Femoral hernia is one of the commonest forms of hernia experienced by women. The group affected is predominantly older women. In rare cases, femoral hernias can also occur in men, for example after previous inguinal hernia surgery.

Overview

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Femoral hernia surgery - Further information

Definition - What is a femoral hernia?

In a femoral hernia, there is a bowel rupture below the inguinal ligament, so that the bulge can generally be seen on the inside of the thigh.

Femoral hernias are generally painful and because bowel parts can quickly become incarcerated in a femoral hernia, hernia surgery is usually performed.

Femoral hernias occur mostly doing a person's lifetime - congenital femoral hernias are extremely rare.

Causes and emergence of a femoral hernia

Before a femoral hernia occurs, there is first of all an increase in pressure in the abdominal cavity which causes fatty tissue to be pressed into the femoral canal. Such an increase in pressure can occur, for example, after one or several pregnancies or in overweight. However, normal pressure in conjunction with connective tissue weakness, which generally occurs in old age, can have the same effect. In rare cases, weak points may also have developed through surgery (e.g. after inguinal hernia surgery).

If the fatty tissue has widened the femoral canal, parts of the bowel can also enter it and pass through. In some circumstances, they can become trapped (incarcerated) at the entry point, in which case these incarcerated parts of the bowel may die through an insufficient blood supply.

In 60% of cases, femoral hernias occur on the right side and in 20% of cases they occur on both sides.

Femoral hernia diagnosis

Not all femoral hernias are recognizable as such at first glance. Particularly with severely overweight people, it is sometimes difficult to identify a femoral hernia because skin and tissue disguise the bulge. Where the femoral hernia is visible externally, it presents as a visible and palpable swelling below the inguinal ligament at the starting point of the thigh - mostly as a fairly large knot or lump. The inguinal ligament is located between the anterior pelvic bone and the pubic bone.

If the femoral hernia cannot be seen or felt immediately, it may be that it won't be detected until bowel parts have already been incarcerated, which will cause intense pain – in some cases accompanied by nausea and vomiting.

If a femoral hernia is suspected but cannot be seen or felt directly, an ultrasound (sonography) examination should in any case be performed. Sometimes computed tomography (CT) or an MRT will also be necessary in order to diagnose the femoral hernia with certainty.

Femoral hernia surgery

Surgery is usually the only productive treatment option for a femoral hernia.  However, one serious reason for not taking the surgical option would be the poor physical condition of the patient. If bowel parts are incarcerated in a femoral hernia, emergency surgery may even be necessary.

Femoral hernia surgery can be performed under either a local or general anesthetic. A general anesthetic is preferred as a rule where a femoral hernia with incarceration is concerned, because the surgical incision can then be extended more easily if required.

In principle, two different techniques are available for femoral hernia surgery:

  • In small hernias it is often enough to close the hernia gap by direct suturing with insoluble thread.
  • For a larger hernia, a large enough piece of synthetic mesh can be applied to the gap to reduce the risk of the femoral hernia recurring (femoral hernia recurrence).

There are also the options of open femoral hernia surgery entailing an abdominal incision and closed, minimally invasive femoral hernia surgery by means of abdominal endoscopy.

Pre-surgical preparations for femoral hernia surgery

Femoral hernias in otherwise fit and healthy individuals can be treated as day-case surgery provided the surgery is endoscopic. This means that the patient attends the clinic on the day of the surgery and then returns home after performance of the femoral hernia surgery and the usual post-surgery surveillance.  In this case, they return two or three days after the femoral hernia surgery for wound inspection.

With incarcerated femoral hernias and hernias treated with open surgery, the rule is that in-patient treatment is necessary. On the evening before femoral hernia surgery, the bowel is cleansed with enemas or laxatives Additionally, a presurgery discussion with the attending anesthetist about the type of anesthetic technique planned (general anesthesia or local anesthesia) and with the operating surgeon should be conducted prior to the femoral hernia surgery.

The surgeon briefs the patient on the planned surgical procedure, clarifies the most frequently occurring complications in femoral hernia surgery and discusses with the patient the post-surgery course of events.

Surgical techniques in femoral hernia surgery explained in detail

Femoral hernia surgery can be performed either as open surgery with abdominal incision or as closed (laparoscopic) surgery. 'Open' means that the surgeon makes a long incision directly by the hernia and so exposes the hernia sac. In closed femoral hernia surgery, no large incision is needed. Instead, the surgeon works with small instruments which he handles via a video optical system within the patient's body.

In larger hernias, direct suturing of the hernial ring can lead to tension which can cause pain and a recurrence of the hernia. Because of this, as a rule, a synthetic mesh is also fitted, which provides additional stability.

