Introduction to Femoral Hernia

Contents 1 Pinyin 2 English reference 3 Overview 4 Name of the disease 5 English name 6 Classification 7 ICD number 8 Epidemiology 9 Etiology of femoral hernia 10 Pathogenesis 11 Clinical manifestations of femoral hernia 11.1 Symptoms 11.1.1 Reproducible mass 11.1.2 Flatulence 11.1.3 Intestinal obstruction 11.2 Signs 11.2.1 Difficulty in finding a distinct mass 11.2.2 Not easy to retract with manipulation 11.2.3 Cough impact test 11.2.4 Signs of peritonitis 12 Complications of femoral hernia 13 Examination 14 Diagnosis of femoral hernia 14.1 History 14.2 Clinical features 14.3 Ancillary investigations 14.4 Precautions 15 Differential diagnosis 15.1 Inguinal hernia 15.2 Enlarged inguinal lymph nodes 15.3 Lipoma in the region of the fossa ovalis 15.4 Saphenous vein varicose 15.5 Closed hole hernia 15.6 Cold abscess of the lumbar major muscle (lumbar major cold abscess) 15.7 Cyst of the round ligament 16 Treatment of femoral hernia 16.1 Transinguinal surgery 16.1.1 Suprainguinal approach (Fig. 3) 16.1.2 Inferior inguinal approach (Fig. 4) 16.2 Femoral approach 16.2.1 Procedure 16.2.2 Precautions 17 Prognosis 18 Prophylaxis of femoral hernia Attachment: 1 Acupuncture points for treating femoral hernia 1 Pinyin

2 English reference

femoral hernia

3 Overview

Femoral hernia occurs when an intra-abdominal organ herniates out of the fossa ovalis through the femoral ring and femoral canal. It is mostly acquired and congenital femoral hernia is extremely rare. Its development is associated with wider femoral ring, pregnancy, obesity, connective tissue degeneration, increased intra-abdominal pressure and other factors.

Theoretically, the pathogenesis of femoral hernia is simple, diagnosis and treatment is not difficult, but misdiagnosis and mis-treatment are common in clinical practice. According to scholars at home and abroad reported that 40% to 60% of patients with femoral hernia in the clinic has occurred incarcerated and strangulation, and in some obese patients were missed or misdiagnosed as Rosenmtiller lymph node enlargement (inflammation) is not rare. The reason for this may be related to the rarity of femoral hernias and the lack of physician awareness of their clinical features.

Femoral hernia is easy to incarcerated, strangulation, so it should be timely surgical treatment, in order to close the femoral canal, blocking the viscera to the femoral canal into the pathway. After surgical treatment, healing is often better.

4 Disease name

femoral hernia

5 English name

femoral hernia

6 Classification

General surgery > Hernia > Extra-abdominal hernia

7 ICD No.

K41

8 Epidemiology

Femoral hernia has a relatively low incidence, accounting for about 5% of extra-abdominal hernias. It is higher in females than in males and is especially prevalent in middle-aged and elderly women. According to Ponka (1980), about 60% of femoral hernias occur on the right side and 20% are bilateral.

9 Etiology of femoral hernias

Femoral hernias are most commonly seen in women over middle age, which is closely related to their physiologic and anatomic basis (Figure 1). The femoral ring is the upper mouth of the femoral canal, which is only covered with loose connective tissue; the femoral canal is a conical blind tube, a significant portion of the anterior wall is seen in the saphenous vein fissure, and its superficial structure is the sieve fascia, with no muscular protection; the inguinal falx stops narrowly away from the pubic comb ligaments; the female pelvis is wider, and ligamentous muscles and blood vessels are finer than those of males, so the femoral ring is significantly larger than those of males, which is considered one of the main reasons for the prevalence of femoral hernias.

