Hernia

abdominal wall hernia

Dr. Sulaiman fakhouri

General surgeon & Reconstructive surgery (fellowship )
22/08/2024
1. Anatomy of abdominal wall & inguinal canal
2.Definition of hernia
3. Classification of Hernia
4.Pathlogy ( structure of hernia )
5. Diagnosis of ventral hernia
6. Clinical Picture
7. Complication
8. Treatment
Anterior Abdominal Wall Layers :
.
Understanding of groin anatomy is essential to successful surgical treatment of inguinal hernias ( antlateral)

From sides of the abdomen :

• Skin
• Superficial fascia
• Outer : Camper (fatty)
• Deeper : Scarpa's (fibrous)
• External oblique
• Internal oblique
• Transversus abdominis
• Transversalis fascia
• Extraperitoneal connective tissue
• Parietal peritoneum.
 Inguinal ligament :
• is the inferior rolled under aponeurotic fibers of
the external oblique
• that extend between the anterior superior iliac
spin and the pubic tubercle.
• Medially, the fibers of the inguinal ligament form
a flattened, horizontal shelf called the lacunar
ligament that attaches deeply to the pectineal
line of the pubis and continues as the pectineal
ligament.
• Lacunar ligament forms the medial border of a
femoral hernia.(strangulation)
Contributions of the external abdominal
oblique muscle and aponeurosis:
• Ant wall of the inguinal canal
• Inguinal ligament
• Superficial inguinal ring
• Lacunar ligament.
• External spermatic fascia
• Floor of inguinal ligament
• Reflected part of inguinal ligament
 Inguinal canal :
• It is an oblique intermuscular passage in the lower part of the anterior abdominal wall transmitting the spermatic
cord in male and round ligament of uterus in female.

• About 4 to 6 cm

• It is situated just above the medial ½ of the inguinal ligament. .

• Beginning at the deep inguinal ring and end at Superficial inguinal ring .

Direction Downward , forward and medially.

• Contents:
• Male:
• Spermatic cord
• Ilioinguinal nerve
• Female
• Round ligament
• Ilioinguinal nerve
 Deep(internal)inguinal ring
• is a small opening in the fascia transversalis immediately above
the midpoint of the inguinal ligament and represents the lateral and deep
opening of the inguinal canal.
• The inferior epigastric vessels are medial to the deep ring.
Superficial (external )inguinal
ring :
• is a vertical triangular cleft in the external oblique aponeurosis
• that represents the medial opening of the inguinal canal just superior
and lateral to the pubic tubercle.
• It transmits the structures of the female and male inguinal canals.
Wall of inguinal canal :
Anterior wall :
• Aponeurosis of external oblique( along entire length)
• Internal oblique on lateral half of the ant wall
Posterior wall :
• Fascia transversals
• Conjoint tendon on medial half of the post. wall
• Roof :
• Arching fibres of internal oblique & Tranversus abdominis
• Floor :
• Reflection point of inguinal ligament
• Lacunar ligament
Triangle of Hasselbech’s
(inguinal triangle):
• It is a part of the posterior wall of the
inguinal canal
• It is bounded by:
• Laterally : inferior epigastric vessels.
• Medially: Lateral border of rectus sheath.
• Inferior: inguinal ligament (only medial
half).
• Floor : transversalis fascia
• Surgical importance : It is the triangle
through which direct inguinal hernia
passes
 Conjoint tendon :
• is formed by the combined arching fibers
of the internal oblique and the
transversus abdominis muscles that
insert on the pubic crest posterior to the
superficial inguinal ring.
• It forms & strengthens the medial part of
the posterior wall of inguinal canal.
• Nerve supply : ilio-inguinal nerve.
Covering of the spermatic cord: ( 3 covering from outward )

1. External spermatic fascia from external oblique muscle

2. Cremasteric muscle fascia from Internal oblique muscle
3. Internal spermatic fascia from facia transversal’s

• *constitution of spermatic cord: ( 3 structure + 3 artery + 3 nerve )

