Primary Femoral Hernia: Open Anterior Treatment

Abstract

A femoral hernia is an acquired and direct hernia. It is an insidious hernia often asymptomatic; in 30% of cases, the onset is a strangulation, with bowel resection and mortality. In literature, there are three main types of approach. The authors describe an anterior femoral approach performed in the last two decades, with a double disc prosthesis fashioned in a tailored prosthetic repair, with the use of four prosthetic devices according to the characteristics of the femoral ring and femoral canal. The authors show, in detail, the technical steps of this anterior prosthetic procedure, and they highlight some peculiarities in emergency. Finally, they mention their personal series and good results with this technique, which, in their opinion, is fast, reproducible and so easy to perform and to learn.

1 Introduction

A femoral hernia is an acquired hernia and is classified as a direct hernia; its path is constituted by the crural or femoral canal.

Nyhus [1] classifies it as an IIIc form, a special kind of defect of the posterior wall; in the EHS classification [2], it is classified as “F 1,2,3,x” depending on the size of the defect. It is an insidious hernia generally asymptomatic, where a small dimension inside the inguinal femoral area justifies a late diagnosis up to 30% of patients [3].

Even if this hernia is rarer than the inguinal hernia (1–2% repairs undertaken at the Shouldice Hospital in 1 year) [3], it has however a higher mortality rate, more than 25% [3, 4], because the diagnosis is often difficult (it is relatively small and harmless), and therefore there is a late, incorrect diagnosis which frequently occurs at the moment of complications [5].

Therefore, strangulation of a femoral hernia determines a misunderstood and delayed emergency, which could even put an expert surgeon on the wrong track [3,4,5,6].

Since the beginning of the last century, three main types of open approach have been used (Table 45.1).

Table 45.1 The main types of open approaches and techniques

The ideal treatment of a femoral hernia is up to today object of great discussion, and there is a lack of evidence: prospective trials are still not definite for strategy of early diagnosis, surgical techniques and mandatory prosthetic use, for the choice of approach and finally for outcomes, recurrences, pain, complications, etc.

The femoral access (low approach) represents the classical way undertaken in the past, as being simple and reliable, but in tissue repair techniques, this results in an unacceptable rate of recurrence [3], even if subsequent report showed a recurrence rate of 3.1%, at the Shouldice Hospital, in case of high approach, [7] selecting the use of low approach only after an inguinal intervention.

To be thorough, it is necessary to underline that between the preperitoneal access [8] and the laparoscopic one, the latter has gained considerably in its indication over the last two decades. In fact, it is a technique using the posterior approach, a total closure of the myopectineal orifice with a large prosthesis. It also represents a diagnostic technique by evaluating the type and dimension of the hernia defect and the type and vitality of the content after the reduction. Even more, it allows a simultaneous evaluation of contralateral hernia or associated inguinal or abdominal wall ventral hernias, and it is indicated in atypical varieties [9,10,11]. However, a superiority in the results is uncertain in some recent studies [12, 13], although other ones show initial guidelines that recommend the use of laparoscopy in femoral hernias in election [14, 15].

Among the various methods used over the last 20 years, we have performed, after an initial experience with “rolled-plug” technique, an anterior approach using a technique called “mesh-plug” repair with several types of a double disc prosthesis (PHS, 3D patch, UPP, UHS—Ethicon).

In our opinion, this prosthetic repair is extremely adaptable to resolve the technical and tactical problems of this particularly insidious hernia [16, 17].

2 Anatomic Characteristics of the Femoral Canal and the Femoral Fascia

The femoral canal is conical shaped, and his anatomy requires an appreciation of its three-dimensional characteristic [18]. There is a femoral ring (entrance to canal) and a femoral orifice (canal exit). In the typical variety, the femoral canal is located in the medial position with respect to the femoral vein (Fig. 45.1); there are also various atypical varieties (Fig. 45.2). The fossa ovalis, the opening for the great saphenous vein, is at its apex inferiorly. Thus, a femoral hernia may appear as a bulge of the skin over the fossa ovalis.

