CASE REPORT – OPEN ACCESS International Journal of Surgery Case Reports 17 (2015) 85–88
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.casereports.com
Laparoscopic repair of an incarcerated femoral hernia Yagan Pillay ∗ Department of General Surgery,Victoria Hospital, Prince Albert Parkland Health Region, 1521 6th Avenue West Prince Albert, SK S6V5K1, Canada
a r t i c l e
i n f o
Article history: Received 17 September 2015 Accepted 25 October 2015 Available online 30 October 2015 Keywords: Femoral hernia Laparoscopic hernia repair Hernia incarceration
a b s t r a c t INTRODUCTION: A femoral hernia is a rare, acquired condition, which has been reported in less than 5% of all abdominal wall hernias, with a female to male ratio of 4:1. PRESENTATION OF CASE: We report a case in a female patient who had a previous open inguinal herniorrhaphy three years previously. She presented with right sided groin pain of one month duration. Ultrasound gave a differential diagnosis of a recurrent inguinal hernia or a femoral hernia. A transabdominal preperitoneal repair was performed and the patient made an uneventful recovery. DISCUSSION: Laparoscopic repair of a femoral hernia is still in its infancy and even though the outcomes are superior to an open repair, open surgery remains the standard of care. The decision to perform a laparoscopic trans abdominal preperitoneal (TAPP) repair was facilitated by the patient having previous open hernia surgery. The learning curve for laparoscopic femoral hernia repair is steep and requires great commitment from the surgeon. Once the learning curve has been breached this is a feasible method of surgical repair. This is demonstrated by the fact that this case report is from a rural hospital in Canada. CONCLUSION: Laparoscopic femoral hernia repair involves more time and specialized laparoscopic skills. The advantages are a lower recurrence rate and lower incidence of inguinodynia. © 2015 The Authors. Published by Elsevier Ltd. on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction A femoral hernia while a rare occurrence can be problematic as they often present with symptoms of incarceration or strangulation. It is more common in females and the type of repair can be controversial. While open surgery remains the standard of care, laparoscopic surgery has lower recurrence rates and post operative
Fig. 2. Release of the omentum from the hernial defect.
pain (Fig. 1). This type of repair however has a steep learning curve and still presents a challenge for surgeons. 2. Case report
Fig. 1. Incarcerated omental contents in the femoral hernia (blue arrow).
∗ Fax: +1 3067643091. E-mail addresses: [email protected], [email protected]
A 45 year old female presented with right groin pain of one month duration. There was no history of trauma. Past history: Open right inguinal herniorrhaphy three years previously Clinical exam revealed a swelling in the right groin below the inguinal ligament (Fig. 2). The swelling could not be completely reduced. There was no erythema or fluctuance around the swelling. The rest of the abdom-
http://dx.doi.org/10.1016/j.ijscr.2015.10.031 2210-2612/© 2015 The Authors. Published by Elsevier Ltd. on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
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Y. Pillay / International Journal of Surgery Case Reports 17 (2015) 85–88
Fig. 3. Incidental ovarian cyst and hernial defect (blue arrow).
inal examination was uneventful. The patient was well systemically (Fig. 3). Ultrasound of the pelvis showed a recurrent inguinal hernia or a differential diagnosis of a femoral hernia on the right side (Fig. 4). The patient was operated upon laparoscopically as she had
Fig. 4. Femoral canal (blue arrow), pubic bone (double arrow) and broad ligament (curved arrow) after peritoneal flap creation.
Fig. 5. Diagrammatic representation of the relevant anatomy [6].
CASE REPORT – OPEN ACCESS Y. Pillay / International Journal of Surgery Case Reports 17 (2015) 85–88
Fig. 6. Lacunar ligament (blue arrow) medial to femoral canal (double arrow).
87
Fig. 8. Superior mesh fixation to the anterior abdominal wall.
Fig. 9.
Fig. 7. Mesh fixation to coopers ligament medially.
a previous open repair. She had a trans abdominal pre-peritoneal (TAPP) mesh repair. Her post operative recovery was uneventful and she was discharged home on post operative day one (Fig. 5). 3. Discussion Femoral hernias are relatively uncommon (Fig. 6). They account for less than 5% of all hernias. Femoral hernias occur just below the inguinal ligament, when abdominal contents pass through a naturally occurring weakness called the femoral canal. They are more common in females because of the wider bone structure of the female pelvis by a ratio of 4:1 (female:male) [1]. Femoral hernias are more common in multiparous females as compared to non-parous females (Fig. 7). Approximately 60% of femoral hernias are found on the right, 30% on the left, and 10% bilaterally [2]. An enlarged femoral ring is thought to be the cause of the femoral hernia [7]. The lacuna vasorum increases in size as a person ages and is thought to be the reason for the increased incidence in the elderly [8]. Three approaches have been described for open surgery: Lockwood’s infra-inguinal approach, Lotheissen’s trans-inguinal approach and McEvedy’s high approach (Fig. 8). The infra-inguinal approach is the chosen method for elective repair while McEvedy’s approach is preferred in the emergency setting when strangulation is suspected as this approach allows better access for visualisation of bowel and possible resection if needed [3]. Laparoscopic repair involves the extraperitoneal (TEPP) or transabdominal preperitoneal (TAPP) approach (Fig. 9). While there is good evidence for this method of repair it is still not the standard of care. This is in part due to the abnormally steep learning curve for surgeons (Fig. 10). It involves more time and specialised laparoscopic skills. The advantages are a lower recurrence
Fig. 10. Mesh reperitonealisation.
