---fsdffemoral-hernia4627-160120091851.ppt

hernia

1. Femoral HerniaFemoral Hernia
Raymond G Buick FRCS

2. Femoral Hernia
A femoral hernia is the protrusion of a viscus
from the abdominal or pelvic cavity, through
the femoral ring into the femoral canal.
The (peritoneal) hernia sac may contain pre-
peritoneal fat, omentum, small bowel, or
other structures.

3. femoral Triangle
RightRight
laterallateral
femoral canal
medialmedial
anteriorlyanteriorly: inguinal ligament
mediallymedially: lacunar ligament (part
of the inguinal ligament)
posteriorlyposteriorly: pectineal line on the
superior ramus of the pubis
laterallylaterally: femoral vein.
femoral ring

4. incidence
•uncommon
•F>M
•more common in parous
•> 65 years
•3% of all hernias
•7% of groin hernia
•nearly 5000 / year in UK

5. presenting symptoms
•Only 50% of patients are aware of
the hernia before strangulation.
•Around 60% present in the
emergency situation
•49% were emergency repairs and
48% waiting list repairs.
non-acute non-acute acute - emergency acute - emergency

6. presenting symptoms
50%
non-acute non-acute acute - emergency acute - emergency
50%

7. presenting symptoms
non-acute non-acute
•pain or discomfort in groin
•groin lump
•mild pain exacerbated by bending or
lifting
•small lump (may be no lump)
•mild tenderness
•usually not reducible

8. presenting symptoms
obstruction
•vomiting
•colicky abdominal pain
•abdominal distension
•constipation
•blood in stools
•lump irreducible
•lump tender
acute - emergency acute - emergency

9. presenting symptoms
obstruction
•vomiting
•colicky abdominal pain
•abdominal distension
•constipation
•blood in stools
•lump irreducible
•lump tender
acute - emergency acute - emergency
strangulation
•lump very tender
•skin red / inflamed
•signs of shock

10. difficulties with diagnosis
•1/3of patients do not complain of
symptoms directly attributable to a
hernia
•a groin lump is not always present.
•obese
•elderly - other diagnoses

11. differential diagnosis
•osteoarthritis
•gastroenteritis
•diverticulitis
•constipation
•inguinal lymph node
•lymphoma
•lymphogranuloma venerium
•femoral artery aneurysm
•saphena varix
•psoas abscess
•psoas bursa
•ectopic testis
•lipoma

12. differential diagnosis
inguinal herniainguinal hernia

13. differential diagnosis
inguinal herniainguinal hernia
ABOVE and MEDIALABOVE and MEDIAL
to pubic tubercleto pubic tubercle
femoral herniafemoral hernia
BELOW and LATERAL BELOW and LATERAL
to pubic tubercleto pubic tubercle
pubic tuberclepubic tubercle
femoral –v- inguinal femoral –v- inguinal
herniahernia

14. FEMORAL INGUINAL
Sex Female male
Age Elderly > 65 years Younger - all ages
children rare common
Males 1 20
Females 1 5
Cough impulse Often absent Usually present
Reducibility Usually not Often is
Shape Globular Pear shaped
Elective Presentation (of
groin hernia) in Male
1%
Elective Presentation (of
groin hernia) in Female
20%
Present persistent intermittent
Strangulation @ 3 mths22% 3%
Strangulation @21 mths45% 4.5%

15. investigations
•clinical examination
–experienced clinician can usually distinguish
between Femoral and Inguinal hernia
•always examine the groin in patients
–with intestinal obstruction
–with abdominal pain

16. investigations
•clinical examination
•ultrasound
•MRI
•CT

17. treatment
•Surgical Repair
•Open Surgery or Laparoscopic Surgery
•General Anaesthetic
•Local Anaesthetic and/or Regional Anaesthetic

18. treatment
•Surgical Repair
–Dissection of the sac
–Inspection / reduction of the contents
–Ligation of the sac
–Closure of Femoral Ring
•Approximation of the inguinal and pectineal ligaments
•Mesh patch

19. Surgical Repair
•Open Surgery
•Classically 3 approaches:-
–Lockwood’s infra-inguinal approach
–Lotheissen‘s trans-inguinal approach
–McEvedy’s high approach
–ischaemic bowel – high approach

20. treatment
•Surgical Repair
•Open Surgery or Laparoscopic Surgery
–bladder may be involved in medial part of hernia
sac
–Repair suturing the inguinal ligament to the
pectineal ligament non-absorbable sutures
–avoid any pressure on the femoral vein

21. treatment
Local Anaesthetic
•The iliohypogastric and ilioinguinal nerves (T12 and L1)
supply the lower abdomen. They are blocked by an
injection of local anaesthetic between internal and
external oblique muscles just medial to the anterior
superior iliac spine.
•The genitofemoral nerve (L1,2) supplies inguinal cord
structures and the anterior scrotum via its genital
branch and supplies the skin and subcutaneous tissues
of the femoral triangle via the femoral branch.

22. treatment
LA or Regional Anaesthetic -Advantages
•With a careful technique, local anaesthesia causes minimal
physiological disturbance
•patients with cardiovascular or respiratory disease
•The absence of postoperative sedation or drowsiness allows
early ambulation and diminishes the requirement for recovery
facilities.
•provides postoperative analgesia for up to four hours
•When adrenaline is mixed with the local anaesthetic (normally
in a dilution of 1:200,000) useful vasoconstriction is produced
resulting in a relatively bloodless field.

23. treatment
LA or Regional Anaesthetic –Disadvantages
•must be carried out gently.
•Although pain sensation is usually blocked by the anaesthetic,
traction on certain tissues, particularly the peritoneum, is
uncomfortable.
•Larger hernias, particularly those with incarcerated bowel may
prove unsuitable for local anaesthesia.
•Some sedation during the operation may be required for
anxious patients which loses some of the benefits of avoiding
general anaesthesia. Patients who are excessively nervous may
be unsuitable for surgery under local anaesthesia.

24. treatment
•pre-operative consent - risks/complications
•Wound haematoma
•Wound infection
•when using ‘mesh’ antibiotics are usually given during the operation
•lymph (fluid) may collect under the wound and need to be drained off.
•Nerve damage - several nerves cross the operative field in hernia surgery.
•Some patients develop chronic pain after hernia surgery, probably due to
the pressure from the mesh on the nerves (occurs in about 2% of hernia
repairs).
•Recurrence of the hernia - fortunately recurrence after hernia repair
should be rare (1-5%).

25. treatment
presenting as an emergency
•increased morbidity and mortality
•increased rates of bowel resection
•increased complications
•wound infection
•cardiovascular and respiratory complications
•mortality X20 if bowel resection required (cf
elective repair without bowel resection)

26. prognosis
•The mortality for elective hernia repair is:
•0.1% below the age of 60
•0.2% between 60 and 69
•1.6% between 70 and 79
•3.3% over the age of 80
•The risk for emergency repair of a strangulated hernia is
10 times higher and many patients are 80 years or over.
The overall operative mortality for strangulated hernia
is 10%:

27. prognosis
•generally good
•Other co-existing medical conditions influence
outcome
•recurrence rate low

28. EndEnd
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