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48 Results andComplications ofFemoral Hernia Repair
485
and 1936 patients allocated to the control group,
found an incidence of SSI of 3.0% and 6.0%,
respectively. The authors did not nd signicant
association between antibiotic prophylaxis and
incidence of deep surgical site infections [35].
48.5 Persisting Chronic Pain
The prevalence of persisting pain after groin hernia repair is evaluated between 0 and 76% of the
cases.
Chronic postoperative pain affecting everyday
life is a complication as important for femoral
hernia surgery as for inguinal hernia surgery;
however, femoral hernias have previously shown
to have a lower frequency of long-term postoperative pain then inguinal hernia.
Dahlstrand etal. [36] analyzed 1461 patients
who underwent primary, unilateral, and femoral
hernia repair in a period between 1997 and 2006
recorded in the Swedish Hernia Register (SHR).
In this study preoperative pain was yet present in
81.6% of the patients in whom 50.2% reported
pain interfered with daily activities. In 47.6% of
the patients, the pain disappeared within 1month
and in the 13.0% within 2months. In response to
the questions regarding the ability to perform
specic everyday activities, 151 (10.3%) patients
reported that groin pain affected their ability to
perform one or more of the activities.
Emergency surgery and long-lasting surgery
were found to be independently factors related to
a decreased risk for chronic pain. It is common in
emergency surgery to nd bowel incarceration
that requires resection. In this perspective, the
surgeon often limits the dissection to the tissue
below the inguinal ligament. As this area is
devoid of nerves and muscles, there is a lower
risk for neuropathic pain and motion-related
pain. Patients undergoing elective surgery are
identied on the basis of symptoms before surgery, whereas patients undergoing emergency
surgery are operated regardless of pain history.
This may have led to selection of patients perceiving more pain in the electively treated group.
Preoperative pain was strongly related to a
higher risk for postoperative chronic pain. In this
study age or surgery technique had no impact on
chronic pain (at the univariate analysis, preperitoneal mesh surgery is related to an increased risk
of chronic pain).
Others studies, based mainly on inguinal hernia, state that open posterior or laparoscopic
repairs are related to a lower risk of postoperative
chronic pain. In fact, preperitoneal approach does
not include dissection close to the three main
nerves in the area [37, 38].
48.6 Recurrence andReoperation
Recurrence rate after femoral hernia repair was
reported in 1–10% of cases in literature [39, 40],
and it represents one of the most important risk
factors for reoperation.
The cause of recurrent femoral hernia after a
tissue-based repair is most commonly due to
excessive tension. This means that sutures tear
through the inguinal ligament and transversalis
fascia. Tension may alternatively transmit and
cause damage in the internal oblique muscle at
the superior-medial aspect of the inguinal canal
and cause a direct hernia.
Another less common but difcult area to
address is the “prevascular recurrence.”
Aggressive dissection and traction during reduction of the femoral hernia can open this potential
space. It is technically difcult and dangerous to
place sutures in order to close this space.
Recurrences after anterior mesh repair of femoral hernias are usually caused by poor xation.
The lateral edge of the mesh can curl back toward
Cooper’s ligament and results in a recurrence in
the femoral space or in the prevascular location.
It is necessary to x the mesh to the inguinal ligament lateral to the epigastric vessels and to the
internal oblique muscle beyond the deep ring.
The xation deep to the inguinal ligament in the
preperitoneal space, also known as the triangle of
pain, is dangerous.
Technical failure of an infrainguinal mesh
plug repair is also the result of inadequate xation. Dissection of these femoral recurrences usually nds the plug extruded from the femoral
canal.
486
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S. Aleri et al.
If the canal is not sufciently dissected, the
plug may not have been completely inserted.
Other areas of technical weakness are the lateral ones, where sutures cannot be placed because
of the femoral vein and medial in the lacunar
ligament, where sutures are not usually placed.
G. Chan et al. [41] conducted a prospective
trail between 1999 and 2003 to examine 225
elective femoral hernia repairs for recurrence and
complication with a follow-up once a year for
5years. One-hundred twenty-three hernia defects
were repaired with suture and 102 with mesh.
None required a bowel resection or suffered any
signicant comorbidity. The overall rate of recurrence was 3.1% with a median time of 12months
(3–48 months): complete groin repair 3.3%, anterior sublay mesh 2.6%, and subinguinal plug
4.2%. There were no statistical differences in
recurrence rates between the techniques of repair:
primary vs recurrent, isolated femoral vs concurrent inguinal hernia, age, gender, BMI, chronic
pain, size of femoral hernia, or preoperative
symptoms.