In addition, changes in the thickness of the external iliac vein can also have a direct impact on the femoral ring opening, especially in the middle and late stages of pregnancy, uterine compression caused by the external iliac vein and femoral vein reflux obstacles caused by the thickening of the blood vessels, the release of vascular compression, caliber thinning, will obviously affect the size of the femoral ring and its neighboring gap. Pregnancy can cause stretching of the abdominal muscles, ligament laxity, due to the special anatomical characteristics of the femoral ring, making these structures weaker, any factors that cause an increase in intra-abdominal pressure such as abdominal distension, constipation, bronchitis, cirrhosis, ascites and other diseases, as well as age, chronic wasting disease, muscle atrophy or degenerative changes can be triggered femoral hernia.

In addition, the onset of femoral hernia may be associated with inguinal hernia repair surgery, as reported by Glassow (1970), more than 25% of patients with femoral hernia have a history of inguinal hernia repair surgery. This is because traditional inguinal hernia surgery utilizes an inguinal ligament repair, which is pulled upward, and its tension suture repair results in an opening of the femoral ring, opening the door for hernia protrusion.

10 Pathogenesis

In the process of femoral hernia development, often the extraperitoneal fat first protrudes, playing the role of the "opener", then the peritoneum protrudes, followed by herniation of the intestinal tube or the greater omentum to form a femoral hernia. Since the femoral canal is vertically downward, the direction of development of femoral hernia is that the hernia contents fall in a straight line to the upper edge of the saphenous vein fissure and turn forward, forming an acute angle and bulging at the root of the femur. The overlying structures of the hernia sac include the skin, superficial fascia, sieve fascia, anterior wall of the femoral sheath, and extraperitoneal tissue. Unlike other hernias in the inguinal region, the femoral ring has few protective factors, except for the inguinal falx, which is attached to the pubic comb ligament, which can be a protective structure, and the transversus abdominis fascia, which lacks protection because the transversus abdominis fascia is already involved downward in the formation of the femoral sheath. Once the femoral hernia pushes away from the inguinal falx and enters the femoral canal, the neck of the hernia sac becomes embedded in an annular opening surrounded by the trapezoidal ligament, inguinal ligament, pubic comb ligament, and the fibrous compartment of the femoral sheath ( Hernia ring). These structures are tough and inelastic, thus predisposing to incarcerated strangulated femoral hernia and strangulation.

Depending on the location of the hernia sac, femoral hernias are divided into six types (Figure 2): (1) typical femoral hernia; (2) prevascular hernia; (3) exfemoral hernia; (4) femoral hernia of pubic comb ligament; (5) femoral hernia of pectineal ligament; (6) femoral hernia of pectineal ligament; (7) femoral hernia of pectineal ligament; (8) femoral hernia of pectineal ligament. pectineal ligament); ⑤pubic hernia (pectineal hernia); and ⑥postvascular hernia (retrovascular hernia).

11 Clinical manifestations of femoral hernia

Femoral hernias are far less common than inguinal hernias, despite the fact that women have a wider pelvis and a wider gap in the deeper surface of the inguinal ligament, which predisposes women to femoral hernias more than men.

Usually, femoral hernias have no special discomfort, but only a rounded mass in the lower part of the groin near the base of the thigh. Because the femoral canal is thin, the femoral hernia zigzagging, rest and lying down is not easy to make the hernia block shrink or completely back to disappear. Coughing impact is not obvious.

About half or more of the femoral hernias can be complicated by incarceration and strangulation, mostly due to acute abdominal pain or strangulated bowel obstruction. Therefore, inguinal and femoral examination should not be omitted in patients with acute surgical abdominal pain. The hernia contents are often the greater omentum, and an intestinal wall-to-wall hernia (Richter's hernia) is not uncommon. Femoral hernias are characterized as refractory and prone to incarceration and strangulation.

11.1 Symptoms

Recurrent femoral hernias are mild and often go unnoticed by the patient, especially in the obese, and are more likely to be overlooked and missed.

11.1.1 (1) Reproducible mass

Femoral hernia mass is usually small, the patient in standing, coughing, exertion, etc. caused by the increase in intra-abdominal pressure, found at the root of the thigh (oval foramen) appeared hemispherical bulge, the size of a walnut or egg, the texture is soft. When lying down, the hernia mass usually cannot be returned by itself, and needs to be returned by retrograde repositioning along its protruding pathway. Due to the rich fatty tissue outside the sac, sometimes the mass does not disappear after the hernia content is returned while lying down. If the hernia content for the greater omentum and other tissues, frequent episodes are easy and hernia sac adhesion, the mass is not easy to completely disappear, and the formation of difficult to restore the femoral hernia.