• Structures: 3

1. Vas deferens
2. Pampiniform plexus
3. lymphatic

• Arteries: 3

1. Testicular artery
2. Vas deferens artery
3. Cremasteric artery

• Nerves: 3

1. Ilioinguinal nerve ( out of spermatic cord )

2. Sympathetic nerve fiber
 Mid-Inguinal Point and Midpoint of the Inguinal
Ligament :
• These two terms are often (mistakenly) used
interchangeably:
• Mid-inguinal point :
Halfway between the pubic symphysis and the
anterior superior iliac spine.
The femoral pulse can be palpated here, and for
ABGs.
• Midpoint of the inguinal ligament :
Halfway between the pubic tubercle and the
anterior superior iliac spine (the two attachments
of the inguinal ligament).
The internal ring to the inguinal canal is located
just above this point.
 Definition :
. A hernia : is defined as an abnormal protrusion of an organ or tissue through a defect in its
surrounding walls.

Although a hernia can occur at various sites of the body, these defects most commonly involve
the abdominal wall, particularly the inguinal region.

.
 Classification :
• According to : ( Visualization . Site . Etiology )
A) Visualization : internal and external

1) External: appear on the surface of the herniation site (more common)

Inguinal, Femoral, Umbilical…..
2) Internal: : not appear on the surface of the herniation site

Diaphragmatic hernia
B) Site : inguinal , femoral , umbilical , Obturator....

• 1) Inguinal hernia:

Above inguinal ligament medially to the pubic tubercle

include Direct and Indirect inguinal hernia.

The most common Hernia in male & female

• 2) Femoral Hernia:

Below inguinal ligament laterally to the pubic tubercle

More common in Femoral

3) Umbilical & Para-umbilical Hernia

4) Epigastria Hernia: from umbilicus to xiphoid process

Defect in Linea Alba

5) Incisional Hernia: Hernia through an incisional site;

most common cause is a wound infection

Other type of Hernia

6) Obturator Hernia through obturator foramen
7) Lumbar Hernia through lumbar triangle
8) Gluteal Hernia through greater sciatic foramen

9) Sciatic Hernia through lesser sciatic foramen

10) Spigelian Hernia through Linea semi-lunaris below
arcuate line
11) Hiatus Hernia Through esophageal opening
 Hernias through the superior lumbar triangle (GreenFleet triangle) are
more common. The superior lumbar triangle is bounded by the twelfth
rib, paraspinal muscles, and internal oblique muscle.

• Less common are hernias through the inferior lumbar triangle (Petit
triangle), which is bounded by the iliac crest, latissimus dorsi muscle,
and external oblique muscle
C ) Etiology : congenital and acquired

1) Congenital :
congenital inguinal hernia )persistence remnant of processes virginals(
congenital umbilical hernia (exomphalos)

2) Acquired: due to

a) Increase intra-abdominal pressure by:

1.Chronic straining:
Respiratory system ……… Cough
GIT system ………. constipation
Urology …….. BPH
2.Occupational : worker …. lifting heavy object .

3. Abdominal swelling :
Pregnancy. Ascites & Organomegaly(Hepatomegaly)
b) Weakness of abdominal wall :

Obesity .Old age .collagen disease .

Pregnancy . Previous surgery

Structure of hernia ( Pathology ) :

Defect :
through which the sac bulges out
Coverings :
These are the structures that are stretched over the sac
Sac :
This is the peritoneal pouch which bulges out through the abdominal wall defect.
It has a neck (its junction with peritoneum), body and fundus
Contents :
Any abdominal viscus can protrude out into the sac except the pancreas
(it is retroperitoneal and fixed structure ).
The usual contents are intestine, omentum or both.
 Basic feature of Hernia: ( ventral hernia )

diagnosis of ventral hernia : clinically

( non complicated hernia )

may need U/S. CT .MRI .