rate and post operative pain [3,5]. Once the learning curve has been breached this repair is eminently feasible as evidenced by the repair of this patient’s hernia in a rural hospital in Saskatchewan, Canada by a surgeon with no formal training in minimally invasive surgery. Conflict of interests Not applicable. Funding No funding.
CASE REPORT – OPEN ACCESS 88
Y. Pillay / International Journal of Surgery Case Reports 17 (2015) 85–88
Consent I have consent from the patient. I submitted the incorrect form previously. That form was for another case report already published. Research registry UIN is 554. Author contribution
[3] N. Stoikes, E. Mangiante, G. Voeller, Laparoscopic repair of a man with massive bilateral femoral hernias, Am. Surg. 75 (2009) 1189–1192. [5] R.C. Read, Crucial steps in the evolution of the preperitoneal approaches to the groin: an historical review, Hernia 15 (1) (2011) 1–5. [6] George A. Sarosi Jr., Kfir Ben-David, Laparoscopic inguinal and femoral hernia repair in adults, in: T. Post (Ed.), UptoDate, UptoDate, Waltham, MA, 2015 (Reference for Figure 5). [7] C.B. McVay, L.E. Savage, Etiology of femoral hernia, Ann. Surg. 154 (1961) 25–32. [8] T. Hachisuka, Femoral hernia repair, Surg. Clin. North. Am. 83 (2003) 1189–1205.
Yagan Pillay—only author. Acknowledgement None.
[4] Ioannis Nikolopoulos, Eshan Oderuth, Eleni Ntakomyti, Case Reports in Surgery, Hindawi Publishing Corporation, Vol. 2014; 3 p, 10.1155/2014/195736, Article ID 195736.
References [1] R.T. Kochupapy, G. Ranganathan, S. Dias, D. Shanahan, R. Ann, Coll. Surg. Engl. 95 (2013) e14–e16. [2] A. Mahajan, A. Luther, Incarcerated femoral hernia in male: a rare case report, Int. Surg. J. 1 (2014) 25–26.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.casereports.com
Laparoscopic repair of an incarcerated femoral hernia Yagan Pillay ∗ Department of General Surgery,Victoria Hospital, Prince Albert Parkland Health Region, 1521 6th Avenue West Prince Albert, SK S6V5K1, Canada
a r t i c l e
i n f o
Article history: Received 17 September 2015 Accepted 25 October 2015 Available online 30 October 2015 Keywords: Femoral hernia Laparoscopic hernia repair Hernia incarceration
a b s t r a c t INTRODUCTION: A femoral hernia is a rare, acquired condition, which has been reported in less than 5% of all abdominal wall hernias, with a female to male ratio of 4:1. PRESENTATION OF CASE: We report a case in a female patient who had a previous open inguinal herniorrhaphy three years previously. She presented with right sided groin pain of one month duration. Ultrasound gave a differential diagnosis of a recurrent inguinal hernia or a femoral hernia. A transabdominal preperitoneal repair was performed and the patient made an uneventful recovery. DISCUSSION: Laparoscopic repair of a femoral hernia is still in its infancy and even though the outcomes are superior to an open repair, open surgery remains the standard of care. The decision to perform a laparoscopic trans abdominal preperitoneal (TAPP) repair was facilitated by the patient having previous open hernia surgery. The learning curve for laparoscopic femoral hernia repair is steep and requires great commitment from the surgeon. Once the learning curve has been breached this is a feasible method of surgical repair. This is demonstrated by the fact that this case report is from a rural hospital in Canada. CONCLUSION: Laparoscopic femoral hernia repair involves more time and specialized laparoscopic skills. The advantages are a lower recurrence rate and lower incidence of inguinodynia. © 2015 The Authors. Published by Elsevier Ltd. on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction A femoral hernia while a rare occurrence can be problematic as they often present with symptoms of incarceration or strangulation. It is more common in females and the type of repair can be controversial. While open surgery remains the standard of care, laparoscopic surgery has lower recurrence rates and post operative
Fig. 2. Release of the omentum from the hernial defect.
pain (Fig. 1). This type of repair however has a steep learning curve and still presents a challenge for surgeons. 2. Case report
Fig. 1. Incarcerated omental contents in the femoral hernia (blue arrow).