Fig. 45.1

Femoral hernia—typical variety (reproduced from The Surgical Anatomy of Hernias of the Groin by Henri Fruchaud—translated and edited by Robert Bendavid, 2006)

Fig. 45.2

Femoral hernia—atypical varieties (from Bocchi P, Paravascular hernias. In: Bendavid R, editor. Prostheses and abdominal wall hernias, Austin: R.G. Landes Company; 1994)

The characteristic rigidity of the osteo-fibrotic-fascial structures of this canal predisposes this one towards strangulation. The “less rigid” edge is the lateral one, consisting of the femoral vein and connective tissue. The posterior border is Cooper’s ligament. The inguinal ligament and ileo-pubic tract form the anterior limit. The transversalis fascia and aponeurotic insertion of the transversus abdominis muscle and, principally, the lateral edge of the lacunar ligament constitute the medial border. The importance of the femoral ring is equal to the internal inguinal ring; the former represents a second weakness in the lower part of the myopectineal orifice, which is covered only by the transversalis fascia. This assumes a particular disposition in the femoral canal (Figs. 45.3 and 45.4).

Fig. 45.3

Myopectineal orifice of Fruchaud (reproduced from George Wantz’s Atlas of Hernia Surgery, Raven Press, 1991, NY)

Fig. 45.4

Transversalis fascia and myopectineal orifice of Fruchaud (reproduced from Francesco Ruotolo)

It is very important to underline the limits of transversalis fascia funnel:

The anterior limit is the fascia lata, the posterior limit is the pectineus fascia medially and the fascia lata laterally, the medial limit is the lacunar ligament, and the lateral limit is the femoral vein.

The difficulty in closing the femoral ring without tension is due to the lack of elasticity of anatomical structures; in fact, it is difficult to approximate the inguinal ligament to Cooper’s ligament.

For this reason, all the femoral hernia tissue repairs presented high recurrence rates, mainly in the cases of a very large femoral ring (> 2 cm) (Fig. 45.5) and after a surgical inguinal hernia repair [9, 19, 20].

Fig. 45.5

Groin hernia tissue repairs: risk of femoral hernia after inguinal herniorrhaphy and vice versa (from Nocentini et al. Piccin Editore 1981)

A dilated femoral ring can be due to the repeated increase of intra-abdominal pressure (i.e. coughing, pregnancy in women, etc.) but also in the case of degenerative changes and weaknesses of the structures in the subinguinal region with the deterioration of the descending aponeurotic fibres of the transversus abdominis (elderly) [21].

3 Materials: Important Element for a Rational Use

At the end of the 1980s, on the base of several techniques and the results of dedicated surgeons, the plug technique has become widely used: Lichtenstein’s “rolled plug” [22], Gilbert’s “cone-shaped plug” [23], Trabucco’s “dart-shaped plug” [24] and Rutkow’s “PerFix plug” [25] (all made in polypropylene).

In fact, evidence showed and documented a large number of recurrences using the tissue repair techniques even in a dedicated hernia centre with a numerous amount of admissions for non-prosthetic treatment (Shouldice technique). For this reason, in that hospital in 1989, Bendavid proposed a prosthetic repair by positioning a preperitoneal umbrella [3, 26, 27] (Fig. 45.6). This enabled a reduction of the important number of recurrences sustained after the tissue repair technique [3, 28].

Fig. 45.6

Femoral hernia: Bendavid’s umbrella technique (reproduced from G. Valenti—Le Ernie Inguinali—Utet 1992 Milano)

In 1995, our proposal was born. We have used the double disc polypropylene prosthesis, PHS mesh much used by Gilbert in United States [29], shaped into dimensions in order to fit the anatomical characteristics of the femoral canal. This technique has allowed us to achieve interesting and progressive results with an improvement of outcomes. These results, concerning especially the rate of recurrences and chronic pain, have been obtained thanks to the use of more modern prosthetic materials, partially absorbable and macroporous bilayer device, in recent years. These have different sizes and diameters and can be shaped according to the anatomical characteristics of the hernia and the femoral canal achieving a prosthetic tailored surgery:

• UHS: it represents the technological evolution of PHS (Fig. 45.7).

