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Femoral Hernia

1. ANATOMY

  • The femoral canal is an anatomical compartment located in the anterior thigh within the femoral triangle
Femoral triangle  
  • Borders
    • Superior – inguinal ligament
    • Lateral – medial border of the sartorius
    • Medial – medial border of the adductor longus
  • Contents (from lateral to medial)
    • Femoral nerve, femoral artery, femoral vein, femoral canal
  • The femoral artery, vein and canal are contained within a fascial compartment called the femoral sheath
    • The femoral sheath has three compartments, with the femoral canal located in the medial compartment
Femoral canal
  • Borders
    • Anterior – inguinal ligament
    • Posterior – pectineal/Cooper’s ligament
    • Medial – lacunar ligament
    • Lateral – femoral vein
  • Contents – Lymph node of Cloquet, lymphatic vessles, loose areolar tissue
  • The entrance to the femoral canal is via the femoral ring

2. FEMORAL HERNIA

Etiology

  • Wide femoral canal
  • Most common in females with multiple pregnancies

Pathology in femoral hernia

  • Through the femoral ring, the hernial sac descends through the femoral canal vertically to saphenous opening and then escapes out into the loose areolar tissue to expand out
  • Because of its irregular pathway and narrow neck it is more prone for obstruction and strangulation
  • During surgery precaution should be taken about the femoral vein and pubic branch of obturator artery

Clinical features

  • Swelling in groin below and lateral to pubic tubercle
    • Inguinal hernia is above and medial to the pubic tubercle
  • Swelling, impulse on coughing, reducibility, dragging pain
  • When obstruction and strangulation occur it presents with features of intestinal obstruction
    • Painful, tender, inflamed, irreducible swelling
    • Abdominal distension, vomiting, features of toxicity

Types of femoral hernia

  • Hydrocele of femoral hernia – when adherent omentum secretes fluid into the sac
  • Laugier’s hernia – herniation through a gap in the lacunar ligament; it is always strangulated
  • Narath’s hernia – in congenital dislocation of the hip, femoral hernia occurs behind the femoral artery
  • Hesselbach’s hernia – hernia occurs lateral to the femoral artery
  • Cloquet’s hernia – sac lies under the pectineal fascia
  • Cooper’s hernia – a femoral hernia with two sacs

Treatment

  • Lockwood-low approach – incision is below the inguinal ligament, directly on the sac (for elective repair)
  • McEvedy-high operation – incision is made over the femoral canal extending vertically above the inguinal ligament (preferred in an emergency setting when strangulation is suspected)
  • Lotheissen’s operation – incision through the inguinal canal
  • Inguinal approach – when concomitant inguinal hernia needs repairing.
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