Femoral hernia repair Flashcards

(10 cards)

1
Q

What are the principles of femoral hernia repair?

A

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

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2
Q

How do you repair femoral hernias electively, acutely, and in the context of a concurrent inguinal hernia?

A

Elective, small hernia → Low Approach (Lockwood)

Concurrent Inguinal & femoral hernia → High Approach (Lothiesen - Transinguinal approach

Emergency, incarcerated hernia → High Approach (McEvedy’s)

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3
Q

How do you prepare your patient preoperatively, and position them?

A

For emergency, obstructed hernia NBM, fluid resusication, NGT +- Ivabx

GA. Supine.

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4
Q

Describe your incision and exposure for a low approach

A

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

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5
Q

Describe your incision and approach for a transinguinal femoral hernia repair

A

Trans-inguinal Approach

Similar incision to inguinal hernia

Incise the transversalis fascia

Reduce sac pre-peritoneal plane

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6
Q

Describe your incision and approach for a McEvedy repair

A

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.

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7
Q

How do you open the sac of a femoral hernia? What might you encounter at this point?

A

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

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8
Q

How do you repair a femoral hernia defect?

A

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

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9
Q

What is a dangerous subtype of femoral hernia and how do you deal with this?

A

Prevascular femoral hernia

Extends laterally in front of vessels

Identify early

Preserve vessels

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10
Q

What are four manouvres to try if you are unable to reduce a femoral hernia?

A

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

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