Notes on Femoral Hernia Operation

Femoral hernia: It is an abnormal protrusion of viscus through a weak spot in femoral canal. I have compiled few operative techniques regarding this technique.

Things to remember:

• Inguinal to femoral ratio is 18:1, and female to male ratio for femoral hernia is 3.9-1. 
• There is high risk of strangulation in femoral hernia. 
• Boundaries of femoral canal are inguinal ligament anteriorly, lacunar ligament medially, pectineal ligament posteriorly and iliopsoas with its fascia medially. 
• Femoral vein may get compressed laterally and it may be distended in case of femoral hernia. 
• Most common operation performed is Crural operation.

Can you tell which type of hernia each one is?

Crural operation for femoral hernia:

• Incision is 2cm below inguinal ligament directly over the hernia, 6 cm long and oblique parallel to inguinal ligament, continue dividing till the sac is reached, achieve haemostasis, mobilize the sac by wiping the fascial layers off it using gauze swab.
• Neck of sac is cleared medially and anteriorly first from lacunar and inguinal ligament followed by lifting the sac and clearing it from posteriorly placed pectineal ligament. 
• Now palpate the femoral artery and the vein will be between the sac and the artery, use the curved on flat scissors and clear the neck of sac from the femoral vein.
• Open the sac only from the lateral side as the medial side may contain the urinary bladder in it. 
• While the opening the sac first the extraperitoneal covering is encountered and then the sac is encountered. Once sac is opened the contents are examined and reduced if viable. 
• However if the contents are not viable then suck all fluid, send some for microbiology, release the neck of sac by diving the fat and place the contents in warm saline packs for minutes and then examine if viable return if not than prolapsed in the wound and resect and anastomose OR resect in the wound and then do anastomosis from the paramedian incision.
• Place transfixion suture at neck and cut redundant sac and then perform figure of eight repair.
• Fist suture is passed from inside out from pectineal ligament retracting femoral vein laterally at a place where femoral vein is than from the same length take a bit from outside in from inguinal ligament and then from mid of first bit and its attachment pass another suture from pectineal ligament and than from same midpoint from inguinal ligament and then tie knot between two loops. 
• Place a flap of fascia of pectineus muscle over the repair to deal with the risks of in tension first stage repair.
• Close via standard technique.

Inguinal operation:

• Not preferable as inguinal anatomy is distorted. 
• Time consuming as well very technical. 
• Reach the extraperitoneal fat via the same approach as Shouldice by cutting the transversalis fascia. 
• Sac is identified and it is delivered either above or below the inguinal ligament and then contents examined and dealt with and sac transfixed and closed and same figure of eight repair done and then transversalis fascia is closed and it is reinforced on the repair as well. 
• Followed by reminder of Shouldice operation.

Extraperitoneal Operation:

• Developed by Mcevedy and Henry. 
• Not for beginner. 
• In this Operation the Bladder is emptied and suprapubic midline vertical incision is given. 
• The aponeurotic layer is opened and peritoneum is exposed, recti are retracted on either side and space between the peritoneum and abdominal wall muscles is opened by blunt dissection in order to approach femoral canal bilaterally and repair is done after dealing with the sac and then closure is done.