11.1.2 (2) Pain and swelling

If the femoral hernia is large, the mass can be turned upward, and the base can be extended to the inguinal region, and the patient is often accompanied by inguinal distension and discomfort; or localized pain and swelling and a feeling of falling after a long period of standing.

11.1.3 (3) Intestinal obstruction

About 60% of the cases can be embedded, resulting in increased localized pain and acute intestinal obstruction. Therefore, patients with acute intestinal obstruction, especially middle-aged women, should be examined for femoral hernia to avoid missed diagnosis and misdiagnosis.

11.2 Signs

Femoral hernias are often not characterized by typical extra-abdominal hernias.

11.2.1 (1) Difficulty in finding an obvious lump

The hernia is usually the size of a thumb, located below the inguinal ligament, due to the narrowness of the femoral canal, the hernia sac is often more fatty tissue, if the femoral hernia hernia is not too large, it is easy to be overlooked. A femoral hernia can also be unseen, which is often seen in Richter's hernia.

11.2.2 (2) manipulation is not easy to retrieve

femoral hernia hernia contents to the greater omentum and intestinal side wall, often and hernia sac adhesion, not easy to manipulate the retrieval, in the inguinal region to form a constant mass, with the development of the mass can gradually increase in size, similar to the lipoma, enlarged lymph nodes, or saphenous varicose vein nodule-like dilatation, and so on. However, the base of the mass is fixed, and it is not as active as enlarged lymph nodes or lipomas.

11.2.3 (3) Cough impingement test

The femoral hernia mass does not have a pronounced cough impingement.

11.2.4 (4) Signs of peritonitis

When strangulation occurs in an incarcerated femoral hernia, the patient may develop signs of peritonitis, which are evident in the affected side of the abdomen, with the hernia mass being swollen, painful to the touch, unable to be returned, and even red and swollen skin, with manifestations of soft tissue infection. Whether or not necrosis occurs in the incarcerated intestinal tube is related to the time of incarceration, the tightness of the hernia opening and the degree of intestinal blood flow obstruction. For patients with intestinal obstruction of unknown causation, in addition to abdominal examination, can not forget to carefully examine the inguinal region, pay attention to the presence of inguinal hernia incarceration, but also pay special attention to the presence of femoral hernia incarceration.

12 Complications of femoral hernia

Intestinal necrosis and intestinal fistula are serious complications of incarcerated femoral hernia. After an incarcerated femoral hernia, if strangulation occurs and the hernia contents become necrotic, suppurative lymphadenitis or other abscess-like changes occur, and once incised, intestinal fistula results.

13 Examination

Herniography and ultrasound help in diagnosis.

14 Diagnosis of femoral hernia 14.1 History

Note whether the patient is obese, constipated, pregnant, etc.; find out whether she has a history of inguinal hernia surgery, chronic bronchitis, cirrhosis, ascites and chronic wasting disease. Ask in detail about the time of the appearance of the mass, the accompanying symptoms and the degree, whether it can be returned and the way of return; whether there is a similar situation in the past and how to deal with it.

14.2 Clinical features

Middle-aged women with a semicircular mass at the femoral foramen ovale, accompanied by distension and pain; the mass cannot be returned naturally, and has to be returned by manipulation, and sometimes does not disappear completely; physical examination reveals a spherical bulge at the lower part of the inguinal ligament and at the fossa of the foramen ovale, but signs of an extra-abdominal hernia are not obvious. Local inguinal skin redness, swelling, tenderness, accompanied by intestinal obstruction symptoms, should be alert to femoral hernia incarcerated.