• UPP: the plug is soft and easy to handle, allowing an easy and fast positioning (Fig. 45.8).

Fig. 45.7

UHS

Fig. 45.8

UPP

Both are composed of Prolene (macroporous polypropylene) and Monocryl (poliglecaprone 25).

The rational use, as mentioned above, implies the positioning of a reduced amount of prosthetic material because:

• They are light meshes, principally containing less prosthetic material.

• They have a large amount of absorbable material.

• The inner disc of the prosthesis of different sizes lies deeply in the Bogros space, an indispensable condition for the optimal prevention of recurrences without an excessive separation of the space.

• A softer device fills the femoral canal by a mechanism of auto fixation of the two discs. This not only avoids recurrences but also discomfort, numbness and chronic pain. Fixation is limited to a few sutures in order to distend the prosthesis and to avoid migration.

4 Anaesthesia

We perform, if possible, preferably a step-by-step local anaesthesia or an ultra-thin needle epidural anaesthesia (over recent years, the latter has been our preference).

The general anaesthesia is realized only if strictly necessary.

5 Surgical Techniques

Double disc mesh-plug technique—surgical steps (Table 45.2).

Table 45.2 Step-by-step technique

5.1 UHS: Ultrapro Hernia System

(Figs. 45.9, 45.10, 45.11, 45.12, 45.13, 45.14, 45.15, 45.16, 45.17 and 45.18)

Fig. 45.9

Anatomic landmarks

Fig. 45.10

An anterior groin incision, in the shape of a golf club, retracted to expose the femoral region

Fig. 45.11

Wide dissection of the femoral sac and hole

Fig. 45.12

Wide dissection of the femoral sac and hole

Fig. 45.13

Digital evaluation of crural orifice after hernia sac reduction (without excision)

Fig. 45.14

The clamp holds inside the reduced hernia sac

Fig. 45.15

UHS prosthesis is tailored reducing the anterior sheet to a small border

Fig. 45.16

UHS prosthesis is made as a mesh-plug

Fig. 45.17

Final position of UHS mesh plug; we can see the small ring of the anterior sheet

Fig. 45.18

Final view with three cardinal points and a few sutures to extend the anterior edge of the prosthesis in the pectineal fascia

5.2 PHS: Prolene Hernia System

(Figs. 45.19, 45.20, 45.21, 45.22 and 45.23)

Fig. 45.19

The femoral sac is opened to assess the content

Fig. 45.20

PHS prosthesis used for femoral hernia

Fig. 45.21

PHS prosthesis before the positioning

Fig. 45.22

The dotted line close to femoral vein

Fig. 45.23

Illustration of final position of the prosthesis

5.3 UPP: Ultrapro Plug

(Figs. 45.24, 45.25, 45.26, 45.27, 45.28, 45.29, 45.30, 45.31, 45.32 and 45.33)

Fig. 45.24

Wide dissection of the femoral sac

Fig. 45.25

The sac is not cut and it is put down without excision to avoid pain

Fig. 45.26

Cleavage of the Bogros space by finger accomplished for inner prosthesis

Fig. 45.27

The UPP Ultrapro prosthesis is a light mesh

Fig. 45.28

The UPP Ultrapro prosthesis is partially re-absorbable

Fig. 45.29

The UPP mesh plug is inserted into the femoral canal with a long clamp

Fig. 45.30

The circular internal sheet of the prosthesis spreads open like Bendavid’s umbrella prosthesis

Fig. 45.31

Final position of the UPP mesh plug; we can see the small ring of the anterior sheet

Fig. 45.32

Final appearance of sutured skin

Fig. 45.33

Diagram showing the position of the UPP double disc prosthesis according to our technique (From Fruchaud modified)

6 Emergency Femoral Hernias: The Surgical Technique

“…… Are the most treacherous of all hernias. When incarcerated, they outnumber all other forms of incarcerated abdominal hernias combined”. (R. Bendavid).

Groin examination must always be part of an abdominal examination.

In many cases, in emergency, the reduction of an incarcerated femoral hernia is impossible without incising the lacunar ligament and the medial femoral sheath to widen the defect (Fig. 45.34).

