I prefer laparoscopic approach with TAPP. In acute incarcerations I use the open approach. But the reconstruction is sometimes very difficult.

I prefer Fabricius repair in incarcerated femoral hernia because the method is simple because 1) there is no opening of the aponeurosis of external abdominal muscle and 2) short - most operations without bowel resection can be performen within 30 minutes minimizing the possibility of wound infection. I had no recurrences in 2 years follow up

Fabricius repair is one kind of treatment, but in some cases of incarcerated hernias you have to open-up the inguinal region and even divide the inguinal ligament. In these cases you may have difficulties in repair.

True. I always divide the lacunar ligament medially and did not have any problems with freeing the incarcerated bowel. Only once i converted to inguinal approach because of Amyand hernia with appendicitis when the base of appendix was not accesible through small opening.

Sorry, wrong. Not Amyand but de Garengeot's hernia

There is no evidence based medecine answer. Both techniques can be performed : laparoscopic hernia repair or plug via direct incision. as it's nearly always a illness of aged people, I think the less risky technique is to perform a plug. This is for me the alone indication for plug.

I prefer to use the laparoscopic TEP technique for all cases. When I finish the procedure and still remain doubts about the viability of the bowel, I run through the peritoneal cavity and clarify.

at Pierre Verhaeghe: which kind of plug do you mean?? The Bard plug? The standard plug in inguinal hernia surgery is in my opinion to bulky to implant beneath the femoral vein.

I agree that there is no evidence based answer.I prefer to do elective cases by laparoscopy and acute cases by Mckewen's high approach.Lacunar ligament devision always helpful.

There was a - to my opinion - very good study published in Hernia 2012 (16:387–392) by Schouten et al. from Utrecht who concluded that, bearing in mind that a femoral hernia is a typical "female problem", the lapararoscopic approach to female inguinale hernias is the better way. Schouten prefers TEP-procedure, but you have to keep in mind that they have more clinical experience in TEP than TAPP. I personally prefer a TAPP-procedure in every case of (preoperatively detected) femorale and/or female inguinal hernia because all (possible) hernia defects in the inguinal region can be explored without extending your surgical approach, mesh-repair has to be recommended anyhow in most of the cases.

I prefer TEP. It gives good exposure but in emergency situation I prefer the cooper ligament repair by high approach

I think anterior preperitoneal approach should be preferred as first choice for repaeir of femoral hernias

Femoral hernia closure using a Plug as described by Rutkow and Robbins :(Hernia 1998:2;73-75) an elegant alternative

For uncomplicated hernias, a laparoscopic TEP repair could be preferred. In female patients, there is a significant amount of combined femoral&inguinal hernia. By using an open approach generally the femoral hernia can be treated well, but the potential inguinal hernia is left untreated. A laparoscopic repair treats both weak spots and therefore should be first choice.

In incarcerated femoral hernia, there is not much evidence but it seems logical to perform TAPP if there is a significant suspicion on bowel ischaemia.

The femoral hernias traits are:

1) As a rule, it begins as incarcerated one due to the small size and rigid edges of the femoral canal, so that a possibilty of the small bowel resection is very high;

2) the most popular age for the femoral hernia to develop is about 70 years and older; usually, the patients are ladies of very frail body lacking fat tissue even in the Retzius and Bogrot spaces, and that in the paravasal shealves as well. And weighing as light as a sheet of paper.

So that, both TEP and TAPP are possible relatively rare, in elective surgery.

Unfortunately, I do not know the procedures' eponyms aforementioned by colleagues, so that I may suggest the method that is used successfully in my hospital (perhaps, it has just another name among listed above):

The Ruggi-Parlavecchio method for the femoral hernia repair:

An oblique incision is made from the outer edge of the right abdominal muscle 1 inch above and parallel to the inguinal crease. The trans-inguinal canal approach is perform then to cut open the transversal fascia and the parietal peritoneum consequtively. Care should be made to not injure the a. et v. epigastricae inferiores at the lateral angle of the dissection (they could be ligated and transsected, if necessary). This approach is wide enough to permit in routine cases to have made a bowel resection. On the other hand, it would not weaken the inguinal canal because the canal is very narrow in women. The Lichtenstein technique may be use in conclusion if the tranversal fascia is loose and unreliable. As for the inner femoral repair, the best way is a plug technique.

By the way, both these approach and prug are even more useful for the obturatorial hernia to deal with. The latter one seemingly is confused not so infrequently with the femoral one, especially in case of gangrena of the incarcerated loop occurence and at night. The obturatorial canal is quite near from the femoral one, in an old and tiny woman, not fare than 1 inch or less.

In case of peritonitis, the midline approach should be made from the very beginning.

The anterior, or femoral approach is the worst for both elective surgery and emergency. It is narrow, uncomfortable, and incommodius, does not allow to perform nor inspection, neither a bowel resection, if not only to continue incision upwards and cut the inguinal ligament through. And, despite this devastational incision, the approach is always insufficient.