14.3 Auxiliary examination 14.4 Precautions

(1) detailed history, systematic examination: femoral hernia is clinically atypical, some patients are only manifested in the inguinal area of the mass, smaller, no obvious symptoms, easy to confuse with inguinal hernia, inguinal lymph node inflammation or inguinal cysts; elderly people are slow to respond, most of them are combined with chronic diseases, the emergence of new symptoms can not be noticed, or there are some psychological and social factors, and can not be detected. Psychological and social factors, and can not seek early medical treatment, or even inaccurate medical history, and physical signs are often not obvious, easy to give a false impression. Therefore, the patient and meticulous history, comprehensive and systematic physical examination, to avoid misdiagnosis.

(2) be alert to incarcerated hernia: because of the narrow femoral ring, incarcerated part of the intestinal wall is small, in the physical examination of the root of the thigh may not be able to touch the mass, but as long as a careful examination of the affected side of the femoral root is often tenderness, and more full than the opposite side.

(3) deep investigation of intestinal obstruction: femoral hernia in the early stage of the disease is often manifested as incomplete intestinal obstruction, in the middle and late stages of the complete intestinal obstruction, peritonitis due to strangulation and necrosis, should be based on a detailed history, systematic and comprehensive examination, combined with X-ray, ultrasound or CT examination, in-depth investigation of the causes of intestinal obstruction.

(4) Deepen the understanding of the disease, improve the vigilance of the disease, and master the diagnosis and differential diagnosis of the disease and related diseases. Analyze the history of ideas to be wide, the clinical symptoms of atypical cases should be further examination, especially obese women with menstruation, where the diagnosis of inguinal hernia, or acute abdominal pain and intestinal obstruction, peritonitis signs, should be examined in the fossa of the ovary, in order to exclude the presence of femoral hernia.

15 Differential Diagnosis

A differential diagnosis should be made with:

15.1 Inguinal Hernia

If the inguinal ligament is used as a boundary, the inguinal hernia mass appears above the inguinal ligament and above the pubic tubercle; the femoral hernia mass should be located in the inner lower part of the inguinal ligament and outer lower part of the pubic tubercle. Femoral hernia masses are generally smaller, less easily retracted, and often have no history of recurrent prolapse; whereas inguinal hernia masses are more easily retracted and retract by a different route than femoral hernias. Inguinal hernias are in close proximity to the spermatic cord, while femoral hernias are the opposite. In inguinal hernia protrusion, the subcutaneous ring is examined for the presence of a hernia mass, whereas in femoral hernia protrusion, the subcutaneous ring is empty. Inserting the index finger into the subcutaneous ring and asking the patient to cough, there may be a sensation of impact in inguinal hernias, but not in femoral hernias.

15.2 Enlarged inguinal lymph nodes

Especially the lower group of superficial inguinal lymph nodes and the deep inguinal lymph nodes are easily confused with femoral hernia. A femoral hernia is round in shape and has a deep stalk; whereas an enlarged lymph node is oval in shape, has no stalk, and can be pushed. In inguinal lymphadenitis, there is often a history of acute infection, such as lower limb infection, perianal abscess, etc., should be treated with antibiotics, and the lump becomes smaller and the symptoms are reduced. In addition inguinal lymph node enlargement can be used as a local manifestation of certain systemic lymph node enlargement, or regional lymph node enlargement of certain malignant tumors, which should be differentiated.

15.3 Lipoma of the fossa ovalis

Lipoma has no root, can not be returned, pinch the base of the mass, the lobularity of the lipoma is particularly obvious. Special attention should be paid to certain patients with clinical manifestations fully consistent with lipoma, and even surgical exploration of the appearance of the mass and lipoma similar to the presence of femoral hernia should not be casually ruled out, because the fat mass may be femoral hernia protruding, the preperitoneal fat out of the cause, should be further search for the hernia capsule, to avoid the leakage of the diagnosis.

15.4 Varicose saphenous vein

varicose saphenous vein at the confluence of the fossa ovalis into a mass, lying down or elevate the affected limb, the vein mass quickly disappeared, after standing up the mass reappeared, and accompanied by varicose veins of the lower limbs; compression of varicose vein nodules above the nodes, the nodes increased, and compression of the nodes below the nodes narrowed; the patient with varicose vein take the standing position, knocking on the mass at the fossa ovalis, there is a fluctuation of varicose veins along the conductivity. The patient with varicose veins is in a standing position, tapping the mass at the fossa ovalis, there are fluctuations along the varicose veins. The femoral hernia patient lying down, the lump disappears slowly, sometimes need to be compressed to return to the individual lump compression can not completely disappear.

