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Femoral Hernia

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Femoral Hernia Femoral Hernia-Significance Femoral hernias compromise about 6% of hernias. This is about 1/10 the incidence of inguinal hernias. – PowerPoint PPT presentation

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Title: Femoral Hernia


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Femoral Hernia
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Femoral Hernia-Significance
  • Femoral hernias compromise about 6 of hernias.
    This is about 1/10 the incidence of inguinal
    hernias. About 85 of direct and indirect
    hernias are male. However about 85 of femoral
    hernias occur in females.
  • Femoral hernias are a not uncommonly missed
    source of SBO. Always check the inguinal area
    carefully for femoral hernias which are easily
    missed unless actively looked for. You will save
    a life!

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Femoral hernia- etiology
  • All are acquired.
  • Are secondary to an expanded femoral ring.
  • Probably due to increased intraabdominal
    pressure.As an example of this femoral hernias
    are much more common in nulliparous women

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Femoral hernia -Diagnosis
  • Diagnosis by physical exam.
  • A fixed mass is noted just below the inguinal
    ligament . If incarcerated chronically it will be
    medial to the femoral vessels.
  • Differential diagnosis includes lymph node,
    lipoma or saphenous varicosity
  • The masses may be differentiated by clinical
    characteristics

5
Femoral hernia -Diagnosis
  • Femoral hernia Chronically incarcerated. Mobile
    inferiorly, medially and laterally but appears
    fixed to the inguinal ligament.
  • Femoral hernia-Reducible. Will be obvious due to
    the ability to reduce the mass and the gurgling
    sensation if bowel is present within it
  • Lymph node- Usually more mobile in all directions
    .It is not fixed at the top. Also more
    superficial. If fixed usually deep.
  • LIpoma Can be lifted off the deep fascia
  • Saphenous varix-Collapse completely on lying down
    . Do not have as firm a character as femoral
    hernia.

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Femoral Hernia- Diagnosis
  • CT scan or Ultrasound may be useful in some cases.

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Femoral hernia- Surgical Repair
  • Anatomy is key. External iliac vessels run along
    the surface of the iliopsoas muscle in the
    pelvis, pass between the iliopubic tract and
    Coopers ligament and course beneath the inguinal
    ligament The opening of femoral canal is a
    musculoaponeurotic ring consisting of coopers
    ligament inferiorly,the femoral vein laterally
    and the ileopubic tract medially and superiorly.

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Femoral Hernia Repir- Primary From Below
  • Original approach was inferior to inguinal
    ligament with excision of sac and closure of
    inguinal ligament to pectineal fascia and Coopers
    ligament from below.
  • Approximately 5 recurrence rate.
  • Advantage is simple approach . Poor exposure
    intestine.

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Femoral Hernia Repair- Inguinal Approach
  • Hernia is approached via inguinal incision and
    Coopers Ligament repair performed.
  • Advantage is lower recurrence rate of femoral
    hernia and ability to approach intestine in more
    direct manner. Reported low recurrence rate.
  • Disadvantage is repair under tension and painful
    repair with longer recovery

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Femoral Hernia Repair-Extraperitoneal Approach
  • Transverse incision 4 cm above pubic tubercle.
    Expose the Femoral ring preperitonealy. Coopers
    ligament sutured to ileopubic tract.
  • Good exposure to incarcerated bowel. Low
    reccurrence rate reported -1

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Femoral hernia repair-Mesh Plug
  • Approach is from below inguinal ligament .
  • Hernia is exposed , sac opened ,bowel reduced.
  • Rolled mesh or plug is inserted into canal and
    fixed into position with sutures.
  • Hernia canal completely obliterated.
  • Must be careful not to damage vein

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Femoral hernia repair-Laparoscopic
  • Same approach as for inguinal . Either TEP or
    TAPP.
  • Advantage is good exposure and low recurrence
    rate.
  • Disadvantage is need for general anesthesia, more
    extensive surgery. Difficult to handle edematous
    or compromised bowel.