Laparoscopic Transabdominal pre-peritoneal (TAPP) approach is my preferred method for inguinal and femoral herniae.

For open repair:

1. Elective femoral repair: via low approach suture closure of the canal.

2. Emergency repair: via McEvedy's approcah. The abdomen is eneterd if bowel is strangulated.

Laparoscopic (TAPP or TEP) approach

Plug is the easiest methiod for femoral hernia as described by Dr. Rutkow and me in Surgical Clinics of North America 2003. The Perfix plug is a little bit bulky, so Light Perfix Plug without petals is better. The mean operating time is less than 20 minutes.

I prefer to use Ira Rotkows open approach. I feel using a laparoscopic technique in these cases gives satisfaction to the surgeon, but converts a 15-20 min operation into an hour long operation and at a great extra cost plus almost no benefit to the patient. If one is unlucky enough to get a hernia stuck to the femoral vein medially, God Help!

I have experienced many femoral hernia cases by mesh plug, bu no case of femoral vein thrombosis.

In elective femoral hernia repair open or laparoscopic way can be performed. But in acute incarceration I always prefer open technique with cooper ligament repair.

Dear Raza and all,]

Thank you for starting a nice topic. I will give my answer and operative strategy and reasons:

Dr. Heemskerk is making sense, but almost certainly in cases of acute incarceration I would recommend a swift (with 4-6 hrs) operation and do an open modified McEvedy approach. This without a doubt gives the best access for every contingency. Anyone doing a low Lockwood and lower midline is missing out on a much more elegant and sensible approach. A low approach that requires cutting the inguinal ligament is not ideal also, as is a Lotheissen approach which inherently weakens the inguinal canal and thus necessitates mesh in a case where translocation of gut organisms and transient bacteraemia is likely. TAPP is an option but will double the operating time I suspect in most peoples hands.

The modified McEvedy as I do it (unlike the description from Peter McEvedy from Manchester in the 1950's) is through a transverse incision about 4cm above the ipsilateral inguinal (Poupart) ligament - somewhere midway between an appendix and an inguinal hernia incision. The original description was all vertical. Unlike the description once I get down to the fascia I open it transversely, i.e. EOA and anterior rectus sheath. If you now retract the rectus abdominis muscle medially, then inferiorly with a Langenbeck retractor and you will have a great view of the extraperitoneal space and femoral canal. Palpate the bony landmarks to orientate yourself if need be. Occasionally the epigastrics appear - ligate them.

Once you see the sac, apply external pressure to reduce it. If you struggle I divide the lacunar ligament (being cognisant of the possibility of an aberrant obturator artery!). The best way to do this is to place a Lahey forceps in the lacunar ligament very superficially (i.e. immediately under it) and diathermy its most lateral edge with the hand held finger-switch diathermy (Bovie) - often this is enough to release the sac. Then open it using clips, when you'll almost certainly find a Richter's hernia and wrap in warm wet swabs, and fix the defect.

The simplest and probably best way to do this is an emergency is to use braided suture i.e. Ethibond on a J needle. Inguinal to pectineal ligament - by the time this is complete you will notice that the bowel is viable. Naturally beware the femoral vein laterally.

Then a layered closure and post-op VTE prophylaxis, mobilisation and E+D as tolerated and your patient will be ready for home soon. Of note, I give 1 shot of ABx on induction and if the bowel is viable no further doses.

In the elective setting a low Lockwood approach is sufficient, and in those cases indeed a mesh can be used, either normal polypropylene cut as a long rectangle and rolled up as a cigarette and pushed in, or a Bard plug. To be honest, I think simple sutures work fine also. As I say, Dr. Heemskerk makes a point that a co-existing inguinal hernia can exists also, in which case TEP is an option. I suspect in the most NHS trusts, for a unilateral femoral hernia, would only fund open surgery.

Hope that helps!

BW,

John.

Modified mcevedy

I used polyester or polypropilene mesh rolled as a cigaret filter of the good size. The direct crural access takes lower time and even can be performed under local or loco regional anesthesia for older patients. So

I consider laparoscopic techniques for inguinal hernias and I’m not sure it’s best for crural hernias in old people.

Remember : no EBM in this case!

We prefer laparoscopic approach

ТАРР

A lot of the bulk of the femoral hernia is layers of extra peritoneal fascia and fat before you get to the real hernial sac. For this reason I prefer to start with a short vertical incision extending down from the bony landmarks of the femoral hernial orifice. This enables one to dissect away all the adherent fascia and fat easily reaching the hernia sac and inspecting its contents. A low repair can then often be performed but if the contents are incarcerated or strangulated this incision can then be extended above the inguinal ligament obliquely and laterally to give easy access to inguinal canal and having incised the posterior wall of the canal in the line of this incision the hernia can be approached from above, freed up, and if necessary the peritoneal cavity can be entered after having secured the contents as they enter the neck of the sac and placed packing and made ready the sucker. Hope this helps.