∗ Fax: +1 3067643091. E-mail addresses: [email protected], [email protected]
A 45 year old female presented with right groin pain of one month duration. There was no history of trauma. Past history: Open right inguinal herniorrhaphy three years previously Clinical exam revealed a swelling in the right groin below the inguinal ligament (Fig. 2). The swelling could not be completely reduced. There was no erythema or fluctuance around the swelling. The rest of the abdom-
http://dx.doi.org/10.1016/j.ijscr.2015.10.031 2210-2612/© 2015 The Authors. Published by Elsevier Ltd. on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
CASE REPORT – OPEN ACCESS 86
Y. Pillay / International Journal of Surgery Case Reports 17 (2015) 85–88
Fig. 3. Incidental ovarian cyst and hernial defect (blue arrow).
inal examination was uneventful. The patient was well systemically (Fig. 3). Ultrasound of the pelvis showed a recurrent inguinal hernia or a differential diagnosis of a femoral hernia on the right side (Fig. 4). The patient was operated upon laparoscopically as she had
Fig. 4. Femoral canal (blue arrow), pubic bone (double arrow) and broad ligament (curved arrow) after peritoneal flap creation.
Fig. 5. Diagrammatic representation of the relevant anatomy [6].
CASE REPORT – OPEN ACCESS Y. Pillay / International Journal of Surgery Case Reports 17 (2015) 85–88
Fig. 6. Lacunar ligament (blue arrow) medial to femoral canal (double arrow).
87
Fig. 8. Superior mesh fixation to the anterior abdominal wall.
Fig. 9.
Fig. 7. Mesh fixation to coopers ligament medially.
a previous open repair. She had a trans abdominal pre-peritoneal (TAPP) mesh repair. Her post operative recovery was uneventful and she was discharged home on post operative day one (Fig. 5). 3. Discussion Femoral hernias are relatively uncommon (Fig. 6). They account for less than 5% of all hernias. Femoral hernias occur just below the inguinal ligament, when abdominal contents pass through a naturally occurring weakness called the femoral canal. They are more common in females because of the wider bone structure of the female pelvis by a ratio of 4:1 (female:male) [1]. Femoral hernias are more common in multiparous females as compared to non-parous females (Fig. 7). Approximately 60% of femoral hernias are found on the right, 30% on the left, and 10% bilaterally [2]. An enlarged femoral ring is thought to be the cause of the femoral hernia [7]. The lacuna vasorum increases in size as a person ages and is thought to be the reason for the increased incidence in the elderly [8]. Three approaches have been described for open surgery: Lockwood’s infra-inguinal approach, Lotheissen’s trans-inguinal approach and McEvedy’s high approach (Fig. 8). The infra-inguinal approach is the chosen method for elective repair while McEvedy’s approach is preferred in the emergency setting when strangulation is suspected as this approach allows better access for visualisation of bowel and possible resection if needed [3]. Laparoscopic repair involves the extraperitoneal (TEPP) or transabdominal preperitoneal (TAPP) approach (Fig. 9). While there is good evidence for this method of repair it is still not the standard of care. This is in part due to the abnormally steep learning curve for surgeons (Fig. 10). It involves more time and specialised laparoscopic skills. The advantages are a lower recurrence
Fig. 10. Mesh reperitonealisation.
rate and post operative pain [3,5]. Once the learning curve has been breached this repair is eminently feasible as evidenced by the repair of this patient’s hernia in a rural hospital in Saskatchewan, Canada by a surgeon with no formal training in minimally invasive surgery. Conflict of interests Not applicable. Funding No funding.
CASE REPORT – OPEN ACCESS 88
Y. Pillay / International Journal of Surgery Case Reports 17 (2015) 85–88
Consent I have consent from the patient. I submitted the incorrect form previously. That form was for another case report already published. Research registry UIN is 554. Author contribution
[3] N. Stoikes, E. Mangiante, G. Voeller, Laparoscopic repair of a man with massive bilateral femoral hernias, Am. Surg. 75 (2009) 1189–1192. [5] R.C. Read, Crucial steps in the evolution of the preperitoneal approaches to the groin: an historical review, Hernia 15 (1) (2011) 1–5. [6] George A. Sarosi Jr., Kfir Ben-David, Laparoscopic inguinal and femoral hernia repair in adults, in: T. Post (Ed.), UptoDate, UptoDate, Waltham, MA, 2015 (Reference for Figure 5). [7] C.B. McVay, L.E. Savage, Etiology of femoral hernia, Ann. Surg. 154 (1961) 25–32. [8] T. Hachisuka, Femoral hernia repair, Surg. Clin. North. Am. 83 (2003) 1189–1205.
Yagan Pillay—only author. Acknowledgement None.
[4] Ioannis Nikolopoulos, Eshan Oderuth, Eleni Ntakomyti, Case Reports in Surgery, Hindawi Publishing Corporation, Vol. 2014; 3 p, 10.1155/2014/195736, Article ID 195736.
References [1] R.T. Kochupapy, G. Ranganathan, S. Dias, D. Shanahan, R. Ann, Coll. Surg. Engl. 95 (2013) e14–e16. [2] A. Mahajan, A. Luther, Incarcerated femoral hernia in male: a rare case report, Int. Surg. J. 1 (2014) 25–26.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
