Femoral hernia

Femoral hernia: It's protrusion of viscus or part of viscus through the femoral ring.
Hernia has many serious complications if not managed properly.

1. Mohame d Kh . Elmesery Tanta University Femoral Hernia

2. C O NTENTS Anatomy Definition Incidence Causes Clinical features Diagnosis T reatme n t

3. FEMORAL TRIANGLE

4. INTRODUCTION BOUNDARIES CONTENTS

5. B OU N D ARIES (Base) Inguinal ligament (laterally ) Sartorius medially) Adductor longus Apex Right Thigh

6. R OO F Skin Superficial fascia --Superficial inguinal lymph nodes --Femoral branch of genitofemoral nerve --Branches of ilioinguinal nerve --Branches of femoral vessels --Great saphenous vein. Deep fascia -- Saphenous opening and --Cribriform fascia.

7. Ili a cus Psoas major P ectine u s Adductor longus F L OO R Lateral Medial

8. --Fatty tissue Rosenmuller group of lymph nodes(Deep inguinal) Femoral sheath

9. FEMORAL SHEATH

10. Femoral sheath > Lateral /arterial compartment > middle /venous compartment > medial compartment/ FEMORAL CANAL Walls : Fascia TRANSVERSALIS (Ant) -Fascia ILIACA (Post) compartments

11. Femoral Canal - it’s the medial compartment of femoral sheath - Conical , 1.5 cm long . -Allows the Femoral Vein to expand -Contains lymph vessels, A Lymph node ( CLOQUET ) , fat Femoral Ring

12. Opening of the canal :

13. FEMORAL RING L y m p hat ics Areo l a r tissue

14. Boundaries of femoral ring Anterior: Inguinal ligament Posterior: Ligament of Cooper ( pectineal ligament ) . Medial: Lacunar ligament (Gimbemat's ligament) Lateral: Thin septum which separates the femoral canal from femoral vein (silver fascia).

15. Femoral Hernia - Through femoral ring into Femoral cana l -Females > Males -wider femoral ring -wider pelvis -small size of femoral vessels - repeated pregnancies Right side 2:1

16. . DOWNWARDS BACK W A R D S . . U P W A R D S . DOWNWARDS . FOR W AR D S . • UPWARDS Direction of hernial sac is Typical. Repair of hernia Femoral canal Sap h en o u s opening Superficial vessels course

17. DDx Femoral hernia - Inferior - Lateral Inguinal hernia - Superior - Medial To Pubic Tubercle

18. INGUINAL VS FEMORAL HERNIA INGUINAL FEMORAL Above and medial to the pubic tubercle Below and lateral to the pubic tubercle Above the crease of the groin Below the crease of the groin Can be reduced completely Cannot be reduced completely Cough impulse usually present Many do not have cough impulse

19. CLINICAL FEATURES Right side is more commonly affected swelling below the inguinal lig . , 4cm below and lateral to pubic tubercle Expansile impulse on cough but often not present  due to narrow canal Gaur sign : dilatation of superficial epigastric / circumflex iliac veins due to compression Reduction : …. Strangulation  30-80%

20. INVESTIGATION No specific investigations are required Ultrasound & CT scan Emergency patient , small bowel obstruction usually occurs  plain X-ray

21. TREATMENT 3 classical approach : Low approach ( Lockwood ) below the inguinal ligament Inguinal ( high ) approach ( Lotheissen ) through inguinal canal iii. High approach ( McEvedy ) mainly above the inguinal canal *some cases can be managed laparoscopically

22. High approach of Mc Evedy Transinguinal approach of Lotheissen Low approach of Lockwood

23. TREATMENT 1. Low approach (Lockwood) An incision is made over 1cm below and parallel to the inguinal lig. The sac is opened and the contents are reduced Non-absorbable sutures are placed between inguinal ligament & iliopectineal ligament

24. TREATMENT 2. Inguinal approach (Lotheissen) Transversalis fascia is opened from deep inguinal ring to pubic tubercle. Hernia is reduced by combination of pulling from above and pushing from below. Once reduced, neck of hernia is closed with sutures/ mesh plugs

25. TREATMENT 3. High Approach ( McEvedy ) Horizontal incision is made in lower abdominal centered at lateral edge of rectus muscle. Ant. Rectus sheath is incised and rectus muscle displaced medially. Hernia is reduced and sac is opened for careful inspection of bowel. Femoral defect then is closed with sutures/ mesh

26. TREATMENT 4. Laparoscopic approach TEP and TAPP approach can be used A standard mesh is inserted Ideal for reducible femoral hernias, not in emergency cases nor for irreducible hernia

27. DIFFERENTIAL DIAGNOSIS Direct inguinal hernia Lymph node Saphena varix Lipoma Femoral artery aneurysm Psoas abscess Rupture of adductor longus with haematoma

28. THANK YOU