Clinical assistant physician coaching essence: femoral hernia

Femoral hernia (femoral hernia) refers to the organs or tissues through the femoral ring protruded into the femoral canal, and then protruded through the femoral canal ovoid fossa. Femoral hernia is most common in women of middle age or older who are menstruating, and is more common on the right side. The femoral canal is a narrow, funnel-shaped gap with two openings: the upper opening is the femoral ring, which is oval in shape; the lower opening is the fossa ovalis, where the saphenous vein crosses into the femoral artery. The anterior border of the femoral canal is the inguinal ligament, the posterior border is the pubic comb ligament, the inner border is the ligament of the trap, and the outer border is the femoral vein. The femoral canal is almost vertical, but as soon as it exits the fossa ovalis, it turns forward and forms an acute angle. Coupled with the narrowness of the femoral ring itself, the surrounding ligaments are tough and very susceptible to incarceration, and rapidly develop into strangulation. Because the female pelvis is wider, the gap between the deep surface of the inguinal ligament is also wider, so women are more prone to induce femoral hernia than men; but femoral hernia is less common than inguinal hernia.

I. Clinical manifestations

1. Usually the femoral hernia has no special discomfort, only in the inguinal lower part of the thigh near the root of the round mass. Because the femoral tube is thin, femoral hernia line zigzag, rest and lie down is not easy to make the hernia block shrink or completely back to disappear. Coughing impact is not obvious.

2. About half or more of the femoral hernia can be complicated by incarceration and strangulation, mostly due to acute abdominal pain or strangulated bowel obstruction. Hernia content is often the omentum, intestinal wall hernia (Richter's hernia) is also not uncommon. Femoral hernias are characterized by refractory nature and are prone to incarceration and strangulation.

Second, the diagnostic basis

1. The inguinal ligament below the emergence of reversible mass. It is more common in older women.

2. The mass protrudes from the saphenous vein fissure (fossa ovalis) under the inguinal ligament and is not easy to return.

3. Paroxysmal abdominal pain, accompanied by nausea and vomiting, may occur after the mass is embedded.

Third, easy to misdiagnose the disease

1. Inguinal hernia femoral hernia: sometimes confused with inguinal hernia. If the inguinal ligament is the boundary, the femoral hernia mass should be located in the inguinal ligament below, outside the pubic tubercle below, while the inguinal hernia mass is located in the inguinal ligament above. A femoral hernia is usually small and not easy to retrieve, and there is often no history of recurrent prolapse, while an inguinal hernia is easier to retrieve, and its retrieval path is different from that of a femoral hernia.

2. Chronic lymphadenitis: chronic lymphadenitis of the femoral triangle can be palpable several enlarged lymph nodes, and easy to push, may also have a history of acute infection. The femoral hernia is a single difficult-to-recover mass.

3. Varicose saphenous vein: the varicose saphenous vein at the confluence of the fossa ovalis can form a venous mass, which must be differentiated from the femoral hernia. If the affected limb is elevated after lying down, the vein mass disappears rapidly and reappears after standing up, accompanied by varicose veins in the lower limbs.

4. Round ligament cyst: located in the inguinal canal, in the inguinal ligament above, according to which can be identified with femoral hernia. In addition, the mass is round or oval, with greater mobility and cystic sensation.

5. Cold abscess of lumbar major muscle: Cold abscess formed by tuberculosis of lumbar spine often extends downward along the iliopsoas muscle and appears on the medial thigh root. It is actually not in the part of the femoral hernia, such as carefully determine the anatomical signs, it is not difficult to make the identification. In addition, the cold pus ulcer has a clear sense of fluctuation, combined with lumbar spine X-ray film will find tuberculosis foci.

Fourth, the principle of treatment

femoral hernia should be surgical treatment, surgical access to the inguinal and subinguinal two.

1. Inguinal access: the use of oblique hernia incision, layer by layer dissection to reveal the posterior wall of the inguinal canal, the round ligament - spermatic cord upward, in the inguinal ligament on the medial side of the transversus abdominis fascia incision, you can find the femoral ring and the hernia sac neck. The neck of the hernia sac is incised, the hernia contents are retracted, and a high hernia sac ligation is performed above the femoral ring; the distal hernia sac does not need to be treated. In case of incarcerated femoral hernia, the iliopubic bundle of the inner boundary of the femoral ring must be cut open to loosen the iliopubic bundle and trap ligament, and then the hernia block will be pushed back into the hernia, do not lift the incarcerated hernia content in the upper mouth of the femoral canal.

The femoral hernia is repaired by suturing the inguinal ligament, the iliopubic bundle, the entrapment ligament, and the pubic comb ligament to close the femoral ring, taking care to avoid inadvertent injury to the femoral vein; the McVay method can also be used to suture the internal oblique muscle, the arch of the transversus abdominis tendon membrane, the upper cut edge of the transversus abdominis fascia, and the conjoint tendon to the ligament of the pubic comb, and the lateral suture is made to the femoral sheath and the spermatic cord on the medial aspect of the femoral sheath.

2. Inferior inguinal access: an incision is made all the way down the inguinal ligament at the fossa ovalis, the sieve fascia is incised to reveal the hernia sac, the hernia sac is incised to retrieve the hernia contents, the hernia sac is ligated high and the inguinal ligament, ilio-pubic bundle, and the trapezius ligament are sutured with the ligament of pubic symphysis, and the pubic fascia to close the femoral ring.

Although the femoral hernia surgery has two entry paths, but more use of the inguinal entry path, the advantage is that it can clearly reveal the femoral ring, the real hernia sac high ligation and suture closure of the femoral ring. For strangulated femoral hernia should be used in order to better deal with the strangulated hernia content, these are the lower inguinal access can not be done, the latter advantage is simple operation, less trauma.