1. FEMORAL HERNIA & SLIDING HERNIABy
Aneesha Thomas
2002 MBBS

2. 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

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

4. 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. .

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

6. 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

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

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

9. 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

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

11. 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

12. 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

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

14. 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

15. 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

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

17. 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.

18. 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.

19. 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.

20. 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.

21. 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.

22. 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

23. 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.

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

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

26. TREATMENT

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

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

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

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

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

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

33. 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

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

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

36. 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.

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

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

39. SLIDING HERNIA

40. 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.

41. 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.

42. MANAGEMENT
USG
Cross sectional imaging
Diagnosis established during surgery

43. 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

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

45. 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

46. 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.

47. Thank You