*They occur at a weak spot

*They reduce on lying down or with manipulation

*They increase with cough and straining

How to differentiated between
omentocele & enterocele :
Omentum ( Omentocele) Intestine (Enterocele)

Doughy Soft Consistency

None Occurs during reduction Gurgling

last part is more difficult to reduce First part is more difficult to reduce Ease of reduction
than the last

Dull Maybe resonant Percussion

 Types of hernia :
• Richter's hernia.
• This type is common in a femoral hernia or trocar sites after laparoscopic
surgery.
• the antimesenteric wall of the bowel is herniated without comprising its
lumen which may lead to str angulated & perforation
• Maydl's (W) hernia.
• It contains two loops of intestine while an intermediate loop lies in
peritoneal cavity .
• Mild lobe which may be strangulated in peritoneal cavity .
• Intraoperative should be explore the whole segment of intestine
(w to u shaped)

Parastomal Hernia :
Parastomal hernia is a common complication of
stoma creation.
• Sliding hernia:
• A sliding hernia occurs when an internal organ composes a portion of the wall
of the hernia sac.
• The most common viscus involved is the colon or urinary bladder.
• The primary danger associated with a sliding hernia is the failure to recognize
the visceral component of the hernia sac before injury to the bowel or
bladder.
• The sliding hernia contents are reduced into the peritoneal cavity, and any
excess hernia sac is ligated and divided.

Littre's hernia :
The content is Meckel's diverticulum.

Amyand hernia :
• Pantaloone ( dual hernia ) :
Contains of both indirect & direct hernia .
The inferior epigastric vessels between tow sacs .
( Interstitial hernia ) Spigelian Hernias :
A spigelian hernia occurs through the spigelian fascia, which is composed of
the aponeurotic layer between the rectus muscle medially and semilunar
line laterally.
Almost all spigelian hernias occur at or below the arcuate line.
These hernias are often interparietal, with the hernia sac dissecting
posterior to the external oblique aponeurosis.
Patients often present with localized pain in the area without a bulge due to
small in size & because the hernia lies beneath the intact external oblique
aponeurosis. …..
Ultrasound or CT of the abdomen can be useful to establish the diagnosis.
Need surgical treatment
Umbilical hernia : he umbilicus is formed by the umbilical ring of the linea alba
types :
1)congenital : minor & major exomphalos
2)infantile: weakness of umbilical scar from infection of the umbilical cord stump,
increase with cough or crying
3)Adult
Paraumbilical hernia
• Definition: hernia passes through defect in the linea alba above or below umbilicus
• Etiology: as before This is because linea alba is wider and weaker above umbilicus than below it
• More frequent in middle aged females especially in obese multiparous women,
found partially irreducible with positive expansile cough .
• Pathology ：
• Defect: in the linea alba
• Sac:
Starts small, gradually enlarging . Narrow neck.
Multilocular fundus due to: Adherence of content to the fundus
. Site & shape : Crescentic in shape
• i. Usually above umbilicus (Supra-umbilical hernia).
• ii. Occasionally below the umbilicus (Infra-umbilical hernia).
• Contents: Omentum, transverse colon, and small intestine.
• Covering: Skin - Superficial fascia
• Descent: At first, directly forward then downward .
* Treatment Paraumbilical hernia : Surgery: the ONLY line of treatment
Small defect: anatomical repair.
Moderate size defect: → Mayo's Operation - (The standard repair)
• Incision: Transverse elliptical incision done over the dome of the hernia & enclosing
umbilicus
• Steps:
• The sac is opened at neck (due to adhesions at fundus & multilocation) & contents are
reduced after division of adhesions.
• The sac is excised
• Multiple overlapping transverse mattress sutures are inserted 3.5cm from the edge of upper
flap & 0.5cm from lower flap → the lower flap is drawn under cover of upper flap
• The remaining free edge of upper flap is then sutured to anterior rectus sheaths
• Large defect: → Hernioplasty
• In-lay to fill the defect
• On-lay after closure of defect
• Underlay: mesh is sutured to under surface of the peritoneum followed by closure of the
• Differential diagnosis: From other causes of umbilical swelling
• 1- Umbilical granuloma.
• 2- Umbilical adenoma or polyp.
• 3- Umbilical endometrioma.
• 4- Caput medusa.
• 5- Iry carcinoma
• 6- Sister-mary-Joseif nodule
• 7- Vitillo-intestinal duct cyst
• 8- Urachal cyst.
• 9. lipoma
• 10. sebaceous cyst
• 11. abscess
• 12. Umbilical PNS
Epigastric hernias :
are defects in the midline of the abdominal wall located between the
umbilicus and the xiphoid process (Linea alba).
These hernias are usually small but may be associated with multiple defects.
They result from multiple factors, including:
muscle weakness, congenitally weakened epigastric fascia, or increases in
intra-abdominal pressure.
Epigastric hernias rarely contain bowel and usually contain portions of the
omentum or falciform ligament.
Treatment : as paraumbilical hernia
Incisional Hernias :
Hernias that develop at sites of previous abdominal incisions .
Incisional hernias occur due to
Surgical site infection.
As a result of excessive tension and inadequate healing of a previous incision,
Obesity, advanced age, malnutrition, ascites, pregnancy, and conditions that increase intraabdominal
pressure are factors that predispose to the development of an incisional hernia .
Incisional hernias can be the most challenging and difficult to treat.
Treatment : hernioplasty
• Recurrent hernia : s/p hernial repair
• Incomplete removal of the sac
• Missing a second sac
• Inadequate repair bad choice of repair
• Suture: under tension - absorbable
• Imperfect haemostasias
Three types of hernias occur in
inguinal region :

