Accuracy of clinical diagnosis of inguinal and femoral hernia and its usefulness for indicating laparoscopic surgery

Summary The preoperative diagnosis of inguinal hernias is one of the surgeon's most commonplace duties yet one of the least valued aspects in the treatment of this pathology. The introduction of the laparoscopic technique for inguinal hernia repair may stimulate an interest in this problem. The aim of the study is to analyse the diagnostic accuracy of clinical examination of inguinal and femoral hernias. 278 patients with a possible inguinal and femoral hernia received from the same surgeon a thorough clinical examination and preoperative diagnosis of the type of hernia (indirect or direct inguinal, and femoral). The data obtained were compared to the intra-operative findings. The influence of age, sex and site was studied with regard to the sensitivity of the clinical diagnosis. Direct inguinal hernias accounted for 35% of the total. Indirect inguinal hernias were diagnosed more accurately (85%) than direct (64%) and femoral (39%) hernias. Clinical diagnosis was not influenced by age, sex or site of the femoral hernia. Statistically significant differences were revealed only for inguinal hernias in the group of patients aged over 50 years and with a unilateral site (p<0.05). Thorough physical exploration should never be underrated in the diagnosis of inguinal hernias as it may help classify hernias with great accuracy.     

Female ‘groin’ hernia: totally extraperitoneal (TEP) endoscopic repair seems the most appropriate treatment modality

Background

About 30% of all female ‘groin’ hernias are femoral hernias, although often only diagnosed during surgery. A Lichtenstein repair though, as preferred treatment modality according to guidelines, would not diagnose and treat femoral hernias. Totally extraperitoneal (TEP) hernia repair, however, offers the advantage of being an appropriate modality for the diagnosis and subsequent treatment of both inguinal and femoral hernias. TEP therefore seems an appealing surgical technique for women with groin hernias.

Methods

This study included all female patients ≥18?years operated for a groin hernia between 2005 and 2009.

Results

A total of 183 groin hernias were repaired in 164 women. TEP was performed in 85% of women; the other 24 women underwent an open anterior (mesh) repair. Peroperatively, femoral hernias were observed in 23% of patients with primary hernias and 35% of patients with recurrent hernias. There were 30 cases (18.3%) of an incorrect preoperative diagnosis. Peroperatively, femoral hernias were observed in 17.3% of women who were diagnosed with an inguinal hernia before surgery. In addition, inguinal hernias were found in 24.0% of women who were diagnosed with a femoral hernia preoperatively. After a follow-up of 25?months, moderate to severe (VAS 4-10) postoperative pain was reported by 8 of 125 patients (6.4%) after TEP and 5 of 23 patients (21.7%) after open hernia repair (P?=?0.03). Five patients had a recurrent hernia, two following TEP (1.4%) and three following open anterior repair (12.5%, P?=?0.02). Two of these three patients presented with a femoral recurrence after a previous repair of an inguinal hernia.

Conclusion

Femoral hernias are common in women with groin hernias, but not always detected preoperatively; this argues for the use of a preperitoneal approach. TEP hernia repair combines the advantage of a peroperative diagnosis and subsequent appropriate treatment with the known good clinical outcomes.     

The role of laparoscopy in the management of suspected recurrent pediatric hernias

BACKGROUND: This report examines recurrent pediatric groin hernias and the role of diagnostic laparoscopy in the management of these recurrences. METHODS: A chart review of 19 children presenting with recurrent hernias was performed, analyzing the type of primary hernia, nature of recurrence, preexisting medical conditions, surgical complications at primary repair, and time to recurrence. Diagnostic laparoscopy (DL) was used during the remedial repair of the last nine patients. RESULTS: Seventeen indirect hernias were repaired during the primary repair, and 1 femoral hernia was identified. In one child, no inguinal hernia was identified at the initial operation. Overall, 11 recurrences were found to consist of indirect sacs, and 4 were found to have attenuation of the inguinal floor. Four additional recurrences were found to be femoral hernias. In only 1 patient was a wound factor (infection) thought to play a role in the recurrence. Diagnostic laparoscopy in 9 patients found 4 (44%) to have unsuspected intraoperative findings. Four femoral hernias were identified (3 with unsuspected contralateral femoral hernias). Additionally, 1 unsuspected recurrence of an indirect sac was identified. CONCLUSIONS: Laparoscopy accurately identifies the nature of the defect in children with recurrent groin hernias, detecting unsuspected contralateral indirect, direct, or femoral hernias in 44% of those undergoing laparoscopy.     