15.5 Obturator hernia

Patients with medial thigh pain should be differentiated from obturator hernias, which are less common than femoral hernias. According to the HowshipRomberg's sign, rectal palpation or pelvic examination can help in the diagnosis of anteriorly palpated corded mass in the rectum or the *** side wall.

15.6 Cold abscess of the lumbar teres major muscle (lumbar teres major cold abscess)

Cold abscesses formed by lumbar spine tuberculosis often extend downward along the iliopsoas muscle appearing on the medial aspect of the root of the thigh, with a distinct fluctuating sensation. Further questions should be asked about the history of low-grade fever, night sweats, and loss of appetite, and CT and lumbar spine plain radiographs should be performed if necessary.

15.7 Round ligament cyst

Located in the groin, above the abdominofemoral ligament, according to which it can be distinguished from femoral hernia. In addition, the mass is round or oval in shape with high mobility and cystic sensation.

16 Treatment of femoral hernia

Femoral hernia is easy to incarcerate, strangulation, so timely surgical treatment should be closed to the femoral canal, blocking the viscera to the femoral canal into the pathway. There are two types of surgery: trans-femoral access and trans-inguinal access.

16.1 Transinguinal surgery

Divided into two types of surgery: suprainguinal access and infrainguinal access.

16.1.1 (1) Upper inguinal approach (Figure 3)

Using an oblique hernia incision, the posterior wall of the inguinal canal is exposed by layer-by-layer dissection, the round ligament (spermatic cord) is pulled upward, and the transversus abdominis fascia is incised medially over the inguinal ligament, so that the femoral ring and the neck of the hernia sac can be found. The neck of the hernia sac is incised, the contents of the hernia 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 border of the femoral ring and the trap ligament must be cut open and loosened, 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 bundle of bones, the ligament of the trap, and the ligament of the pubic commissure to close the femoral ring, taking care to avoid inadvertent injury to the femoral vein; the transversus abdominis tendon arch, the superior incision of the transversus abdominis fascia, and the conjoint tendon can also be sutured to the ligament of the pubic commissure using the Mc Vay method, and sutured posterolaterally to the femoral sheath and the medial aspect of the spermatic cord.

16.1.2 (2) Inferior inguinal access (Figure 4)

A straight incision is made in the fossa ovalis below the inguinal ligament, the sieve fascia is incised to reveal the hernia sac, the hernia sac is incised to retract the hernia contents, and the inguinal ligament, ilio-pubic bundle, and trap ligament are sutured to the pubic comb ligament and the pubic fascia to close the hernia sac with a high ligature.

Although there are two ways of inguinal access, the suprainguinal access is mostly used. The advantage is that it can clearly reveal the femoral ring, really high hernia sac ligation and suture closure of the femoral ring. For strangulated femoral hernia femoral ring, it is more important to use the upper inguinal access, in order to better deal with strangulated hernia contents, which are unable to do the lower inguinal access, the only advantage of the latter is that the operation is simple, less traumatic.

16.2 Femoral access

Transfemoral surgery allows direct access to the hernia sac, which is easy to perform intraoperatively, but the visualization is poor, especially when the hernia sac is large, and it is not easy to ligate high, and it is not easy to dislodge a femoral hernia when it is incarcerated, and it is not easy to perform an enterotomy when intestinal necrosis occurs.

