Plate 217

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

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.

(See Plate 207.)

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.

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

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 (Plate 207). 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 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 until the hernial sac is exposed as it appears in the femoral canal beneath Poupart's ligament (Figure 5). Following this procedure, it is frequently possible to withdraw the hernial sac from the femoral canal, converting the femoral hernia to a diverticular type of direct hernia (Figure 6).

If the contents of the hernial sac appear to be reduced so that it can be opened without possible injury to incarcerated bowel, the sac is opened (Figure 7). A purse-string suture, which should include transversalis fascia as well as peritoneum, is placed at the junction of the sac and the peritoneal cavity so that when it is tied, no residual peritoneal pouch remains (Figures 8 and 9). Great care is taken that the suture closing the neck of the sac does not include intestine or omentum.

There are several methods of preventing recurrence of the hernia. The transversalis fascia and the aponeurotic margin of the transverse abdominal muscle may be approximated from the spine of the pubis upward along Cooper's ligament (Figure 10), as in the repair of a direct inguinal hernia by the McVay technique (Plate 212). It is essential to have adequate exposure of the iliac vessels such that they are not injured when these interrupted sutures (Figures 11 and 12) are placed. Several sutures are taken in Cooper's ligament and the lacunar ligament on the inferior edge of Poupart's ligament in order to close the femoral canal (Figure 11). The iliac vessels should not be constricted as the transition suture is placed near the medial wall of the femoral vein. The repair then proceeds laterally in the McVay manner, with interrupted sutures securing the conjoint tendon (internal oblique muscle) to the shelving edge of the inguinal ligament (Figure 12). The round ligament in the female or the cord in the male is returned to normal position or transplanted as in other types of hernia repair. The external oblique is closed without constriction about the cord or round ligament, followed by the usual approximation of the subcutaneous tissue and skin. A continuous subcutaneous absorbable suture is used to approximate the skin. Adhesive strips and a dry sterile dressing are then applied.

It is wise to keep the thigh slightly flexed during the immediate postoperative period. The patient is encouraged to ambulate as soon as possible. Heavy manual labor, especially such as which greatly increases intra-abdominal tension, should be avoided for about 1 month.