• Indirect inguinal hernias

• Direct inguinal hernias
• Femoral herni

Most commom hernia

• inguinal hernia ( indrect & direct hernia ) 70%
• Incisional hernia
• Femoral hernia
Nyhus classification of groin hernia :
Direct hernia :
• Causes :
• Caused by transversalis fascia breakdown
• Its due to muscle weakness . Common in old age
• Injury of ilio-inguinal nerve. during appendectomy →paralysis of conjoint tendon
→direct inguinal hernia .

• Protrudes through Hasselbech's triangle

• Bowel bulges “directly” through abdominal wall
• Origin is medial to epigastric vessels
• Through external ring (not deep/internal)
• Direction forward & reduction backward
• bulge not reach into the scrotum
Indirect Inguinal Hernia :
• Most Common form of hernia in both males and female
• Indirect hernias are most common in the young whereas direct hernias are most common in the
old".
• Indirectly… through abdominal wall through internal ring .
• Then Travel through inguinal canal
• Origin lateral to epigastric vessels

• Follows path of descent of testes

• Covered by all layers of spermatic fascia

 Descent : downward forward & medially .

• Reduction : Upward backward & laterally

• Shape: pyriform in shape

• According to size ( bubonocele hernia . Funicular hernia .complete or scrotal hernia )

Q) In the first decade of life, the indirect inguinal hernia is more common on the right side in the male?

A) Due to later descent of the right testis and a higher incidence of failure of closure of processes vaginalis.

Herniotomy for children is a different operation from herniorrhaphy for adults as there is no need to repair
the posterior wall of the inguinal canal in children because there is no defect there.
 CLINICAL PICTURE OF HERNIA :
• Workup for inguinal hernia begins with a detailed history.
• The most common symptom of inguinal hernia is a groin mass that protrudes
while standing, coughing, or straining. It is sometimes described as reducible
while lying down.
• The pain is thought to be due to compression of the nerves by the sac,
causing generalized pressure, localized sharp pain, or referred pain. Referred
pain may involve the scrotum, testicle, or inner thigh.
• Symptoms that are extra inguinal such as a change in bowel habits or urinary
symptoms are far less common
• Picture of complication ( obstruction .strangulation) which need urgent
surgical intervention .
• Physical examination is essential to the diagnosis of inguinal hernia.
• The patient should be examined in a standing position to increase intra-
abdominal pressure, with the groin and scrotum fully exposed. Also to see
number of hernia
• Inspection is performed first, with the goal of identifying an abnormal
bulge along the groin or within the scrotum.
• If an obvious bulge is not detected, palpation is performed to confirm the
presence of the hernia.
• Thiers may maneuvers that can be performed to help distinguish direct vs.
indirect inguinal hernias. (Occlusion test . Zeman test .Invagination test )
• Invagination test :Palpation is performed by advancing the index finger
through the scrotum towards the external inguinal ring . The patient is
then asked to perform a Valsalva maneuver to increase intraabdominal
pressure.
• In addition to inguinal hernia, a number of other diagnoses may be
considered in the differential of a groin bulge.
Differences between indirect and
direct
Direct herniaIndirect
: Feature