16.2.1 (1) operation steps

① in the abdominofemoral ligament below 2 ~ 3cm, in order to the position of the femoral tube as the center, the ligament parallel oblique incision, the length of about 6cm, such as incarcerated hernia, it is appropriate to make a longitudinal incision in the femoral tube, and according to the situation of the operation, upward to extend the scope of the extension. ②Reveal the hernia sac: after incising the skin and subcutaneous tissue (Figure 5A), separate the fatty connective tissue covering the surface of the hernia sac (sieve fascia, femoral septum and extraperitoneal adipose tissue, etc.) below the abdominofemoral ligament, and reveal the hernia sac. After clamping the hernia sac with two small hemostatic forceps, the posterior wall of the hernia sac is incised (Figure 5B), and the cut edge of the hernia sac wall is clamped with hemostatic forceps, and the hernia sac incision is spread and lifted up, so that the intracystic viscera (small intestine or omentum) can be seen. (small intestine or large omentum). The saphenous vein is visible outside the neck of the hernia sac, and care should be taken to avoid injury (Figure 5C). (iii) High ligation of the hernia sac: the hernia content is returned to the abdominal cavity, and the hernia neck is ligated in high position with a No. 4 silk thread. Cut off the excess hernia sac (Figure 5D). ④ Repair of the femoral canal: There are two ways to repair the femoral canal, one is to suture the inguinal ligament to the pubic ramus fascia (Figure 5E), and the other is to suture the inguinal ligament to the pubic ligament (Figure 5F). Use No. 4 silk thread to interrupt 3 to 4 stitches, and then ligate them one by one when they are all sewn. Avoid the saphenous vein and femoral vein when suturing to avoid injury.5 Suture: after careful hemostasis, suture the fascia, subcutaneous tissue and skin around the inferior femoral canal.

16.2.2 (2) Precautions

①Because the sieve fascia is compressed when the femoral hernia protrudes externally from the abdominal cavity, which mutates the layers of tissues outside the hernia sac, when the hernia sac is revealed surgically (especially by the trans-femoral route), it is easy to mistake the wall of the bowel loops in the hernia sac for the wall of the hernia sac and incise it. Therefore, intraoperative identification of the hernia sac encountered difficulties, can be changed to transinguinal surgical route, the first incision of the abdominal cavity, and then identify the wall of the hernia sac.

② The origin of the obturator artery is often abnormally variable, and when surgery requires incision of the entrapment ligament to loosen the femoral ring, a separate oblique inguinal incision should be made to reveal the ligament. Abnormal vessels should be ligated before incising the ligamentum teres.

③ Femoral hernia, the inner edge of the hernia sac is often close to the bladder, especially if the bladder has not been emptied before the operation, the separation of the hernia sac should be avoided to damage the bladder.

④Femoral hernia sac near the external iliac and femoral arteries and veins, the inferior abdominal wall artery, saphenous vein, etc., should be careful to avoid injury.

⑤ The success of femoral hernia repair depends largely on whether the neck of the hernia sac is ligated in high position. When repairing by the transfemoral route, the hernia sac must be carefully separated and ligated and cut off above the neck. In the case of large recurrent femoral hernias, it is preferable to use the transinguinal route, or a combined longitudinal inguinal and femoral incision, which is more convenient and reliable.

17 Prognosis

Femoral hernias tend to heal better after surgical treatment.

18 Prevention of femoral hernia

1. Strengthen the exercise, especially the abdominal muscles and ligaments.

2. Reduce or avoid factors that increase intra-abdominal pressure, such as constipation and coughing.

Acupuncture points for femoral hernia Yinmen

Leg pain, lower limb impotence paralysis (lower limb atrophy paralysis), lumbar back pain, post-femoral swelling and pain, hernia, back headache, and in modern times, Yinmen acupoints are mostly used to treat lumbar intervertebral disc herniation, sitting ...

Qi Chong

Beginning, for the main channel of the meridian qi, so the name Qi Chong. The main treatment of abdominal pain, hernia, inguinal pain, partial fall, testicular swelling and pain, urinary dribbling, spermatorrhea, impotence ...

Hernia Point

"Acupuncture and Moxibustion" (Jiangsu Province School of Traditional Chinese Medicine). The original name of hernia moxibustion.

Acute Pulse

Name Acute Pulse. Acute pulse point main treatment of the abdomen, anterior yin and other disorders: such as pain in the abdomen, hernia partial fall, pain in the middle of the stem, yin ting, medial femoral pain, hernia, abdominal pain, less abdominal ...

Hernia Moxibustion