Fig. 45.34

(reproduced from George Wantz’s Atlas of Hernia Surgery, Raven Press, 1991, NY)

7 Personal Technique in Emergency

CASE I Richter hernia (Figs. 45.35, 45.36, and 45.37).

CASE II Femoral epiploic strangulated hernia – Combined repair (Figs. 45.38, 45.39, 45.40, 45.41, 45.42, 45.43, 45.44, and 45.45).

CASE III Strangulated small bowel femoral hernia – Combined repair (Figs. 45.46, 45.47, 45.48, and 45.49).

Fig. 45.35

Strangulated Richter’s hernia

Fig. 45.36

Prosthesis insertion

Fig. 45.37

Final position

Fig. 45.38

Femoral epiploic strangulated hernia

Fig. 45.39

Femoral epiploic strangulated hernia. The internal femoral ring after epiploic reduction

Fig. 45.40

The femoral sac is dissected and reduced into the abdomen by anterior approach ...

Fig. 45.41

... under laparoscopic control

Fig. 45.42

The 3D patch mesh plug is inserted into the femoral canal with a long clamp

Fig. 45.43

Superficial disc is anchored with three cardinal sutures

Fig. 45.44

The femoral sac inverted is anchored to the peritoneum

Fig. 45.45

Final view of the abdomen with incisions

Fig. 45.46

Strangulated small bowel in femoral hernia. Laparoscopic view

Fig. 45.47

Reduction of the content into the abdomen by laparoscopic approach

Fig. 45.48

PHS prosthesis is shaped and inserted, according to our technique, by anterior approach

Fig. 45.49

Final view for late evaluation of the bowel integrity

In several cases, (12 cases), there was an indication to carry out our technique in a combined procedure (open/laparoscopic approaches) [17].

In our opinion, this technique is indicated in selected cases of complicated femoral hernias, e.g. the elderly and the frail patients with other comorbidities thanks to the collaboration with the anaesthesiologists, for different reasons:

• A “short” general anaesthesia.

• A rapid low-pressure pneumoperitoneum (a few minutes).

• Diagnostic aim of laparoscopy: only to explore the type and vitality of the contents after reduction and the evaluation of the size of the femoral ring.

• The combined technique (laparoscopy and a simple infrainguinal low approach) permits the reduction of the sac into the peritoneal cavity, and it represents a great advantage in avoiding contact between the prosthesis and the hernia content (infections) as well as the intraperitoneal fixation of the sac and, most importantly, the late evaluation of the viability and possible ischemic troubles of the contents.

• The combined technique avoids a negative prognostic factor: an associated laparotomy [30, 31], the latter was carried out in 11 patients, in our case series.

• An alternative technique is the hernioscopy (hernia sac endoscopy) [32, 33]; moreover it is achievable in case of inguinal strangulated hernia, and, in our opinion, it is not possible in femoral one, in consideration of the femoral canal anatomy.

8 Personal Experience (1996–2015)

Over a period of 20 years, we have performed 244 surgical procedures using the plug technique, 68 on men and 176 on women; 129 (52.9%) patients underwent emergency surgery and 115 (47.1%) were elective cases. We have performed only 11 laparotomies and the recurrence rate was 2%. This percentage can be underestimated because a great number of elderly patients have been operated on having complications in an emergency setting (dedicated emergency department, patients lost in follow-up). The overall mortality rate was 2% (five patients). The mortality (3.9%) occurred only in strangulated femoral hernias, associated with a bowel resection (three cases) and laparotomy (three cases). Therefore, there was no mortality in elective cases.

