Femoral hernia repair Flashcards
(10 cards)
What are the principles of femoral hernia repair?
Femoral hernia have a higher rate of presenting with acute incarceration and strangulation. So all femoral hernias should be repaired.
Same principles: dissection of hernia sac, assessment and reduction of hernia contents and repair of femoral canal by reapproximating Inguinal lig. And pectineal lig.
Making sure not to impinge on femoral vein
How do you repair femoral hernias electively, acutely, and in the context of a concurrent inguinal hernia?
Elective, small hernia → Low Approach (Lockwood)
Concurrent Inguinal & femoral hernia → High Approach (Lothiesen - Transinguinal approach
Emergency, incarcerated hernia → High Approach (McEvedy’s)
How do you prepare your patient preoperatively, and position them?
For emergency, obstructed hernia NBM, fluid resusication, NGT +- Ivabx
GA. Supine.
Describe your incision and exposure for a low approach
Low Approach
Infra-inguinal incision
4-5cm incision crease of groin below medial half of ligament
Dissect superficial tissues over hernia
Ligate tributaries to GSV. Expose fat covered hernia sac
Describe your incision and approach for a transinguinal femoral hernia repair
Trans-inguinal Approach
Similar incision to inguinal hernia
Incise the transversalis fascia
Reduce sac pre-peritoneal plane
Describe your incision and approach for a McEvedy repair
Incision 3-4cm above pubic tubercle running obliquely upwards and laterally for 7cm
Divide subcut tissue, expose the lateral boarder of Recus sheath
Verticle incision lower rectus sheath 1-2cm from and parallel to lateral border
Lift lateral edge of sheath, retract rectus muscle medially
Option
Open peritoneum: if concern about strangulated bowel
Don’t open peritoneum: Stay pre-peritoneal plane. Incise thin transversalis fascia from 2.5cm above pubic tubercle.
How do you open the sac of a femoral hernia? What might you encounter at this point?
Dissection of Sac
Open sac between artery forceps
Bladder may be forming medial wall
Sweep away fat within sac to expose neck (deep)
Low approach - direct
High approach - pre-peritoneal reduction
Identify femoral vein and preserve
Empty sac, transfix and ligate neck with 2/0 absorbable suture excising sac 1cm distal to ligature
How do you repair a femoral hernia defect?
Repair of defect
Unite inguinal and pectineal ligaments 1cm laterally without constricting femoral vein
Use curved retractor to lateralise femoral vein
Alternatively plug with mesh
What is a dangerous subtype of femoral hernia and how do you deal with this?
Prevascular femoral hernia
Extends laterally in front of vessels
Identify early
Preserve vessels
What are four manouvres to try if you are unable to reduce a femoral hernia?
Manually reduce externally with preperitoneal tension
Intraperitoneal reduction +- lower mid line laparotomy
Dissect sac to free surrounding tissue with blunt and sharp dissection
Formally divide lacunar ligament, note to avoid aberrant obturator artery present