Old age Children/ young people Age

Pass through hesselbech’s triangle Coming down the inguinal canal, may Pathway of protrusion
and rarely inter the scrotum inter the scrotum

Hemispheric, wide base Elliptic, pear shaped Contour of sac

Not controlled Controlled Compress the internal ring after

reduce

backword Upward, laterally, backward Reduction of hernia

Sac neck is medial to it Sac neck is lateral to it Relationship of sac neck with inferior
epigastric artery
Low High Incarcerated incidence
complication
1. Inflammation
2.Irreducibility.
3.Obstruction
4. Strangulation
5. Traumatic rupture of hernia:
This is usually due to blunt trauma to the abdomen .
It can occur during overenthusiastic attempts at reduction.
Rupture usually occurs at the neck of the sac.
Urgent laparotomy is needed.
 Inflammation
-This is an uncommon problem in a hernia, it means inflammation of the contents. .
-Causes :
fitting truss.
Spontaneous inflammation of contents (appendix, fallopian tube or ovary).
-Clinical features.
The hernia is tender but not tense, and the overlying skin is red and edematous.
-Treatment.
Operation is essential, as strangulation cannot be excluded.
Irreducibility
It means failure to return the contents into the abdomen.
Causes:
1)Adhesions that form within the sac either …..between the contents and the sac
or between the contents themselves.
2)Protrusion of more omentum or intestine within the sac.
Irreducibility predisposes to obstruction and strangulation and so operation is
essential..
Irreducibility without other symptoms of obstruction is almost diagnostic of
incarceration .
 Obstruction
This occurs in irreducible hernias due to occlusion of the intestinal lumen .
In a purely obstructed hernia the blood supply is unaffected.
There are symptoms of intestinal obstruction as vomiting, distension, colic's, and
constipation.
The picture simulates strangulation but is less severe.
Its difficult to distinguish between these two types so its better to do an early procedure
as it is strangulated
 Strangulation : (Strangulation is the most serious hernia complication )

-constriction of contents leading to interruption of their blood supply.

