents, it can be ligated at this time.

The defect can be repaired by a number of methods. The simplest repair involves suturing the inguinal ligament anteriorly to Cooper’s (pectineal) ligament posteriorly, with a permanent monofilament suture to close the defect. Care should be taken to avoid injuring or narrowing the femoral vein because it is the lateral border of the repair.

As an alternative, the transversalis fascia can be affixed to Cooper’s ligament medially and the iliopubic tract laterally.

Another method of open repair involves the use of mesh reinforcement. Recent studies comparing open mesh repairs with open nonmesh repairs showed a similar rate of postoperative complications. However, fewer hernia recurrences were reported in patients who underwent mesh repair.

Laparoscopic Surgical Repair

The laparoscopic repair of a femoral hernia is performed in the same manner as that of a standard inguinal hernia (see Chapter 28). Studies have reported both a transabdominal preperitoneal (TAPP) and a total extraperitoneal (TEP) approach for femoral hernia repair. For TAPP repair, traditionally three ports are used. Initial access is obtained at the umbilicus, and the additional working ports are placed to the right and left of midline at the level of the umbilicus. Initial examination reveals the defect near the femoral canal (Fig. 30-3).

The surgeon begins the procedure by taking down the peritoneum from the lateral abdominal wall to the midline. The femoral hernia can then be identified in the femoral triangle, and the hernia sac reduced into the abdominal cavity to expose the borders of the defect. For repair of the defect, a 12 × 15–cm piece of synthetic mesh is introduced into the abdomen through one of the laparoscopic ports. The mesh is laid in place overlying the defect, and is usually secured with tacks or fibrin glue. To complete the surgery, the created peritoneal defect is closed with titanium staples.

For TEP repair, the surgeon begins by making a 2-cm incision inferior and slightly lateral to the umbilicus. The rectus muscle is retracted laterally to allow visualization of the posterior rectus sheath. Using an S retractor or a finger, the surgeon develops the preperitoneal plane. A dissecting balloon is then passed into the space and insufflated under direct laparoscopic visualization. The dissecting balloon is then removed, and a port with a small stay balloon is inserted. Two 5-mm working ports are placed in the midline 2 cm and 5 cm superior to the pubic tubercle. The preperitoneal space can be developed with the assistance of a laparoscopic Kitner dissection. The repair technique is similar to that used for a TAPP repair, with the placement of mesh overlying the defect. However, because the surgery remains extraperitoneal, there is no need to close a peritoneal flap.

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