9 Consideration on Personal Case Studies from 1996 to 2015

9.1 Type of Prosthesis

• Rolled plug n 56 (22.9%)

• Umbrella plug n 45 (18.4%)

• Mesh and plug n 11 (4.5%)

• PHS n 62 (25.4%)

• 3D plug n 22 (9.1%)

• UPP n 21 (8.6%)

• UHS n 27 (11.1%)

9.2 Anaesthesia

• Local: 123 cases

• Local + neuroleptanalgesia: 24 cases

• General 18: cases

• General (conversion): 20 cases

• Epidural: 59 cases

9.3 Local Complications n. 41 (16.8%)

• Serohaematomas 20

• Wall’s oedema 4

• Lymphorrhea 2

• Infection 5

• Recurrence 5

• Pain discomfort 5

• Deep vein thrombosis 0

• Major vascular injury 0

• Major vascular bleeding 0

• Retroperitoneal haematoma 1

• Removal prosthesis  4 (pain—infection)

  • Rolled plug 2

  • 3D patch 1

  • PHS 1

9.4 Abdominal Complications

• Adynamic ileus    3 (NOM—nonoperative management)

• Obstructive ileus   2 (redo laparoscopic surgery)

  • Littrè hernia (ileal resection)

  • Single adhesion by plug (adhesiolysis)

• Upper digestive bleeding  1 (NOM—nonoperative management)

There is a great difference of pathway in election (preventive surgery in young people) and in emergency (mandatory therapeutic surgery in elderly patients), as in our case studies that report an acceptance of patients in an emergency surgical department of a third-level hospital. In these complicated cases, a quick and easy intervention, if possible, is the first choice for these elderly patients.

As referred by other surgeons [31], there are several limitations (bias) also in our experience:

• Retrospective design

• Lack of randomization and blinding

• Single-centre experience

• Inconsistency in follow-up schedule

• A lot of patients lost

• Many patients with early mortality (elderly patients with several comorbidities)

• Lack of standardized hernia surgery database, in the past

• With underestimating:

  • Late hernia recurrence

  • Late chronic pain

  • Long-term complication rate

Also in our experience, this disease is correlated by age (elderly people).

“…The older the patient, and the longer the delay in diagnosis, the higher the mortality rate…”. (R. Bendavid) (Fig. 45.50

Fig. 45.50

Femoral hernias - Incidence by age (V. Mandalà)

).

10 Tactical Considerations: Tips and Tricks

10.1 The Choice of Materials and Shape: UHS Mesh and UPP Plug

• Does not expand the preperitoneal space (flat disc prosthesis)
• Three-dimensional characteristic shape:
Little fixation
No plug migration		• Low rate of recurrence
• Lightweight prosthesis:
Large pore and partially absorbable  Increased flexibility		• Low rate of chronic pain
Reduction in foreign body sensation
• The rational use of double disc prosthetic device according to our technique:
Crural orifice <2 cm → UPP Plug—3D Patch
Crural orifice >2 cm → PHS—UHS meshes

10.2 Advantages of the Infrainguinal Approach

• Can be performed under local or epidural anaesthesia (high-risk surgical patients)

• Has been proved to be convenient [34] (direct approach to femoral canal)

• Shorter operative time vs laparoscopic procedures

• Easy to learn and teach

10.3 What Does a More Minimally Invasive Approach Mean?

• A direct approach to the femoral canal.

• It is not necessary to dissect the inguinal canal.

• Spermatic cord and nerves within the inguinal region are protected.

• Decrease of chronic postoperative pain.

10.4 Infrainguinal Open Approach in Emergencies

• Incarceration and obstruction.

• Strangulation.

• Irreducible hernias.

• It is easier to partially cut the inguinal ligament using the infrainguinal approach rather than an inguinal one [34].

11 Conclusion: Low Approach Double Disc Prosthesis

• Rapid and straightforward execution

• Suitable for the elderly, frail and “complicated” patients

• Treats both the mechanical and biological problems (prosthetic use)

• Allows short hospitalization, even in emergency cases

• Low recurrence rate

• No increase in chronic postoperative pain

• Applicable in all presentation patterns

12 Femoral Hernias: General Key Points

• Lack of evidence.

• Need of multicentric RCT, international registers and consensus conferences.

• A thorough imaging analysis (CT scan) especially in an emergency is mandatory.

• Tailored surgical procedure according to anatomy.

• Several technical options and approaches sometimes combined.

• Mandatory use, if possible, of prosthesis.

• Surgeons should perform the technique they are most confident with.

• No delay surgery.