CHAPTER 109: REPAIR OF FEMORAL HERNIA

INDICATIONS

All femoral hernias should be repaired unless contraindicated by the patient’s condition.

PREOPERATIVE PREPARATION

The preoperative preparation is directed by the patient’s general condition. When the contents of the hernia sac are strangulated, the fluid and electrolyte balance is restored by Ringer’s lactate solution administered intravenously. Antibiotics are instituted if the examination indicates the possibility of nonviability of the bowel and consequent necessity for resection of intestine. Sufficient time is taken to fully resuscitate the patient. Constant gastric suction is instituted. A slowing of the pulse and a good output of urine are signs favorable to early surgical intervention. Uncomplicated femoral hernias may be repaired as ambulatory surgical procedures.

ANESTHESIA

(See Chapter 104)

POSITION

The patient is placed in a supine position with the knees slightly flexed to lessen the tension in the groin. The entire table is tilted slightly with the patient’s head down.

OPERATIVE PREPARATION

The skin is prepared in the routine manner. A sterile transparent plastic drape may be used to cover the operative area.

INCISION AND EXPOSURE

The surgeon should have in mind the relationship of the hernia sac to the deep femoral vessels and Poupart’s ligament (figure 1). The usual incision for inguinal hernia is made just above Poupart’s ligament in the line of skin cleavage (figure 2). The incision above Poupart’s ligament is preferred because it gives the best exposure of the neck of the sac and provides better exposure if bowel resection and anastomosis are necessary. The incision is made and carried down to the external oblique fascia. After the fascia has been dissected free of the subcutaneous fat, retractors are inserted in the wound. The external oblique fascia is divided in the direction of its fibers, as in the incision for inguinal hernia (Chapter 104). The round ligament or spermatic cord is retracted upward along with the margin of the conjoined tendon (figure 3). The peritoneum, covered by transversalis fascia, now bulges in the wound. The neck of the hernia sac is freed from the surrounding tissues.

DETAILS OF PROCEDURE

The operator must now choose one of two procedures. If the sac can be pulled upward through the femoral canal to the surface, it may be unnecessary to open the abdominal cavity until the sac itself is opened. This is facilitated by retracting the neck of the sac upward with forceps, while the operator applies counterpressure below Poupart’s ligament through the hernial mass (figure 4). If the sac cannot be reduced from beneath Poupart’s ligament by this maneuver, it becomes necessary to dissect the subcutaneous tissue from the lower leaf of the external oblique ...