-If not relieved, gangrene may occur within a few hours
-Causes :
• Extrusion of new contents following straining. eg
Narrowing of the neck
sharp edge of the defect ( femoral )
Irreducibility .obstruction .& inflammation
▪ Repeated attempts at reduction, producing oedema.
Pathology of strangulated hernia : all types of hernia mostly femoral & then
paraumbilical hernia
*A resistant structure outside the sac as femoral ring or any defect as deep
inguinal ring .
*The neck of the sac is very constricted
*Bands of adhesions within the sac .
1. Initially, only the venous return is impeded.
2. The wall of the intestine becomes congested and bright red with the
transudation of serous fluid into the sac.
3. The intestinal pressure increases, distending the intestinal loop and impairing
venous return further.
4. As venous stasis increases, the arterial supply becomes more and more
impaired…… ischemia ….. Necrosis …..Perforation ….. Peritonitis .
Clinical picture of strangulated hernia :
1. History of hernia then Sudden enlargement
2. Acute pain at the site of hernia. Colicky stabbing pain (neurogenic shock )
3. Tense ( sever tenderness ) .No impulse on cough and Irreducible .
4. If the hernia contains intestine the patient develops symptoms of acute
ischemia
5. May be presented with clinically with picture of intestinal obstruction …
fluid loss lead hypovolemic shock
6. May be presented with septic shock due to perforation & peritonitis
7. If the hernia contains omentum which lead to omental infarction .
8- Emergency surgery . Monitoring & ( NPO . IVF .NGT. F catheter IV
antibiotics . IV analgesia )
Evaluation of intestine at time
of surgery :
Differential diagnosis of groin and
scrotal masses :
• Inguinal hernia • Hydrocele • Varicocele
• Ectopic testis • Epididymitis • Testicular torsion
• Lipoma • Hematoma • Sebaceous cyst
• Lymphoma • Femoral hernia • Femoral lymphadenopathy
• Femoral artery aneurysm or pseudoaneurysm
• Inguinal lymphadenopathy Metastatic neoplasm
• Hidradenitis of inguinal apocrine glands
Approach to “a patient with lump in
groin”
Approach to “a patient with lump in
groin”
Treatment :
• Certain elements of the review of systems such as chronic constipation, cough, or
urinary retention should prompt the surgeon to perform a thorough workup to rule
out any underlying malignancy.
• Conservative management of asymptomatic inguinal hernias is recommended.
• The use of prosthetic mesh as a reinforcement significantly improves recurrence
rates, whether the repair is open or laparoscopic.
• Laparoscopic inguinal hernia repair results in less pain ; however, mastery of this
technique has a longer learning curve. ( bilateral hernia . Recurrent hernia )
• Surgery :
Herniotomy . pediatric & children
Herniorrhaphy
Hernioplasty
• Surgical treatment of inguinal hernia : the most common operative
approach for inguinal hernias. Tension-free repairs are now standard, and
there are a variety of different types
• Main aims of inguinal hernia repair:
Reduce hernia contents
Remove hernia sac
Repair defect
Main approaches For primary uncomplicated inguinal hernias:
Bassini repair
• McVay–Cooper ligament operation
• Lichtenstein’s mesh repair
• Shouldice technique
• Laparoscopic repair
• Suitable for day case? • Local, spinal or general anesthesia? Urgent or
emergency repair
• Position: supine.
• Incision:
2.5 cm above medial two-thirds of inguinal ligament along a skin crease.
• Procedure
opened in layers incision to external oblique aponeurosis
• Ligate and divide superficial veins
• With scissors slit along fibers of external oblique as far as the superficial
inguinal ring
• Identify the ilioinguinal nerve .The genital branch of the genitofemoral
nerve and the ilio-hypogastric nerves are identified and avoided or mobilized
to prevent transection and entrapment .
• Protect the cord with a sling
• The Bassini repair is performed by suturing the transversus ab dominis and
internal oblique musculoaponeurotic arches or con joined tendon (when
present) to the inguinal ligament.

• Cooper ligament repair.

• also known as the McVay repair, has traditionally been popular for the
correction of direct inguinal hernias, large indirect hernias, recurrent hernias,
and femoral hernias.
• Interrupted nonabsorbable sutures are used to approximate the edge of the
transversus abdominis aponeurosis to Cooper ligament.
• When the medial aspect of the femoral canal is reached, a transition suture is
placed to incorporate Cooper ligament and the iliopubic tract. Lateral to this
transition stitch, the transversus abdominis aponeurosis is secured to the
iliopubic tract.
• In the Lichtenstein repair (tension-free Anterior Inguinal Hernia Repair)
A piece of prosthetic nonabsorbable mesh is fashioned to fit the canal.
Fixation of mesh to the pubic tubercle itself should be avoided to minimize the
risk of chronic groin pain.
A slit is cut into the distal lateral edge of the mesh to accommodate the
spermatic cord.
The inferolateral edge of the mesh is sutured to the shelving edge of the inguinal
ligament using a nonabsorbable suture.
This suture is taken to a point just lateral and superior to the internal inguinal
ring and tied.
Interrupted sutures are then placed affixing the superomedial aspect of the
mesh to the conjoined tendon. Great care is taken to visualize
• The Shouldice repair :
Emphasizes a multilayer imbricated repair of the posterior wall of the inguinal
canal with a continuous running suture technique.
After completion of the dissection, the posterior wall of the inguinal canal is
reconstructed by superimposing running suture lines progressing from deep to
more superficial layers.
• Laparoscopic repair
Postop. (Non complicated case )

• Often home the same day

• Eat, drink and mobilize on waking
• Back to sedentary job within 2 weeks
• Back to heavy lifting, strenuous sports in 6 weeks
• Oral analgesia may be needed for a few days Follow-up
 COMPLICATIONS After surgery :
( to anesthesia & surgery )

surgical side : open and laproscopic

As with other clean operations, the most common complications of inguinal
hernia repair include:
• Bleeding Haematoma & seroma, . Infection,
• urinary retention, . Ileus, and injury to adjacent structures

