All femoral hernias should be repaired unless contraindicated by the patient’s condition.
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 isotonic crystalloid solution administered intravenously. Antibiotics are instituted if the examination indicates the possibility of nonviability of the bowel and consequent need 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.
Patients are 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.
The skin is prepared in routine manner. A sterile transparent plastic drape may be used to cover the operative area. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.
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). An 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 into the wound. The external oblique fascia is divided in the direction of its fibers, as in the incision for inguinal hernia (see Chapter 109). 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.
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 hernia mass (FIGURE 4). If the sac cannot be reduced from beneath Poupart’s ligament by this maneuver, it becomes necessary to ...