A five-year U.S. Army experience with 36,250 abdominal hernia repairs

Thirty-six thousand two hundred fifty abdominal hernia repairs were performed in U.S. Army medical treatment facilities during a five-year period. This study presents data about the type of hernia, incidence of complications by obstruction or strangulation, age, sex, and mortality. Hernias occurring with intestinal obstruction or gangrene (strangulation) are referred to as complicated hernias. Inguinal hernias in children less than two years of age, femoral hernias, and unusual (such as internal or obturator) hernias were found to have an increased incidence of complications. Surgical repair of ventral, umbilical, and femoral hernias was done with a low surgical risk and the presence of complications did not significantly increase this risk. An increased risk of mortality is associated with the repair of complicated unusual hernias and complicated inguinal hernias in patients more than 60 years of age.     

Laparoscopic diagnosis and repair of pediatric femoral hernia

Femoral hernias are often misdiagnosed and treated as inguinal hernias. Thus, laparoscopic groin exploration may be a valuable means of evaluating children with presumed recurrent inguinal hernias. This study describes the feasibility of laparoscopic groin exploration and femoral hernia repair in children. Four children (aged 2, 2, 3, and 17 years) with reported unilateral recurrent inguinal hernias underwent diagnostic laparoscopy via a 4-mm pediatric laparoscope. Contralateral defects were visualized in all four patients; there were three femoral hernias and one direct inguinal hernia. None of the contralateral defects had been suspected clinically. Of the seven femoral defects, five were repaired laparoscopically. One patulous defect was repaired by reapproximating the iliopubic tract to Cooper's ligament and overlaying a preperitoneal Teflon felt(R) patch. The other four defects were repaired using a Teflon felt(R) plug and preperitoneal patch. A total of three ports were required in each patient (umbilical, suprapubic, and one in between). Two femoral defects in one patient required open repair because a large lipoma prevented adequate visualization and diagnosis. The direct inguinal hernia was also repaired using the open technique. Laparoscopic groin exploration and femoral hernia repair in pediatric patients is safe and technically feasible. Its advantages, however, such as superior diagnostic ability and simultaneous bilateral tension-free repair, need to be validated with a larger study and longer follow-up.     

Aneurysm of the femoral vein as differential diagnosis of femoral hernia

Venous aneurysms are rare, especially those of the femoral vein. Groin hernias and femoral hernias are in contrast to this more frequent enteties. The literature includes only six cases of aneurysms of the femoral vein. We report on a 61-year-old patient who underwent an operation for femoral hernia. An aneurysm of the femoral vein was found intraoperatively and directly resected. The differential diagnosis of femoral hernias and the following diagnostic and therapeutic strategies are described.     

Crural hernia, strangulation and surgical treatment]

Anatomical reasons explain that the diagnosis of femoral hernia is sometimes difficult, that controversies still exist on their treatment and that their strangulation is often ignored. The authors propose some remarks on the anatomy of the femoral canal and the femoral hernias, the repair of the latter, and some of the problems related to strangulating. They conclude that research on the femoral canal and hernias anatomy should be valuable; similarly stimulation of surgeons for a better management of the diagnosis of strangulated femoral hernias and for systematically considering surgical repair of all femoral hernias whatever be the risk, should be beneficial. Lastly they underline that a prospective comparison between prosthetic and non prosthetic repairs of common femoral hernias could be organized easily because they are comparative lesions.     