There were 2 supercial surgical site infections treated successfully with oral antibiotics
and 20 patients (8.9%) experienced postoperative
chronic groin pain at 1 year: 18 of these had
minor pain and 2 had moderate pain.
Dahlstrand et al. [42] have also published a
study about the reoperation rate after femoral
hernia repair due to recurrence of hernia. They
analyzed 3980 patients who have undergone femoral hernia repair between 1992 and 2006
recorded on SHR.Five years after surgery, 6.3%
of the patients that underwent emergency hernia
repair and 7.4% of the patients who have undergone elective repair had a reoperation with an
overall reoperation rate of 6.6%. Postoperative
complication, male gender (in men femoral hernia is often related to inguinal hernia), and suture
repair/non-mesh use repair are related to a higher
risk of recurrence than open preperitoneal mesh
repair.
Postoperative mortality rate within 30 days
from surgery for elective repair was 0.16%, while
emergency repair was 4.42%, and male gender,
bowel resection, and postoperative complications
are the found risk factors.
Sandblom etal. [43], in a study published in
1999 about 588 patients who have undergone
femoral hernia repair recorded in the Swedish
Hernia Register between 1992 and 1997, registered an incidence of reoperation of 4.6% (19
patients). They found that patient’s age, emergency/elective surgery, primary/recurrent hernia,
and side of the hernia don’t represent risk factors
for reoperation.
48.7 Risk ofMalignancy
As femoral hernia sacs may include appendix,
Meckel diverticulum, fallopian tube, bowel or
ovaries, endometriosis, perivascular epithelioid
cell tumor and pseudomyxoma peritonei can be
examinated by pathologist [44].
Wang et al., in a series of examination of
1426 sacs of inguinal, femoral, and abdominal
hernia, found 10 malignancies at histology
examination [44].
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Part IV
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Ventral (Midline and Lateral)
Anatomy oftheVentral Region
JérômeLoriau
49
It is essential to consider the ventral region as a
part of a system containing components that
interact together to allow standing of course
(since about a million years!) but many many
other roles.
Without the simultaneous action of the spine,
spinal muscles and psoas iliac muscle posteriorly,
the diaphragm muscle, ceiling of the abdominal
cavity, and perineal oor muscles that build the
ground of the abdomen, the anterior components
of the abdominal compartment system would be
totally useless.
It could be described as a mobile scaffolding
and like in any of it, and the solidity of it depends
on every single small part of it.
It would be impossible to increase pressure
in the abdominal cavity due to the action of the
ventral muscles if the other solid muscular skeletal structures mentioned above were totally
lacking.
J. Loriau, MD
Department of Digestive Surgery, Groupe Hospitalier
Paris Saint Joseph, Paris, France
49.1 Rectus, External Oblique,
Internal Oblique,
andTransverse Muscles:
TheEntwined Quartet
49.1.1 Rectus Muscle
Pronouncing the name of “abdominal wall”
could be taken as a total misunderstanding
of what really is this essential part of the
body.
Considering it as a wall, a static and passive element is widely underestimating the
actual role that the different muscles composing the abdominal wall are playing.
However, the muscles constitute an
active support to the abdominal organs and
are involved or responsible for many
actions or movements. Without them it is
impossible to imagine many movements of
the trunk, impossible to do many “expulsive acts” like coughing, laughing, or even
… straining, and impossible to simply
breathe as the abdominal muscles are the
main coactors for respiratory movements.
All these considerations should lead any
surgeon to know and to RESPECT the ventral region anatomy. Doing that way, he’ll
be beloved by his patients when they’ll
look in the mirror. Forgetting those points
he could face dramatic complications.
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_49
491
492
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J. Loriau
Fig. 49.1 The roman centurion
Muscle body
muscle (reclined)
49 Anatomy oftheVentral Region
Fig. 49.2 Position of
the muscles of the
ventral region. 1 Ribs, 2
tendinous intersection,
3 muscle body, 4
pyramidalis muscle, 6
external oblique muscle
(reclined)
VII
493
V
VI
V
VI
VII
Ribs
Tendinous
intersection
External
oblique
Pyramidalis
muscle
494
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J. Loriau
What better than the school year memories
about the roman centurion armor can represent
the rectus muscle relief on the abdomen!
