Plate 218

All femoral hernias should be repaired unless contraindicated by the physical or medical condition of the patient. Incarceration with possible strangulation is a concern, as the femoral opening is small and its boundaries are unyielding. Ultrasound imaging studies may be useful when the diagnosis is difficult.

The preoperative preparation is determined by the general condition of the patient. Uncomplicated femoral hernias may be repaired in an ambulatory surgery setting. Incarcerated femoral hernias without gastrointestinal signs or symptoms should be repaired expeditiously, while symptomatic hernias are treated urgently. Strangulation requires hospitalization and resuscitation of the patient with nasogastric tube decompression, intravenous rehydration, and parenteral antibiotics. Any general medical conditions are evaluated and sufficient time is allowed for volume and electrolyte stabilization. Improved vital signs and a good urine output indicate readiness for surgery.

Deep sedation with infiltration of a local anesthetic as a field block may be used in elective cases, as can spinal or epidural anesthetic techniques. Patients with strangulation and obstruction should have general anesthesia with an endotracheal tube and cuff to lessen the threat of tracheal aspiration.

The patient is placed in a supine position with the knees slightly flexed by a pillow so as to lessen the tension in the groin.

The skin is shaved and prepared in the routine manner. Parenteral antibiotics appropriate for prophylaxis against the usual skin bacteria are given immediately prior to the start of the procedure and in sufficient time to reach therapeutic tissue levels.

It is important that the surgeon understand the regional anatomy of the femoral space. This opening is approximately 1 to 1½ cm in diameter and lies directly lateral to the pubic tubercle but inferior to the inguinal ligament (Figure 1). The fascia overlying the pectineus muscle forms the posterior wall, whereas the lateral aspect is bounded by the slightly compressible femoral vein as it emerges under the inguinal ligament. Clinically, the femoral herniation presents as a mass that may be confused with superficial inguinal lymphadenopathy. In thin patients, the line of the inguinal ligament from the anterior superior spine to the pubic tubercle can be projected and the femoral herniation will clearly present below this, being immediately lateral to the pubic tubercle and medial to the pulsation of the femoral vessels. If the surgeon is certain of this diagnosis, which may be aided by the use of ultrasonography, then the lower limited oblique incision directly over the mass may be made (Figure 2, B). If the diagnosis is in doubt, the patient is obese, or the possibility of strangulation exists, then the upper incision (Figure 2, A) is made so as to provide maximum exposure and flexibility. This incision is slightly lower than that made for the usual inguinal hernia. It is above and parallel in general to the inguinal ligament with a more transverse medial extension. The incision is made and carried down to the external oblique fascia. The fascia over the canal is cleaned so as to expose the external ring. The external oblique fascia is divided in the direction of its fibers in the manner used for exposure in inguinal hernias. A pair of hemostats are placed on the superior and inferior leaves of the external oblique, which is then cleaned by blunt dissection down to the internal oblique muscle superiorly and the shelving edge of the inguinal ligament inferiorly. The round ligament or spermatic cord with attached ilioinguinal nerve is dissected free and retracted superiorly either with a rubber Penrose drain or a Richardson retractor (Figure 3). The transversalis fascia constituting the floor of the canal is explored to rule out any direct herniation, and thereafter the region of the internal ring is explored to rule out the presence of an indirect herniation.

The inferior leaf of the external oblique is retracted superiorly and the femoral herniation becomes apparent as it emerges just under the inguinal ligament lateral to the pubic tubercle. This same exposure is obtained if the lower incision is made directly over the hernia. The sac is grasped and, using a combination of sharp and blunt dissection, it is freed from the surrounding fat of the upper thigh (Figure 4). As the dissection proceeds, the herniation is found to occur through a narrow opening that is approximately the size of the surgeon's fifth finger. Most often the sac contains preperitoneal fat or omentum, which can be reduced; however, should strangulated gangrenous bowel be encountered, the surgeon must plan for resection with a synchronous laparotomy.

After successful reduction in an uncomplicated case, it is not necessary to open the sac. This is usually invaginated back through the femoral opening, which now presents as a defined hole (Figure 5). A synthetic plug is made according to the method of Lichtenstein by rolling up a piece of polypropylene mesh approximately 2 by 15 cm in length. This spiral winding creates a cylinder of mesh that is grasped with a Babcock clamp (Figure 6) and then inserted into the femoral opening such that a few millimeters protrude externally. Three quadrants of the cylinder are secured with interrupted nonabsorbable sutures of polypropylene or nylon. Each is anchored to the adjacent fascia with the suture extending well into the center of the rolled cylinder so as to prevent an intussusception of the mesh. The superior suture attaches to the inguinal ligament, the medial one to the lacunar ligament and fascia investing the pubic tubercle, and the inferior one to the fascia over the pectineus muscle. No suture is placed laterally, as this wall is the femoral vein (Figure 7). The external oblique fascia is reapproximated with either interrupted or running nonabsorbable sutures and the routine closure of Scarpa's fascia and the skin is performed. A small dressing is applied to cover the incision.

In the uncomplicated case, the patient is quickly discharged home with written instructions concerning activities, signs of bleeding or infection, or any other unusual reaction. Most are able to resume normal activities within a few days.