A new minimally invasive technique for the repair of femoral hernia in children : About 13 laparoscopic repairs in 10 patients

Background

Femoral hernias in children are rare and often misdiagnosed. The classic treatment is through an open anterior approach. Since the advent of laparoscopic treatment of inguinal hernia in children, laparoscopy has been proposed to offer an accurate diagnosis and treatment, especially in case of recurrent hernia or bilateral disease. This review was undertaken to report our experience with the primary laparoscopic diagnosis and treatment of pediatric femoral hernias and to investigate its safety and feasibility.

Methods

All cases of pediatric femoral hernia in a consecutive series of children treated laparoscopically for groin hernias in a single institution over a 7-year period (2001-2007) were identified and studied for patient characteristics, presentation, pre- and perioperative findings, details of the operative repair, and postoperative outcome.

Results

Out of a prospectively studied series of 462 laparoscopic pediatric inguinal hernia repairs in 389 patients, 13 femoral hernias were treated in 10 patients (6 boys), with a mean age of 71/2 years (range, 1.7-12). The preoperative diagnosis of femoral hernia was accurate in 7 patients. Seven femoral hernias were exclusively right sided; 3 were bilateral. All 13 femoral hernias were successfully treated by a standardized transabdominal laparoscopic approach with the use of three 3.5-mm trocars. All patients were treated in a day care setting. No postoperative complications occurred. No recurrences were seen until the present time, with a mean follow-up of 31/2 years.

Conclusions

Laparoscopy provides a straightforward, accurate diagnosis for the rare and often missed pediatric femoral hernias. The new technique described offers a safe and efficient minimally invasive anatomical repair of the crural orifice in children, even when not suspected preoperatively. The laparoscopic diagnosis of 13 femoral hernias from a cohort of 462 laparoscopic groin hernia repairs (2.8%) may suggest a higher prevalence rate of this unusual type of hernia in children than earlier described in literature.     

Femoral hernias: a register analysis of 588 repairs

Summary From 1 January 1992 to 31 December 1997 18,281 inguinal hernias and 588 femoral hernias were recorded in the Swedish Hernia Register. The aim of the present study was to characterise these femoral hernias and to evaluate the reoperation rate following their repair. 64% of all femoral hernias were located in the right groin and 36% in the left groin (p < 0.001). The male to female ratio for femoral hernia was 1:1.6; mean ages of patients with femoral and inguinal hernia were 63.4 ± 17.1 and 59.1 ± 16.4 years, respectively (p < 0.001). Emergency surgery and bowel resection at emergency surgery were more common with femoral than with inguinal hernia. The rate of ambulatory surgery was lower for femoral hernia than for inguinal hernia, mainly due to the higher emergency rate for femoral hernia. At three years the cumulative incidence of reoperation was 4.6% (95% confidence interval 2.4–6.8%) for femoral hernia and 4.0% (95% confidence interval 3.6–4.4%) for inguinal hernia (p > 0.05). Male sex and postoperative complications were associated with a significantly increased risk of reoperation following femoral hernia repair. The relative risk of reoperation was not affected by patient age, elective/emergency surgery, primary/recurrent hernia or hernia side. Repair techniques using mesh were associated with a lower reoperation rate than techniques without mesh, although the difference did not reach statistical significance.     

Risk of strangulation in groin hernias

Although the elective repair of groin hernias is advised to prevent strangulation, the likelihood of this complication occurring is unknown. To quantify this risk, the cumulative probability of strangulation in relation to the length of history has been calculated for inguinal and femoral hernias presenting to this hospital between 1987 and 1989. Of 476 hernias (439 inguinal, 37 femoral), there were 34 strangulations (22 inguinal, 12 femoral). After 3 months the cumulative probability of strangulation for inguinal hernias was 2.8 per cent, rising to 4.5 per cent after 2 years. For femoral hernias the cumulative probability of strangulation was 22 per cent at 3 months and 45 per cent at 21 months. The rate at which the cumulative probability of strangulation increased was in both cases greatest in the first 3 months, suggesting that patients with a short history of herniation should be referred urgently to hospital and given priority on the waiting list.     