In all femoral hernia surgical techniques which are performed with the insertion of a mesh, it should be borne in mind that the size of the synthetic mesh is selected so that the mesh noticeably overlaps the healthy and stable tissue and can be firmly incorporated.  To achieve this, a mesh should be selected which is always bigger than the actual hernia gap because closure of the hernial ring is successful where it is largely tension-free.

Open femoral hernia surgery with an abdominal incision

In open femoral hernia surgery, the hernia sac is exposed and opened by abdominal incision. Then the surgeon shifts the contents of the hernia sac back into the abdominal cavity, shortens the hernia sac and finally closes it.

The hernial ring is also closed. There are different ways of doing this:

  • open femoral hernia surgery with direct suturing: with very small hernias, the hernial ring can be closed directly by suturing.
  • open femoral hernia surgery with fascia doubling: in this method, the edges of the abdominal wall layers (fascia) are doubled. The layers are overlapped and sutured together to create greater stability. This surgical procedure is also called the Shouldice technique(especially in inguinal hernia surgery).
  • open femoral hernia surgery with the Lichtenstein method: in the technique known as Lichtenstein surgery, the synthetic mesh is sutured directly on to the transverse fascia (inner abdominal wall fascia). The mesh inlay is therefore between the abdominal wall fascia and the abdominal muscles. This is also called an onlay technique.

Closed femoral hernia surgery with abdominal endoscopy

Laparoscopic femoral hernia surgery (minimally invasive technique) is performed by means of smaller incisions 2-12 mm in length. The surgical instruments and an optical system with a video camera are introduced into the abdominal cavity via these small incisions and the rupture is exposed at its origin.

This access through the abdominal wall - also known as laparoscopic femoral hernia surgery - has become increasingly popular with surgeons because it is less traumatizing (i.e. lower tissue insult) and bed occupancy time in the clinic is reduced. In closed femoral hernia surgery, basically a synthetic mesh is introduced into the abdominal wall.

Whereas in open femoral hernia surgery the skin incision is directly in the region of the femoral hernia, in minimally invasive closed femoral hernia surgery access to the abdominal cavity is created by means of small skin incisions far away from the actual hernia region.

After the contents of the hernia sac have been relocated, the surgeon stretches a non-resorbable (insoluble) polypropylene mesh over the hernial ring and fixes it from inside to the abdominal wall. The peritoneum is closed again over it. The scar tissue grows into the lattice structure of the mesh and allows a new layer to be formed, which is generally under less tension than if the skin had been sutured together directly.

In the endoscopic femoral hernia surgical techniques, there are mainly two techniques, which are however very similar:

  • TEP technique (total extraperitoneal patch plastic): Extraperitoneal means ' outside the abdominal cavity', which in turn means that there is no need to make an opening in the abdominal cavity. In this technique, both sides can be treated at the same time. It is younger, active people who are the main beneficiaries of this technique because they can be active again quicker after femoral hernia surgery.
  • TAPP technique (transabdominal preperitoneal plastic or transabdominal patch plastic ): transabdominal means 'through the abdominal cavity'. This technique is also suitable for the treatment of both sides and for younger, active people.

Risks and complications of femoral hernia surgery

Together with the potential general complications applicable to all surgery, such as hemorrhage, infections, thromboses and the risk of an embolism, swellings at the surgery site, caused by the bruising or edema in the tissues, are possible in femoral hernia surgery. As a rule, however, these disappear after a short time.

Also slight pain in the surgery area or sensory disturbances may occur after femoral hernia surgery. Whereas the pain soon disappears, sensory disturbances in small areas of the skin may last longer.

Surgery in close proximity to the intestine, the bladder, blood vessels and nerves always carries a potential risk to these structures. Damage to the large vessels in the course of femoral hernia surgery, however, is extremely rare.

Special care should be taken to ensure that the flow of blood in the large vein, which runs through the femoral canal, remains intact because otherwise there is the risk of thrombosis.

The recurrence of a femoral hernia at the same site can happen with all the femoral hernia surgical techniques, but it happens more rarely when synthetic meshes are used.

Hardening and contraction in the area of the synthetic meshes are extremely rare in the context of femoral hernia surgery; allergies to and rejection of the synthetic meshes are practically never experienced.

This is what happens after femoral hernia surgery

Depending on the anesthetic type and the surgical technique, patients can stand up immediately following femoral hernia surgery or after an adequate rest period. Longer times lying down after femoral hernia surgery are unnecessary and should be avoided because of the risk of thrombosis with a subsequent embolism.

The first dressing change takes place on the second or third day after femoral hernia surgery. You should be able to shower again after this period.

The suture threads are removed either on the tenth day after the femoral hernia surgery or no removal is necessary if soluble suturing material was used.

Depending on work-related stress, working capacity is restored two to three weeks after the femoral hernia surgery.

Athletic activities should only be resumed three to four weeks following the femoral hernia surgery.

Lifting heavy objects over ten kilograms should be avoided for approximately two months after the femoral hernia surgery.