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Ventral Incisional Hernia
  • Approximately 2 million laparotomies performed
    in US per year
  • Reported incisional hernia rate of 2 to 3
  • Approximately100,000 ventral hernia repairs in US
    per year
  • Recurrence rates have been reported from 10 to
    50

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Incisional Hernia-Presentation
  • Visible bulge. May be cosmetically upsetting
  • Pain. May limit activities. Pain is increased
    with lifting , straining and coughing
  • Incarceration. Severe acute pain with tenderness
    over the hernia site
  • Bowel obstruction- due to acute or chronic
    incarceration with typical symptoms

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Incisional hernia Diagnosis
  • Physical exam- typical bulge which increases with
    increase in intraabdominal pressure- unless the
    hernia is chronically incarcerated in which case
    there may be a fixed mass. Acute incarceration
    shows sign of inflammation with redness and
    tenderness.In obese patients hernia may not be
    evident.

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Incisional Hernia-Diagnosis
  • CT Scan -very helpful in obese patients.
    Frequently will reveal additional less clinically
    obvious hernia
  • Ultrasound- My be useful especially in office
    setting when P.E. is uncertain.
  • Laparoscopy -For patients with pain and symptoms
    suggestive of hernia, but negative p.e. and
    imaging studies

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Incisional hernia -diagnosis
  • Diastasis recti vs Incisional
    hernia Diastasis is a thinning or weakening of
    the fascial membrane connecting the rectus
    muscle.It is not a hernia and generally is
    asymptomatic and will not lead to incarceration.
    It may be cosmetically unsightly.It is usually
    located in the upper abdomen and may occur
    spontaneously.It is recognizeable by its diffuse
    nature, keel formation and lack of a ring

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Incisional Hernia-Treatment
  • Treatment is surgical unless comorbidities
    preclude this.

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Incisional hernia-Risk Factors
  • Obesity-Up to 20 rate of hernia reported after
    bariatric surgery
  • Wound Infection-Bucknell found a 23 hernia rate
    after wound infection
  • Increased intra-abdominal pressure-Such as
    ascites, ileus or SBO,coughing and vomiting
  • Malnourishment /Hypoproteinemia(makela et al)
  • Emergent operation
  • Anemia
  • COPD/Pulmonary complicatios

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Incisional hernia Risk Factors
  • Type of incision- Transverse stronger then
    vertical. Carlson found 10.5 rate for midline
    vertical vs 7.5 rate for transverse and 2.5 for
    paramedian incision
  • Suture material Non-absorbable-May serve as
    nidus for infection Also has cutting effect on
    tissue over the long term resulting in late
    hernia.Polyglactin suture(long lasting
    absorbable) has been recommended to avoid this.
  • Continuous vs interrupted- No significant
    difference shown

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Incisional Hernia- Primary Repair
  • Bring together fresh fascial edges after trimming
    sac
  • Clean off fascial edges at least 1 cm back
  • Close with interrupted or continuous sutures
  • Even with careful technique recurrence rates as
    high as 50 have been reported

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Incisional hernia repair-Separation of Parts
  • Procedure mobilizes rectus muscle,decreasing
    tension on closure
  • Performed by exposing fascia of abdominal wall
    laterally and vertically incising fascia over
    the external oblique
  • Intra-abdominally a vertical incision is made
    vertically in the peritoneum laterally to the
    rectus muscle.
  • 8 recurrence rate and 10 skin and wound
    complication rate reported with this technique

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Incisional Hernia-Prosthetic Mesh
  • Onlay mesh repair-Primary repair performed and
    then a mesh prosthesis is fixed into position
    over the repair. This should widely cover the
    repair and requires cleaning off the fascia and
    undermining the skin and subq for a wide distance
  • Little data on success of repair but very
    popular.
  • Disadvantages- Still a tension
    repair Large sub q dissection can lead to
    seroma Infection rate may be
    10-20

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Incisional Hernia Repair
  • Inlay mesh-Sac excised and mesh sewn to fascial
    edges.This is a non tension repair. Must use non
    adherent mesh such as PTFE(gortex) if bowel will
    be in contact with the mesh.Disadvantage is
    possible continued bulge after repair.
  • Retro rectus or Stoppa repair. A plane is
    dissected between posterior rectus and
    peritoneum. Mesh is placed in this plane.Reported
    recurrence rate of 10.Reported infection and
    mesh removal rate of 5-10.

