A 40-year lady presented to emergency surgical unit with central abdominal pain, slight abdominal distention and vomiting for one day duration. She had a history of intermittent abdominal pain for 2 months duration, but the symptoms earlier were much milder than this episode. She had no other significant medical problems. Examination revealed a soft non-tender abdomen.
Examination of hernial orifices revealed a firm mass in the right side groin region. It was not obvious in the inspection. But was very much palpable. There was no cough impulse. It was not reducible. The lump was below and lateral to the pubic tubercle. There was mild tenderness over the lump. (Note: Non-strangulated hernia will have the typical cough impulse, but the cough impulse will be absent in a strangulated hernia. A non-reducible tender lump in the vicinity of a hernial orifice should raise the suspicion of a strangulated hernia.)
Considering the history and clinical findings of a femoral region lump raised the suspicion of a strangulated femoral hernia. An ultrasound scan confirmed the diagnosis. Then she was operated for a strangulated femoral hernia through the modified McEvedy approach.
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Figure 1 - Modified McEvedy Approach - Transverse incision 2 to 3 cm above the pubic tubercle going across the semilunar line |
Modified McEvedy approach uses a transverse incision about 2 -3 cm above the pubic tubercle going laterally along the skin tension lines. The incision is deepened to expose the anterior rectus sheath and the semilunar line (Lateral margin of the rectus abdominis muscle). The anterior rectus sheath is divided longitudinally along the semilunar line to expose the rectus abdominis muscle. Muscle is retracted medially to expose the transversalis fascia.
Blunt dissection of the transversalis fascia exposes the femoral canal medial to the femoral vein. Figure 2 shows the peritoneal sac going into the femoral canal.
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| Figure 2 - Peritoneal sac going into the femoral canal |
Before reducing the hernia, it is important to control the neck of the hernia sac, so that the content of the hernia sac does not reduce back to the peritoneal cavity. Thus we applied a non-crushing bowel clamp at the neck while the hernia was reduced.
Often it is difficult to reduce femoral hernias just by pulling at the neck. So pushing inwards from outside (onto the hernia sac) helps reduce the hernia. If both these measures fail we have to divide the inguinal ligament in order to reduce the hernia. Here we were able to reduce the hernia with the first two measures alone.
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| figure 3 - Congested hernia sac controlled at the neck |
Figure 3 shows the congested hernia sac. The hernia sac was opened to inspect the contents while soft bowel clamp was applied at the neck. Figure 4 shows the small bowel segment that was congested due to strangulation at the neck of the hernia. Fortunately, the involved small bowel segment was viable. The bowel was returned to the peritoneal cavity. Opened sac repaired. Femoral canal obliterated using a polypropylene mesh plug.
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| Figure 4 - Congested part of the small bowel. |
The patient had a smooth postoperative recovery and was discharged home on day 2.
Femoral canal is a narrow space just medial to the femoral vein. peritoneum along with extraperitoneal fat can herniate through this canal forming a femoral hernia. Due to this space being relatively narrow and longer, there is a high risk of strangulation. Often these hernias do not form a large hernia sac. But when bowel loops are involved and the hernia strangulates, it causes distressing symptoms.
Due to the high risk of strangulation, it is important to look for a femoral hernia in patients presenting with abdominal pain. If the clinical signs at the groin are not prominent, it is easy to miss these hernias especially if we do not specifically look for a femoral hernia.
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