“Tension-free” herniorrhaphy for groin hernias in patients with cirrhosis: Report of four cases

Tension-free herniorraphies were carried out using either the Mesh Plug repair (M-P) or Perfix plug technique (P-P) in four patients with cirrhosis. Three patients had a lateral inguinal hernia, and the other had bilateral inguinal and femoral hernias. The patients’ ages ranged from 55 to 80 years. The Child-Pugh classifications showed that one was A, two were B, and one was C. The main complaint in two patients was a difficult reduction and the others had discomfort. An M-P was performed in the three patients with inguinal hernias and an M-P was performed for the femoral hernias and a P-P for the inguinal hernias in the patient with both inguinal and femoral hernias. Two patients had fluid collection under the incision and one of them required a single puncture. However, the others had no related complications after the operation. One patient died due to liver failure without recurrence of the groin hernias 31 months after the operation. The others had no recurrence and no related symptoms from 5 to 52 months after the operation.     

Clinically diagnosed groin hernias without a peritoneal sac at laparoscopy—what to do?

Background

Groin or femoral hernias may be concealed behind intact peritonea when the laparoscopic transabdominal preperitoneal (TAPP) mesh technique is used. The aim of this study was to determine the causes, frequency, and surgical procedures in cases of clinically diagnosed hernias without peritoneal defects.

Methods

A prospective controlled study comprising 1795 consecutive patients undergoing 2190 laparoscopic TAPP herniorraphies was conducted. All hernias were first subjected to clinical investigations by the surgeons. Intraoperatively, all suspicious hernias were examined with regard to the presence of peritoneal hernial sacs.

Results

Of 2190 hernias, no hernia was seen transperitoneally in the laparoscopic procedures in 136 cases (6.2%). Forty-one femoral hernias (30.1%) were concealed behind intact peritonea. Forty-six lateral (33.8%) and 31 medial (22.8%) defects were sacless sliding fatty inguinal hernias.

Conclusions

When using the TAPP technique, in addition to femoral hernias, especially sacless sliding fatty inguinal hernias may be overlooked because of intact peritonea. Therefore, in cases of clinically diagnosed inguinal hernias, the preperitoneal space should be inspected intraoperatively to avoid unsatisfactory results.     

First laparoscopic totally extraperitoneal repair of Laugier’s hernia: a case report

An atypical femoral hernia developing through the lacunar ligament is called Laugier’s hernia. Preoperative diagnosis of these atypical hernias is very difficult because of their rarity and similar clinical appearance to conventional femoral hernias. A 52-year-old female presented with right groin swelling. During laparoscopic totally extraperitoneal (TEP) inguinal hernia repair, a hernia sac through an opening in the lacunar ligament was diagnosed and repaired with mesh covering the inguinal floor. The surgeon should be alert to the possibility of an atypical femoral hernia when examining patients with inguinal hernias. A laparoscopic approach should be chosen instead of a conventional approach for the treatment of femoral hernias because of its high diagnostic and therapeutic capacity for all types of femoral hernia, including Laugier’s.     

Femoro-popliteal by-pass occlusion following mesh-plug for prevascular femoral hernia repair

Summary Mesh plug repair for both inguinal and femoral hernias had a minimal number of postoperative complications reported. Among femoral hernias, the prevascular type represents a variant, because of the peculiar position of the sac strictly adjacent to the vessels. The authors report a case of femoral occlusion following femoro-popliteal by-pass and concomitant homolateral femoral hernia repair by cylindrical polypropylene plug not secured by sutures, which laid directly on the vessels. This complication occurs three months following surgery, the plug being displaced over and tightly adherent to the femoral-graft anastomosis. The apposition of a polypropylene mesh plug directly over the PTFE vascular graft could have stimulated the massive local fibrous reaction found at histology, a reaction not explained by the insertion of the PTFE only. The authors suggest that polypropylene plugs for repair of prevascular type of femoral hernias should be avoided, when concomitant or future arterial grafting procedures are needed.     