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Incisional hernia-Mesh repair
  • Dutch study( NEJM 8/20/2000)Luijendijk et.al.
  • Multicenter randomized study compared primary
    suture repair to inlay mesh repair in 200
    patients.Hernias were midline and 6cm or less.
  • 3 year cummulative recurrence rate was 43 for
    suture group and 24 for the mesh group

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Incisional hernia repair-Laparoscopic
  • Placement of mesh intra abdominally. This can be
    done with open technique as well. Need a mesh
    with a least one non adherent side to be facing
    the intestines.
  • Laparoscopic repair involves entering the abdomen
    from sites away from hernia,lysing adhesions and
    fixing the mesh into positon widely around the
    hernia deficit. Has a reported recurrence rate as
    low as 5

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Incisional hernia-Laparoscopic repair
  • Franklin et. al.-184 patients with complex
    umbilical and incisional hernias. 1 to 84 months
    f/u. Infecton rate1.7 . Recurrence rate 1.1
  • Berger et.al.- 150 patients repaired with
    Goretex Dualmesh.3 year follow up. No infections
    of mesh. 4 Cases of recurrence. 4 trocar hernia
    sites occurred. 2 cases of bowel perforation
    occurred.

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Incisional Hernia Laparoscopic Repair
  • Advantages Less pain Good view of
    possible other hernia
  • Disadvantages May still have bulge
    Possible bowel injury Seroma rate 15-20

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Incisional hernia repair-Mesh types
  • Polypropylene-Woven mesh. Most popular and comes
    in many variaties . Has good tissue incorporation
    but if intestine is exposed to it there is a
    tendency for severe adhesions and fistula
  • Polytetrafluoroethylene (PTFE-Gortex)
    Soft and low reaction rate.Low rate of bowel
    adhesion or fistula but higher rate of poor
    tissue incorporation and seroma and infection.
  • Combination mesh with prolene on one side and
    PTFE on the other(Composix,Dualmesh)

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Incisional Hernia-Mesh Type
  • Absorbable mesh-Made from Vicryl or Dexon and
    used in cases of contamination or infection
  • Biologic mesh- Made from decellularized tissue
    from swine or embryo leaving a collagen
    matrix.Also used in high risk cases.Long term
    strength of repair still uncertain.

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Umbilical Hernia
  • Three types Congenital (omphalocoele) Infa
    ntile-Fascial defect only.If less than 1cm
    ,95 close before age 5. Repair indicated for
    hernias greater then 2cm,after age
    4-5 Adult-Acquired

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Umbilical hernia-Risk Factors
  • Multiple Pregnancies
  • Prolonged labor
  • Ascites
  • Large Abdominal Tumors-CT scan may be indicated
    for some patients
  • Activities which result in strenuous physical
    activity(occupational or recreational example
    weight lifting)

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Umbilical hernia
  • More common in women
  • Morbitiy and incarceration rate considered to be
    high enough to warrant repair. One study showed
    incarceration twice that of femoral hernia .

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Umbilical hernia repair
  • Traditional Primary repair-Most well known is
    Mayo or Pants over Vest most widely used in the
    first half of century
  • Unfortunately, recurrence rates as high as 20 -28
    have been recorded.

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Umbilical Hernia Repair
  • Primary repair
  • Primary repair with mesh onlay
  • Non tension repair with mesh inlay or plug and
    patch
  • Laparoscopic.

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  • ..\Desktop\ventral hernia\herL5175umb6

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Umbilical Hernia Repair
  • Randomized study by Arroyo et al.
  • 200 patients.Tension free repair 1 recurrence
    rate vs 11 for primary repair

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Epigastric Hernia
  • Spontaneous hernia . Occur above umbilcus,
    generally in midline.
  • Etiology unknown. May be related to congential
    abnormality of fascial fibers
  • May be several cm in size or small with
    incarcerated preperitoneal fat
  • Maybe painful. Differential dx can include a
    variety of upper abdominal G.I conditions.
  • Repair similar to ventral or umbilical hernia

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Spegelian Hernia
  • Rare-850 reported cases
  • Diagnosis Abdominal pain or mass noted in
    abdominal wall.Frequently tender ovr area
  • Ultrasound or CT may be helpful
  • Primary repair through transverse or vertical
    incision./-Mesh. Laparoscopic approach possible

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Obturator hernia
  • Rare.Primarily older women
  • Presentation-Acute pain and small bowel
    obstruction.
  • Howship- Romberg Sign-Pain extending down medial
    thigh.Hernia mass rarely palpable
  • Frequently have h/o previous attacks

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Obturator hernia
  • Surgical approaches- Abdominal approach probably
    best. Allows for bowel resection if
    necessary.Best place to cut obturator membrane is
    inferor margin. May need mesh.

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