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Indications

• All femoral hernias (high risk of strangulation)

 
Landmarks: inguinal ligament (anteriorly), pectineal ligament (posteriorly), lacunar ligament (medially), femoral vein
 
 
Procedure: Low / crural approach
If any doubt as to bowel viability, laparotomy recommended

1. Dissect down to hernia
   • Groin incision directly over inguinal ligament
   • Identify, dissect superficial fascia down to sac
   • Expose neck of hernia
2. Open hernia, inspect, reduce hernial contents
   • If necrotic bowel, resect and perform laparotomy
3. Close hernie defect
   • Carefully retract femoral vein
   • close defect (suture inguinal ligament to pectineal ligament - use J-shaped needle)
4. Close subcutaneous tissue with interrupted sutures + skin with subcuticular

 
 
High inguinal approach
 
 
Extraperitoneal approach
 
Useful if unsure hernia is inguinal or femoral

1. Dissect down to hernia
   • Supra inguinal incision (Pfannenstiel, midline)
   • Skin, blunt dissect superficial tissues to gain access to hernial sac
   • Open rectus sheath + retract rectus
   • Open up pre-peritoneal space with blunt dissection
   • Continue process down towards inguinal ligament + identify hernia
2. Identify and reduce hernia
   • If sac empty, reduce back to abdomen: pull above, push below
   • If bowel present, stretch femoral ring (with haemostat), transfix sac + excise tissue
   • If irreducible, open peritoneum from above + inspect contents +/- bowel resection
3. Close femoral canal with interrupted non-absorbable sutures between pectineal + inguinal ligament

Intestinal Stenosis of Garre

• Strangulated hernia causes mucosal ulcer
• Intestinal mucosa more vulnerable to ischaemia rather than overlying seromuscular layer - heals by fibrosis
• Annular stenotic stricture of small bowel
• Causes small bowel obstruction