Complications specific to herniorrhaphy include :

Hernia recurrence, Injury to the spermatic cord or testis .
Chronic inguinal and pubic pain see next
Femoral triangle :
• Boundaries :
• Base : inguinal ligament
• Lateral : medial border of sartorius
• Medial : medial border of adductor longus
 Femoral sheet :
Site & shape : a funnel shaped fascial sleeve enclosing the upper 1.5 inches
of the femoral vessels

Its formed by downward extension of the abdominal facia :

Post wall formed by the fascia iliacus lining the post.
Abdominal wall
Ant. Wall formed by the facia transversalis lining the ant. Abdominal wall

Length :
Lateral wall vertical 4cm
Medial wall oblique 1cm
• Content of femoral sheet :
• Divided into three compartments by ant. Lateral septa
• Lateral compartment : femoral artery & femoral branch of Genito-femoral
nerve
• Intermediate compartment : femoral vein
• Medial compartment : femoral canal
Femoral canal :
• Site : medial compartment of femoral sheet
• Shape: conical wide above & narrow below
• Size : ½ inch long & ½ inch at base
• Contents: lymph node of Cloquet
lymph vessels
small amount of areolar tissue CT
Function :
lt act at dead space which accommodate the distention of the femoral vein that
occurs in case of increase venous return during exercise
Canal wide in female due wide pelvis & small diameter of femoral vein
 Anatomy of femoral ring :
• Oval in shaped
• Bounders
• Anterior: Inguinal ligament
• Posterior: Ilio-pectineal ligament
• Laterally : femoral vein
• Medially : the sharp edge of lacunar ligament
Femoral Hernias
 is the 3rd Most common type of primary hernia
• More common in women than men
• But indirect most common type for both genders
 More common in multipara
 Etiology : always acquired & never congenital
due to increase of abdominal pressure ( pregnancy )
 More common on right side; Bilateral in 20%
• Defect :Hernia through femoral ring
• Medial to femoral vessels
• Bowel protrudes below inguinal ligament & lateral to pubic tubercle
• Differentiates from both types of inguinal hernias
• Complication ……High risk of strangulation
• Femoral ring is small opening
• sharp edge of lacunar ligament
• Adhesions
• Retort shaped of hernia ( U shape )
….. Downward through femoral canal then
…… Forward through saphenous opening
…… Upward in the SC tissue may over lie the inguinal ligament
 Treatment of femoral hernia :
• Main aims
Reduce hernia contents
Remove peritoneal sac
Repair defect Three main approaches
Low crural (Lockwood)
High inguinal (Lotheissen)
High extraperitoneal (McEvedy)

Laparoscopic repair can also be performed.

• Indications :
All femoral hernias should be repaired as soon as possible , due to the high risk of
strangulation
. The low approach is the simplest approach and the most often used for elective repair.
It is a controversial approach for an incarcerated or strangulated hernia because it is
difficult to resect compromised bowel through this incision .

Preop preparation:
similar to inguinal hernias. • Suitable for day case? spinal or general anaesthetic? Urgent
or emergency repair? • Open or laparoscopic? Crural, inguinal or extraperitoneal
approach? •
Patient must be consented (mention relevant hazards and complications)

The correct side should be marked

Position: supine.
• Treatment:
• (1). Low approach (femoral approach) = Lockwood operation:
• Incision: 1/2 inch below & parallel to medial portion of the inguinal ligament
• Repair:
• The sac is identified and dissected → transfixion excision of the neck as high as possible
• Repair A Poupart (inguinal) to Pectineal ligaments → to close femoral ring
• (2)High approach (Mc Evedy's approach)
• Incision: A vertical incision is made over the femoral hernia & continued above the inguinal
ligament.
• Repair: Conjoined to Cooper's ligament closing femoral ring
• (3)Inguinal approach = Lotheissen's operation:
• Incision: Like an inguinal hernia incision.
• Repair: Poupart's to Pectineal ligaments.
• Conjoined to Cooper's ligament
• Poupart's to Conjoined to Pectineal ligaments
• (4) Mesh plug (done nowadays)
Approach to “a patient with lump in
groin”