Aetiology of femoral hernias revisited: bilateral femoral hernia in a young male (two cases)

Bilateral femoral hernias are less common in men than in women and rare in young adults. Only one case of a bilateral femoral hernia in a young man has been reported in the literature before. Three main theories have been postulated for femoral hernias. The theory that they are an acquired disease is the most accepted due to the common occurrence of such hernias in multiparous women but the theory lacks enough evidence. We report two cases in young men. Anatomical variations in the femoral canal could be the primary aetiological factor in these patients. A unilateral femoral hernia in young men with acquired aetiological factors requires a clinical examination of the opposite side.     

Complicated presentations of groin hernias.

Elective repair of simple (uncomplicated) inguinal and femoral hernias avoids incarceration and bowel obstruction (complicated presentations). To identify factors that perturb this strategy, we analyzed the records of 1,859 consecutive nonpediatric patients with groin hernias. Incarceration or bowel obstruction prompted operation in 22 of 77 (29%) women and in 15 of 34 (44%) patients with femoral hernia. Patients presenting with bowel obstruction were significantly older than those with incarceration only and/or uncomplicated presentation, and 13 of 25 (52%) required resection of necrotic bowel. Mortality was limited to five patients of advanced age with groin hernia and bowel obstruction. Four of the five patients had undergone resection of necrotic bowel. Complicated presentations of groin hernias are associated with a higher proportion of women and patients with femoral hernias. Gangrenous bowel was encountered only in those patients with groin hernia and bowel obstruction. Early diagnosis and elective repair of uncomplicated hernias should remain our strategy in patients of all ages.     

A rare and frequently unrecognised pathology in children: femoral hernia

A femoral hernia is the protrusion of the abdominal contents through the femoral canal. It accounts for less than 1% of all groin hernias in children and is often confused with inguinal hernia or other inguinal pathologies. Preoperative misdiagnosis has been reported to be between 40 and 75%. We believe that misdiagnosis and mistreatment usually occur due to insufficient physical examination, knowledge and experience about childhood femoral hernias. Here, we report and discuss the clinical appearance and treatment approach of three patients operated with the diagnosis of femoral hernias.     

Recurrences after prosthetic repair of inguinal hernias by the lichtenstein technique

Summary We report a 3.4% incidence of hernial recurrence (all recurrences were reoperated) after inguinal hernia repair by the Lichtenstein technique: 14 reoperated recurrences (in 13 patients) in a series of 440 inguinal hernias (375 primary and 65 recurrent) in 379 patients (62 bilateral) over 5 years (1994–1998). Some 2/3 of all recurrences appeared within a year of surgery. Eleven of these patients were operated on for bilateral and/or recurrent groin hernia, and eleven also showed at least one risk factor for recurrence, such as obesity and other general diseases (specially pulmonary and hepatic). The incidence of recurrence was 0.7% (2 in 272) for primary unilateral hernia, 3.8% for primary bilateral hernia (2 in 52), 11.1% for recurrent unilateral hernia (5 in 45) and 40% for recurrent bilateral hernia (4 in 10). Recurrences were 5 indirect hernias, 4 direct hernias and 5 femoral hernias. Indirect recurrence was attributed to technical errors, but femoral and direct hernias seem to be the consequence of a poor indication for the Lichtenstein technique. Log-rank tests showed very significant statistical differences (p<0.01) in the risk of hernial recurrence between recurrent and primary hernias. We suggest that certain conditions should be contraindications for the standard Lichtenstein technique (bilateral groin hernia, recurrent hernia, obesity, chronic pulmonary and liver disease), and propose for these either a preperitoneal repair or some modifications of the Lichtenstein technique (an extremely floppy mesh and simultaneous femoral repair with the mesh).     

Bilateral retrovascular femoral hernia

A 34-year-old woman with cystic fibrosis presented with bilateral femoral hernias, which were found to be retrovascular at operation. The hernias were not amenable to conventional open or laparoscopic repair, and were repaired using pre-peritoneal mesh inserted deep to transversalis fascia. The anatomical basis and management of uncommon variants of femoral hernia are discussed.