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View Full Version : FEMORAL HERNIA(Etiology-Pathology-Clinical picture-Complications-Investigations-Treatment)



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06-08-2008, 08:21 AM
Definition:
It is a hernia through femoral ring passing through the femoral canal to appear in the thigh.
Anatomy of Femoral Canal:
It is the most medial compartment of femoral sheath. It extends from the femoral ring above to the saphenous opening below.

The femoral ring is bounded by:
Medially ; Concave knife like edge of lacunar (Gimbernat)’s ligament)
Laterally ; A thin septum separating it from the femoral vein.
Anteriorly ; inguinal ligament (Poupart's ligament).
Posteriorly ; Iliopectineal (Astly Cooper's) ligament
The femoral canal contains:
Fat
Lymphatic vessels (transmit lymphatics of the thigh to abd.)
Lymph node of Clocket'
It is closed closed above by septum crural (condensation of extraperitoneal tissue traversed by lymphatics) and below by crebriform fascia.
Incidence:
1. It is the third most common type of primary hernia.
2. 20% of hernias in women and 5% in men.
3. It is rare before puberty, and the prevalence rises with the age.
4. The right side is affected twice as often as the left, 20% of cases are bilateral.
5. Of all hernias it is the most liable to become strangulated because of narrowness of the neck and rigidity of the femoral ring.
Femoral hernia is common in female > male WHY?
1- Wide pelvis with wide femoral canal.
2- Pregnancies causes increase in intra-abdominal pressure.
Pathology:
1) Sac: peritoneal fold with narrow neck so it is common to strangulate.
2) Content: as before but Richter type is common.
3) Covering: skin, fascia & cribriform fascia (which covers the saphenous opening)
4) Descent:
a- Downward through femoral canal then,
b- Forward pushing the cribriform fascia then,
c- Upward and may lie over ing. lig. (Due to attachment of the membranous layer of fascia of the abdomen to deep fascia of lower limb.
Rare types of femoral hernia:
Ä Laugier’s femoral hernia: This is a hernia through a gap in the lacunar ligament. It is more medial in position and nearly always strangulated.
Ä Narath’s femoral hernia: The hernia lies hidden behind the femoral vessels. It occurs only in patients with congenital hip dislocation due to lateral displacement of the psoas muscle.
Ä Cloquet’s hernia: The sac lies below the fascia covering the pectineus muscle. The sac may coexist with the usual type of the femoral hernia.
Clinical Picture:
The symptoms are less than inguinal hernia.
Sometimes unnoticed until strangulate.
If presented without strangulation, it pulges below the pubic tubercle. Ask the patient to do adduction against resistance then follow adductor longus tendon to reach pubic tubercle.
D.D. of Femoral Hernia:
1. Hernia ® inguinal hernia, obturator hernia.
2. Vein ® saphena varix.
3. Artery ® femoral aneurysm.
4. Lymph node ® especially Cloquet's lymph node.
5. Muscle ®Psoas abscess & psoas bursa (increase in size in flexion) Also rupture of adductor longus with haematoma.
6. Lipoma.
Treatment:
Absolutely by surgery WHY?
1- Truss is contraindicated
2- The commonest hernia to strangulate
Operations:
(I) The Low Operation (Lockwood)
* Incision in the thigh below the inguinal ligament.
* Excise the sac then suture inguinal ligament. to iliopectineal line.
(II) The high "Lotheissen's Operation"
* Incision is similar to that of inguinal hernia.
* Fascia transversalis is opened and the sac extracted & excised.
* Then suture conjoined tendon to iliopectineal line.
(III) The "Mc Evedy's Operation"
* Incision is vertical over the femoral canal extending above inguinal ligament (in skin & s. c. tissue)
* Then do 2 incisions, one above the ingunal ligament & one below it, to dissect and excise the sac.
* Then suture conjoined tendon to iliopectineal line
F N.B. High approach is preferred due to:
1- The sac is completely excised
2- Abnormal obturator artery can be seen & ligated
SOURCE: DR. AYMAN SALEM'S BOOK
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