Strangulated femoral hernia

53 year old female patient presented for severe abdominal pain, associated with nausea and vomiting
diagnosed to have bowel obstruction due to incarcerated inguinal femoral hernia

1. Case presentation Georges Khalifeh PGY IV General Surgery AL ZAHRAA UNIVERSITY HOSPITAL

2. Case presentation 53 y o female patient presented for severe abdominal pain ,associated with nausea and vomiting Pain started 2 days ptp Psh : c section (20 y ago ) Pmh : hypertension

3. Physical exam Distended abdomen Diffuse tenderness Left inguinal bulging mass

4. Wbc 11200 Crp 18.38 Lactate 1.19 Ldh 223

5. Ct scan abdo-pelv + IV contrast

6. Trans inguinal approach In our case we used a trans inguinal approach for femoral canal Dissection of sac Reduction/inspection of contents Ischemic omentum identified bowel not found ligation of sac and approximation of inguinal and pectineal ligaments.

7. Midline incision Exploration of peritoneal cavity Running of bowel Identification of constricting ring, anti-mesenteric border No sign of ischemia No need for resection

8. Richter’s hernia A.G. Richter described in 1777 a hernia in which the anti-mesenteric part of the small intestine was incarcerated

9. Inguinal hernia special types

10. Richter’s femoral hernia This type of hernia accounts for 10% of all strangulated hernias . The most common : femoral ring  (36–88 %) inguinal ring (12–36 %) abdominal wall  (4–25 %).  

11. Richter’s femoral hernia The incidence of Richter's hernia has recently increased because of the widespread use of laparoscopic techniques. The growing popularity of  laparoscopic surgery  has resulted in Richter's hernias developing at the trocar site. Trocar site herniation following a laparoscopic procedure has been reported to occur at a rate of 0.2–3%; however, the actual incidence may be higher

12. Decision-making and management strategies Many times, the strangulated hernia is wrongly diagnosed pre-op The correct diagnosis often made only at the time of operation The decision as to which approach is to be adopted depends upon the viability of the bowel.

13. Management strategies Permits resection and anastomosis of bowel A llows repair (+/- MESH)without increased risk of infection leading to decreasing recurrence. A voids unnecessary laparotomy to inspect a loop of bowel slipped into the abdomen .

14. Goals of emergent repair of a strangulated hernia Unlike elective repair of a reducible hernia where in the primary goal is long-lasting closure and prevention of hernia recurrence The goals of emergent repair of a strangulated hernia may be to alleviate bowel obstruction, debride devitalized tissue, and/or mitigate the risk of abdominal catastrophe . Repair must often be accompanied by examination of, and sometimes resection of, bowel or omentum .

15. Surgical incision The type of surgical  incision  varies according to the location of Richter's hernia . This approach affords the surgeon excellent access to repair the hernia defect and to inspect the bowel through one incision .

16. Classical approaches Strangulated inguinal hernia can be managed in a routine fashion . Three Classical approaches are described for an open repair of femoral hernia Low ( Lockwood’s) inguinal ( Lotheissen’s ) ( 1878) high ( Mc Evedy’s ) (1950)

17. Disadvantage of inguinal approach This approach offers little scope for resection and anastomosis of gangrenous bowel P osterior wall of the inguinal canal is disrupted, which has to be repaired. In view of the contamination with the gangrenous bowel, a mesh repair is not possible. R ecurrence rate is high (weakens the abdominal musculature) False recurrence in the form of a direct hernia

18. If the bowel was found to be gangrenous and requires resection and anastomosis

19. If the bowel was found to be gangrenous and requires resection and anastomosis inguinal incision can be extended laterally little beyond the Mc Burney’s point. The extension of incision was done by dividing only skin and external oblique . The internal oblique and transversus abdominis are split open as that of gridiron incison (Second Window)

20. The Thomas Repair of the strangulated femoral hernia -one skin incision for all

21. INCISION IN RECTUS SHEATH

22. EXTENSION FOR LAPROTOMY

23. SURGICAL APPROACHES—LAPAROSCOPY

24. SURGICAL APPROACHES—LAPAROSCOPY One systematic review including 7 articles published between 1996 and 2007 reported on the use of laparoscopy for the management of incarcerated and strangulated inguinal hernia . Most incarcerated and strangulated hernias were reduced using a combination of manual and laparoscopic manipulation under general anesthesia

25. 328 patients 6 conversions to an open procedure 34 complications (mostly minor) 17 bowel resections

26. Conversion to open The reasons for conversion iatrogenic bowel injury need for omentectomy bowel distention making visualization difficult dense intraperitoneal adhesions

27. Complications Complications related to a laparoscopic approach : left colon injury during Veress needle insufflation 3 intraperitoneal mesh infections (2 of which required reoperation)

28. Mesh infection A recent study of patients undergoing laparoscopic bowel resection and concomitant repair of acutely incarcerated inguinal hernia showed a low rate of mesh infection when the mesh was placed in the preperitoneal space .

29. Benefits of laparoscopy A bility to detect and simultaneously repair a contralateral patent processus vaginalis or hernia . In addition, the ability to identify and manage intra-peritoneal contents reduced from the hernia sac may be improved with laparoscopy.

30. Recommendation laparoscopic approach to incarcerated and strangulated inguinal hernia is feasible , facilitates bowel resection as needed, and exhibits an overall morbidity similar to an open approach Deeba S, Purkayastha S, Paraskevas P, et al. Laparoscopic approach to incarcerated and strangulated inguinal hernia. JSLS 2009;13:327–31 Poelman MM, van den Heuvel B, Deelder JD, et al. EAES Consensus Development Conference on endoscopic repair of groin hernias. Surg Endosc 2013;27:3505–19

31. Recommendation In the case of strangulated inguinal hernia, diagnostic laparoscopy is preferred to open exploration spontaneously reduced inguinal hernia via hernia sac laparoscopy: preliminary results of Sgourakis G, Radtke A, Sotiropoulos G, et al. Assessment of strangulated content of the a prospective randomized study. Surg Laparosc Endosc Percutan Tech 2009;19:133–7 . Poelman MM, van den Heuvel B, Deelder JD, et al. EAES Consensus Development Conference on endoscopic repair of groin hernias. Surg Endosc 2013;27:3505–19

32. Recommendation The use of synthetic mesh in the pre-peritoneal space is possible with a relatively low risk of morbidity in clean contaminated situations such as bowel resection Atila K, Guler S, Inal A, et al. Prosthetic repair of acutely incarcerated groin hernias: a prospective clinical observational cohort study. Langenbecks Arch Surg 2010;395:563–8.

33. Take home message Do not give muscle relaxant during induction

34. Take home message Manual reduction attempts should be avoided prior to directly inspecting and evaluating the viability of the  intestine . Early operative intervention is central to the successful management of Richter's hernia.

35. What if ,we combined 2 types of surgery laparoscopic + open L aparoscopic approach for exploration ,resection of bowel if needed (preserving peritoneum intact )+ open inguinal repair +/- Mesh

36. What if ,we combined 2 types of surgery USING SAME INSICION Open inguinal repair Same strategy Sac identified, strangulated omentum , Bowel not found LAPAROSCOPIC TRANSINGUINAL TRANSABDOMINAL RETRIAVIAL OF AFFECTED BOWEL Trocar inserted into hernia sac , insuflation of abdomen

37. Thank you