Femoral Hernia Femoral Canal It occupies the most

Femoral Hernia

Femoral Canal: • It occupies the most medial compartment of the femoral sheath, which is formed by the fascia transversalis anteriorly, and the fascia iliaca posteriorly, and is divided into 3 compartments by 2 perpendicular septa 1. The most medial compartment contains the femoral canal, which allows expansion of the femoral vein during increased venous return as in muscular exercise 2. The intermediate compartment contains the femoral vein 3. The most lateral compartment contains the femoral artery& femoral branch of genito-femoral nerve • The femoral canal is cone-shaped with the base directed upwards • It measures about 1. 25 cm & extends from the femoral ring to the saphenous opening

Femoral Ring: It contains fat, lymphatics & LN of Cloquet. It is covered by the femoral septum & has the following relations: • Medially. . . Lacunar ligament (Giembernat’s Ligament) which is the most medial part of the inguinal ligament (Poupart's Ligament) • Laterally ………. Femoral vein • Superiorly ………. . . Inguinal ligament • Inferiorly …………Cooper's Ligament (Pectineal reflection of the inguinal ligament). It is a thickened band running across the pectineal line of the pubis, incorporated in its periosteum (= Astely Cooper’s Iigament = ilio-ilioinguinal or pectineal ligament)

Pathology • Sac: The hernia passes downwards through the femoral ring & femoral canal till its lower end, then passes forwards pushing the cribriform fascia & then upwards towards the inguinal ligament. The neck of the sac is narrow which increases the risk of irreducibility & strangulation • Contents: Omentum, intestine. . . etc. Richter's hernia is common. Sliding hernia (UB) may occur • Coverings: Stretched femoral septum & transversalis fascia, cribriform fascia, SC & skin

Rare types of femoral hernia Type 1. Pre-vascular Hernia (Narath's Hernia): Description • It passes in front of the femoral artery. • It has a wide sac neck. Strangulation is. . . rare. • It is easy to reduce but difficult to repair. • May be associated with congenital hip dislocation. 2. Pectineal hernia (Cloquet hernia) It passes behind the femoral vessels, between the pectincal muscle & its fascia.

Rare types of femoral hernia Type 3. External Femoral Hernia (Hasselbach's Hernia): 4. Lacunar Hernia (Lagier's Hernia): Description It passes lateral to the femoral artery It passes through the Lacunar ligament of Gimbernat

Clinical picture Sex: It occurs in females> males (2: 1). Why? ? 1. The pelvis is wider (wider pubic ramus & wider femoral ring) 2. The femoral canal (& ring) is wider 3. The downward pelvic tilt in females allows easier descent of the hernia 4. Muscles (ileopsoas & pectineus) & ligaments are weaker. They normally encroach on the canal & thus act as a barrier against the development of femoral hernia

Complaints: A young adult patient (around 25 years) complaining of a lump in the groin, which may cause dragging pain. It may present with strangulation (for the first time) Clinical Examination: A lump in the groin, below & lateral to the pubic tubercle. It is reduced by pushing it downwards, backwards & then upwards. About 20% are bilateral

Differences between femoral hernia& inguinal hernia Femoral hernia Inguinal hernia 1. It is commoner in females 1. It is commoner in males 2. Lateral to the pubic tubercle and below the inguinal ligament 2. Medial to the pubic tubercle and above the inguinal ligament 3. The inguinal canal will be obviously empty 3. The inguinal canal will be occupied by the hernia 4. After reduction, closure of the femoral ring will prevent the hernia from coming down 4. The inguinal hernia will come down when the patient coughs 5. Deep ring test negative (hernia 5. Deep ring test positive will descend) 6. Irreducibility is more Likely 6. Irreducibility is less likely

Complications: Like any other hernia, but more commonly: 1. Irreducibility (10 time > inguinal hernia) due to narrow neck, tortuous course & adhesions with the sac 2. Strangulation due to sharp edge of the Lacunar ligament, narrow opening in the fascia transversalis, and upper sharp margin of the fossa ovalis

Treatment Low Operation (Lockwood Operation): • Incision: overlying the swelling (1 cm below & parallel to the inguinal ligament) • Steps: The sac is dissected, transfixed & excised after reduction of the contents. The femoral canal is closed (repair) by suturing the pectineal ligament to the inguinal ligament (Cooper's to Poupart's ligament) • Disadvantages: I. The sac cannot be completely excised & repair is difficult 2. Liability to injure an abnormal obturator artery (pubic branch of inferior epigastric artery) 3. If it is accompanied by an inguinal hernia, it will be very difficult or impossible to deal with it

High Operations: A. Inguinal Approach (First performed by Annandale in 1876, but named after Lotheissen): • Incision: As in inguinal hernia, but a little lower, in one of the creases • Steps: Scarpa's fascia & EOA are opened. The cord is elevated & the fascia transversalis is opened medial to the inferior epigastric artery (l. EA). The peritoneal sac is identified & isolated. It is pulled upwards into the inguinal canal, opened, transfixed after reduction of its contents & excised • Repair: Cooper's ligament to Poupart's ligament + Poupart's ligament to Conjoint tendon • Disadvantages: It weakens the inguinal canal

B. Mc. Evedy's Approach (1950): • Incision: vertical, made over the femoral canal & continued upwards above the inguinal ligament, at the lateral border of the rectus muscle. It is useful for dealing with irreducible & strangulated hernias • Steps: The anterior rectus sheath in its lower part is incised 2 cm medial to the linea semilunaris, and the rectus muscle is displaced towards the midline. The fascia transversalis is divided to expose the peritoneum, the hernial sac is identified & pulled up to be ligated & excised • Repair : is done by one of the previous methods • Disadvantages: if infected, or if nerves to the rectus muscle are cut, it results in an incisional hernia

C. Posterior (Pre-Peritoneal Approach) (Nyhus Operation): • Incision: horizontal & short, 3 fingers above the pubic tubercle • Steps: Dissection is proceeded down to the preperitoneal region. The hernia is reduced & the femoral canal is closed by suturing the iliopubic tract to Cooper's ligament • Advantages: (1) Direct exposure without opening & weakening the inguinal canal, (2) dissection through normal tissues in recurrent hernia instead of scar tissue, and (3) a sliding hernia can be handled directly