Dr.B.Selvaraj MS;MCh;FICSProfessor of Surgery

Melaka Manipal Medical collegeMelaka Malaysia 75150

GROIN SWELLINGS

FEMORAL HERNIA

Femoral Hernia- Overview

Causes of groin swellings Classical Clinical Vignette of Femoral Hernia Femoral Hernia in detail- one pathology in each

episode Mind map of Femoral Hernia Algorithm to clinch the correct diagnosis Tabular column of differential diagnosis depicting

their characteristic features to differentiate them from Femoral Hernia

Causes of Groin swellings

Inguinal hernia- Indirect & direct Femoral hernia Undescended testis Inguinal lymphadenitis Lipoma of spermatic cord Encysted hydrocele Saphena varix Femoral artery aneurysm Psoas abscess Femoral nerve neuroma

Classical Clinical Vignette

A 65-year-old obese woman presents to the emergency department with nausea and vomiting for the past day. The frequency of vomiting has increased despite the fact that she has not eaten for the past 12 hours.

For the last few months, she has noticed a painful “lump” in her left groin that would protrude upon straining, but would quickly disappear after lying down. She says that the lump appeared a few days ago and has not gone away even after lying down.

She has had no bowel movement and no flatus per rectum for the past 24 hours.

Classical Clinical Vignette

O/E:the patient has a low-grade fever (100.2 °F), blood pressure of 120/80 mmHg, and heart rate of 120/min. She appears ill and uncomfortable with dry mucous membranes.

Her abdomen is non-tender to palpation, but there is a 2 × 2 cm mass in the left groin, below and lateral to pubic tubercle. Her abdomen is mildly distended. Bowel sounds are high pitched- borborygmi+

The overlying skin is slightly erythematous and the mass is irreducible.

Laboratory studies are significant for white blood count of 14.7 × 10 3 (normal 4.1−10.9 × 10 3 /μL).

Femoral Hernia

Femoral Hernia

Herniation of intra-abdominal contents through the femoral canal is called Femoral hernia.

It is the third most common type of hernia after inguinal and incisional hernias.

Women are more affected than men (2:1) and right side is more affected than the left. It is bilateral in 15 to 20 percent cases.

The sac can not pass down into the thigh as the sup fascia of the abdomen (fascia of Scarpa) is attached to the fascia lata of thigh at the lower border of the fossa ovalis.

The shape of the sac thus becomes retort-shaped.

Femoral Hernia- Etiology

Femoral hernia is almost always acquired in nature Pregnancy: Repeated pregnancy causes increased abdominal

pressure which is probably an initiating factor. The maximum incidence is around 30 – 40 yrs.

Wide femoral canal: This is due to narrow insertion of iliopubic tract into the pectineal line of the pubis and may be responsible for a few cases of femoral hernia.

Femoral Hernia- Clinical

Features Presents as a swelling in the groin below and lateral to the pubic tubercle (Inguinal hernia is above and medial to the pubic tubercle).

Swelling, impulse on coughing, reducibility, gurgling sound during reduction, dragging pain, are the usual features.

When obstruction and strangulation occurs which is more common, presents with features of intestinal obstruction—painful, tender, inflamed, irreducible swelling without any impulse.

Gaur’s sign: In femoral hernia, distension of superficial epigastric and/or circumflex iliac veins occurs due to the pressure by the hernial sac.

Femoral Hernia- Clinical

Features

Femoral Hernia- Types

Laugier’s hernia—through lacunar ligament

Serofini’s hernia—occurs behind femoral vessels

Teale’s hernia—in front femoral vessels Callison-Cloquet hernia—through

pectineal fascia Hesselbach’s hernia—occurs lateral to

femoral artery Narath’s hernia—occurs behind

femoral artery, in congenital dislocation of hip

Femoral Hernia Vs Inguinal Hernia

Femoral Hernia-

Treatment

Lockwood-low operation:Here inguinal ligament is sutured to Cooper’s ligament. Fundus of sac is dissected by direct vision and repair is done from below.

Lotheissen’s operation: It is through inguinal canal approach. Transversalis fascia is opened and neck of the sac is identified in the femoral ring. Sac is dissected from above, neck is ligated and repair is done. After herniotomy, conjoined tendon is sutured to iliopectineal ligament by interrupted sutures (2 or 3), using nonabsorbable monofilament sutures.

Femoral Hernia-

Treatment

Mc’Evedy-high operation: A incision is made over the femoral canal extending vertically above the inguinal ligament. Sac is dissected from below, neck from above and repair is done from above. It is done in strangulated femoral hernia.

AK Henry’s approach:Repair of bilateral femoral hernia through lower abdominal incision.

Laparoscopic mesh repair:TEP/TAPP.

A-Inguinal incision (Lotheissen’s approach) B-Low incision (Lockwood

approach)C-Vertical incision (Mcevedy’s

approach)

Femoral Hernia-Complications Of Surgery

Seroma/ Hematoma Urinary retention Wound infection Recurrence Bleeding from aberrant obturator artery Chronic neuralgic pain due to nerve injury or entrapment

Femoral Hernia- Mindmap

Algorithm for Groin Swellings

D/D for Groin Swellings Compare & Contrast; Vertical reading