The rectus muscle, a paired muscle, runs vertically on each side, from the fth, sixth, and
seventh anterior costal cartilages and the xiphoidal appendix to the pubis and its spine. At that
point, some bers go laterally and horizontally
to create the Henle ligament. The wideness of
the muscle is not equal at its all length and as it
is 10–12cm wide at its top and it narrows progressively till 5–8 cm at the umbilicus and
nally about 3cm at the pubis. From the top to
bottom, the body of the muscle is partially
divided by 3–5 tendinous intersections made of
connective tissue (remembrance of the metameric constitution of the body). Looking from
the front, the two bodies of the muscle are separated medially by the linea alba and are limited
laterally by the semilunar line; as the muscle
bodies are divided by the horizontal intersections, six (four to ten depending on the number
of intersections) muscle bellies can be seen in
low fat persons (like on the roman centurion
armor!).
Situated just under the skin, it represents an
anterior strong pillar, symbol of power and manliness! This situation makes him the direct
antagonist to the iliac psoas, the spine, and its
posterior muscles constituting lateral and poste-
rior pillars. But to be able to take this function,
it has to stand vertical in his frontal position. In
case it is translated laterraly, in the setting of a
large medial incisional hernia for example, the
balance beetween anterior, lateral and frontal
forces is scrambled. Important musculoskeletal
troubles can then occur.
Pyramidalis Muscle: Linea Alba Tensioner?
When present (from 30 [1] to 90% [2]), the
pyramidalis is a triangle-shaped muscle
standing in front of the lower part of the
linea alba. It can be paired or not, and as its
pointed superior extremity ends midway
between the pubis and the umbilicus, inferiorly it attaches to the pubic crest and
symphysis.
Whether unclear, its direction makes it
considered as tensioning the linea alba.
For the surgeon, when present, this muscle can be used as a landmark of the linea
alba in a C-section procedure.
The innervation of the pyramidalis is
known to be depending on the ventral portion of T12 (subcostal nerve) but encounters high rate variations [3].
Blood supply to the pyramidalis comes
from the inferior (and superior) epigastric
vessels.
Pubic symphyses
49 Anatomy oftheVentral Region
Laterally, we will see the three at muscles
arranged in crossed directions.
The external oblique is, as the rectus anteriorly, the rst muscular subcutaneous plane. Its
cranial insertions stand on the lateral surface of
fth to 12th ribs. Its bers runs downward and
forward to the caudal insertions contributing, on
the midline, to built the linea alba (see below).
The distal insertions are situated on two medial
thirds of the iliac crest (including the anterior
superior iliac spine) and to the pubic symphysis.
Remember that during their course, the bers
split themselves in two pillars creating the supercial inguinal ring. Remember also that the caudal insertion of the external oblique muscle
constitutes the inguinal ligament. External
oblique is a myoaponeurotic muscle. Its muscular
body is relatively short and from about the midclavicular line, it becomes aponeurotic. From the
xiphoid process to the pubic symphyses on each
side, those aponeurotic bers, as a strong sheet of
dense connective tissue, cross the midline and
interdigitate with the one from the other side in a
chevron pattern. It passes anteriorly to the rectus
muscle and is one of the components of its anterior sheath.
Due to the direction of its bers; contraction
of the External oblique leads to pulling down the
ribs to the pelvis. This contributes to expiration
as an accessory respiratory muscle. It also plays a
495
Cranial insertion
Distal insertion
Inguinal ligament
Inguinal canal
Fig. 49.3 External oblique muscle insertions. 1 cranial
insertion, 2 distal insertion, 3inguinal ligament, 4 inguinal canal, 5 pubic symphyses
role in Valsalva maneuver, coughing, and
straining.
The muscle receives many nervous branches
coming from ventral branches of the lower six
thoracoabdominal nerves and the subcostal nerve
on each side.
496
Internal thoracic
Ext
artery
artery
l
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Rectus abdominis
Superior epigastric
intercostal artery
intercostal artery
abdominis muscle
Inferior epigastric
Inguinal ligament
artery
Musculophrenic
artery
artery
10th posterior
11th posterior
Subcostal artery
External oblique
muscle
Internal oblique
muscle
Transversus
artery
Deep circumflex
iliac artery
Superficial
epigastric artery
Superficial
circumflex iliac
artery
ernal iliac artery
Femoral
Cremasteric
Anterior
cutaneous
branches
Lateral
cutaneous
branches
Lateral cutaneous
branch of subcostal
nerve (T12)
Iliohypogastric
nerve (L1)
Anterior superior
iliac spine
Inguinal nerve (L1)
Inguinal fold (of
skin-overlies the
inguinal ligament)
J. Loriau
Thoracoabdomina
nerves (T7-T11)
Fig. 49.4 Arteries and nerves network of the ventral region
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