FEMORAL HERNIA & SLIDING HERNIA By Aneesha Thomas 2002 MBBS

FEMORAL TRIANGLE BOUNDARIES Superior-Inguinal ligament Medially-Adductor longus Laterally- Sartorius Floor-Iliopsoas&pectineus Roof-Fascia lata, cribriform fascia, subcutaneous tissue&skin Apex-sartorius crosses adductor longus

CONTENTS From lateral to medial Femoral nerve & branches Femoral sheath & Contents Femoral artery & branches Femoral vein & proximal tributaries

FEMORAL SHEATH Funnel shaped fascial tube. Extends 3-4cm inferior to inguinal ligament . Formed by inferior prolongation of Transversalis fascia & ilio-psoas fascia. Encloses proximal parts of femoral vessels & femoral canal. .

COMPARTMENTS Lateral compartment for Femoral artery Intermediate compartment for femoral vein Medial compartment is Femoral canal

FEMORAL CANAL Smallest of the 3 femoral compartments 1.25cm long Base of femoral canal is directed superiorly –Femoral ring Extends distally up to proximal edge of saphenous opening

CONTENTS Loose connective tissue Fat Few lymphatic vessels Deep inguinal lymph node -CLOQUET’S NODE

FEMORAL RING Small proximal opening of femoral canal 1cm wide Closed by extraperitoneal fatty tissue is called FEMORAL SEPTUM

BOUNDARIES Lateral-partition b/w femoral canal & femoral vein. Posteriorly-Superior ramus of pubis & ilio pectineal ligament(Astley –cooper’s ligament) Medially-Lacunar ligament(GIMBERNAT’S LIGAMENT) Anteriorly-Medial part of inguinal ligament

FEMORAL HERNIA DEFINITION Femoral hernia is the protrusion of some portion of viscus or of pre-peritoneal fatty tissue through the femoral canal

INCIDENCE Third most common type of primary hernia More common in females Female to male ratio-4:1. 2%of abdominal wall hernia in men,1\3 in females More common on right side. 20%bilateral High incidence of strangulation

AETIOLOGY Congenital theory no longer holds now. Usually appears after middle age. Natural weakening of tissues & loss of elasticity is the basic cause. Enlarged femoral ring predisposes to the development of acquired hernia. Increased abdominal pressure also contributes More commonly seen in multiparous women

PATHOLOGY Femoral hernias usually enter the femoral Canal at the femoral ring and emerges through the fossa ovalis.

As it emerges from rigid boundaries of femoral canal it dilates to assume a spherical form. Then it pass through fossa ovalis,continue anteriorly,turn upwards

CONTENTS Omentum and small bowel are the most frequent structures Sometimes the sac may be empty. Less commonly colon, bladder,fallopian- tube,ovary,meckels- diverticulum etc Any of the abdominal viscera except liver&pancreas have been reported

CLINICAL MANIFESTATIONS Tend to be small & symptomless. Small reducible lump Dragging pain Strangulation& incarceration Intestinal obstruction

Differential diagnosis Inguinal hernia - neck of the sac above & medial to the pubic tubercle. -femoral hernia lateral & below pubic tubercle. -fundus of femoral hernia- sac may overlie the inguinal lig.

SAPHENA VARIX. -saccular enlargement of the termination of the long saphenous vein. -usually accompanied by other signs of varicose veins. -disappears when the patient lies flat. -In both, there is an impulse on coughing -a venous hum can be heard when a stethescope is applied over a saphena varix.

An enlarged femoral lymph node. If Cloquet’s lymph node alone is affected, it may be impossible to distinguish from a femoral hernia . Lipoma. A femoral aneurysm.

A distended psoas bursa. A psoas abscess fluctuating swelling examination of the spine and X-ray will confirm the diagnosis. A distended psoas bursa. The swelling diminishes when the hip is flexed and osteoarthritis of the hip is present.

FEMORAL RELATED HERNIA Cloquet’s hernia. sac lies under the fascia covering the pectineus muscle. Strangulation is likely. The sac may coexist with the usual type of femoral hernia sac.

Hydrocele of a femoral hernial sac Neck of the sac plugged with omentum or by adhesions. Narath’s femoral hernia in patients with CDH due to lateral displacement of the psoas muscle. lies behind the femoral vessels

Laugier’s femoral hernia This is a hernia through a gap in the lacunar (Gimbernat’s) ligament. The diagnosis is based on unusual medial position of a small femoral hernia sac. nearly always strangulated.

STRANGULATED HERNIA Femoral hernia stangulates frequently. Reason-rigid boundaries of femoral ring. Developes gangrene rapidly.

Richter’s hernia-common in femoral hernia -develop intestinal obstruction. -mimic gastroenteritis. Rx-emergency surgery with resection of all non viable tissue

TREATMENT

TYPES OF OPERATION The low approach (Lockwood) Trans inguinal (Lotheissen) High approach of Mc Evedy Laproscopic repair Plug repair

PRE OPERATIVE PREPARATION pre medication iv infusion urinary catheterisation correct fluid&electrolyte imbalance prophylactic antibiotics

PRINCIPLE OF SURGERY Dissection of sac Inspection of the contents Ligation of the sac Hernia repair

LOW APPROACH Crural approach Advocated for elective repair Simple&easy Disadvantage- less access to strangulated viscus

STEPS OF OPERATION incision-transverse incision over the lump Sac is dissected out Sac is opened Contents inspected

If viable reduce the contents If non viable omentum-is excised Bowel-resection through a lower midline incision

If difficult to reduce make an incision in the lacunar ligament to release its neck Repair with a non absorbable suture approximate the inguinal lig to pectineal ligament

LOTHEISSEN APPROACH Incision-oblique groin incision, above&parallel to inguinal lig. Ext.oblique incised. Inguinal canal opened.

Incise the transversalis fascia. Hernial sac is reduced&repaired. Disadvantage-weaken the inguinal region.

HIGH APPROACH Optimum method for stangulated hernia. Incision- U/Lpfannenstiel. good access to pre-peritoneal space. Hernial sac entering the femoral canal is identified. If sac is small,drawn upwards. if large,fundus opened below. Contents dealt appropriately. Neck of the sac ligated. Hernia repair done.

HENRY’S REPAIR. Pre-peritoneal approach using a lower midline incision. LAPAROSCOPIC REPAIR. Trans abdominal &extraperitoneal approach.

PLUG REPAIR Plug of mesh inserted to femoral canal. Advantage-low rate of recurrence.

SLIDING HERNIA

Definition. -in which viscus forms a portion of the wall of the hernial sac. Slipping of posterior peritoneum on the underlying retroperitoneal structures. Common-sigmoid colon. Rt side-caecum. Others-appendix urinary bladder. fallopian tube. ovary&uterus.

CLINICAL FEATURES Commonly in men. 5/6 on Lt side. Incidence increases with age. Indirect inguinal hernia-most common. Suspect in large complete inguinal hernia.

MANAGEMENT USG Cross sectional imaging Diagnosis established during surgery

TREATMENT AIM- Reduction of viscera into the peritoneal cavity Ligation of hernial sac Repair of floor The hernia sac should be opened on anteromedial border

Another method- Placement of purse string suture &progressive inversion of sliding portion of hernial sac.

SUMMARY Femoral hernia is protrusion of some portion of viscus or preperitoneal fatty tissue through the femoral canal More common in females High chance for strangulation Omentum &small bowel are most frequent content

Contd…. Patient usually doesn’t note until strangulation occurs Inguinal hernia, saphena varix,cloquet lymph node –differential diagnosis Treatment- Low approach Trans inguinal approach High approach.

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