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474
Lacunar ligament
E. D. Kane and B. P. Jacob
posteriorly. The balloon should be repositioned if
the inferior epigastric vessels are noted to be posterior, along the peritoneal layer. If the abdomen
is inadvertently entered via peritoneal injury, the
procedure may be converted to a TAPP approach.
After the potential space has been developed
and the balloon dissector has been desufated
and removed, a balloon-tipped trocar is inserted
into the retrorectus space. Insufation with carbon dioxide is achieved until pressure of the
space reaches between 12- and 15-mmHg. A
45-degree 5- or 10-mm laparoscope is then introduced through the trocar to aid with the insertion
of two more vertically positioned 5-mm trocars:
one suprapubic and one halfway between the
suprapubic trocar and the umbilicus.
The patient is placed in Trendelenburg position
for improved visualization. Tissue within the preperitoneal space is cleared to expose the pubic
bone and Cooper’s ligament to the level of the
femoral canal. The entire myopectineal orice
should be exposed in preparation for mesh implantation [19], as well as to identify other important
vascular structures entering this area, like the
corona mortis and the external iliac vein. A wide
lateral and posterior dissection is essential to make
adequate room for the placement of a large mesh,
as is dissection of the peritoneum off of the spermatic cord or round ligament, anterior abdominal
wall, retroperitoneum, posterior aspect of the
pubis, and psoas muscle so that the mesh will lie
at. The peritoneal reection must be completely
swept back to prevent recurrence of peritoneal hernia under the lower edge of the mesh. Any attachments to the anterior abdominal wall should be
taken down. However, it is recommended to leave
a layer of preperitoneal fat over the abdominal
wall to prevent injury to nerves coursing through
that area and to limit the disruption of small vessels, which are prone to bleeding.
The lacunar ligament should then be exposed.
Reduction of the contents into the peritoneum
may be accomplished at this time with blunt
graspers. Medial retraction of the hernia contents
is key. Blunt dissection is used to sweep the areolar tissue back toward the iliac vein using countertraction aimed medially and superiorly, away
from the vein. Thermal injury due to the use of
electrosurgery must be avoided while working by
the iliac vessels. Optimally, the contents will
reduce easily. However, if there is a large mass
and/or the contents remain incarcerated, a relaxing incision of the femoral ring is advised. To
release the constriction at the femoral ring, the
lacunar ligament can be incised medially with
hook cautery after ligation of the corona mortis
vein, by cutting superomedially (as shown in
Fig.47.1 by the dotted black line). Once the contents are reduced (Fig.47.2), the surgeon should
inspect the femoral canal to ensure hemostasis.
After dissection of the space is completed with
clear visualization of the cord structures and hernia defect (Fig. 47.3), the peritoneum should be
inspected for any defects which may have been
Corona mortis
Fig. 47.1 Dissection of
the femoral canal
Lacunar ligament
Cooper’s ligamen
Exter
v
47 Laparoscopic Femoral Hernia Repair
475
sustained during the dissection. Defects may be
clipped with clip appliers, but small holes often
do not need to be repaired, as they heal quickly
once the edges reapproximate with desufation. If
intraperitoneal insufation occurs via a defect,
insufation pressures should be decreased to
10 mmHg or lower, and if necessary, a Veress
needle may be placed intra-abdominally for
desufation (Fig.47.2).
At this point, with the myopectineal orice
exposed, the hernia mesh may be introduced into
the dissected pocket via the infraumbilical trocar
and directed downward toward the ipsilateral
side of the symphysis pubis as the hernia. The
mesh is then unrolled over the myopectineal orice using graspers, so that the lateral edge
touches the anterior iliac spine, the midline is
Fig. 47.2 Reduction of
the hernia sac
Attenuator
transversalis fascia
overlapped by at least 2 cm, the inferior edge
overlies the cord structures, and the superior edge
extends beyond the hernia defect by at least 4cm.
Once in place, the mesh should then be xated by
placing a permanent tack into Cooper’s ligament
or the bone just below the defect to ensure the
mesh remains in place without clam shelling.
Other surgeons may prefer to use suture or brin
glue for xation, and many will advocate for nonxation in TEP repairs. However, we feel that
permanent xation to one of these durable anatomic structures is essential. The preperitoneal
space may then be desufated under visualization, making sure that the mesh remains
unchanged in the appropriate position. The ports
may then be removed and sites closed in standard
fashion (Fig.47.3).
Fig. 47.3 Inspection of
the canal post-reduction
Femoral hernia
contents
nal iliac
essels
t
476
E. D. Kane and B. P. Jacob
47.5.2 Transabdominal
Preperitoneal (TAPP) Repair
Access to the peritoneum is again initiated at the
infraumbilical fold, carrying the incision down
through the subcutaneous tissues until the median
umbilical raphe is reached. The raphe is then
incised vertically in the midline. Blunt spreading
permits safe entry into the peritoneum and placement of a 12-mm trocar. Once the insufation
pressures reach 15 mmHg, the intra-abdominal
contents may be surveyed with the laparoscope.
The patient is placed in Trendelenburg position,
and left- and right-sided 5-mm trocars are then
placed in-line horizontally with the infraumbilical trocar under direct visualization or in a
straight line which is perpendicular to a unilateral
defect. Any small bowel may be swept away
using blunt-tipped graspers to visualize the pelvis
and any abdominal wall defects.
The peritoneal ap is created using electrosurgery or sharp dissection by making a curvilinear or
“lazy-S” incision, beginning posterolaterally near
the anterior superior iliac spine, curving anteromedially passing anterior to the hernia defect(s), and
stopping medially at the median umbilical fold.
The dissection is carried out bluntly exposing the
medial space until Cooper’s ligament is identied.
The spermatic cord and testicular vessels are dissected off of the posterior peritoneal ap. The
areolar tissues supercial to the urinary bladder
and the fatty tissues between the bladder and the
posterior pubis are dissected bluntly to expose the
pubic tubercle and Cooper’s ligament. Vigilance
should be paid to the possible presence of and
location of the corona mortis to avoid injury. The
ap dissection is carried down to the level of the
iliac vessels, creating a pocket laterally to the
psoas body in order to develop a large preperitoneal space for mesh placement, exposing the myopectineal orice completely [19].
The femoral canal should be apparent within
the eld, and hernia contents should be reduced
back into the abdomen using blunt dissection
along the superomedial and inferomedial aspects
of the canal to avoid injury to the femoral and
external iliac vessels. Reduction of the hernia
contents is conceptually similar to the reduction
described earlier in a TEP repair. A relaxing incision at the medial aspect of the femoral ring,
where the iliopubic tract inserts into Cooper’s
ligament, may be necessary to release the constricted ring and allow for the evacuation of hernia contents into the abdomen.
A large hernia mesh may then be introduced
into the peritoneal cavity and positioned into the
pocket anterior to the peritoneal ap, covering
the entire myopectineal orice in a similar manner to a TEP repair. The mesh should be able to
lay at in this plane without kinking. It should be
secured in place to the transversalis fascia, pubic
tubercle, and Cooper’s ligament using the xation system of the surgeon’s choice; though,
again, we recommend securing the mesh with
permanent tacks to these structures. Care should
be taken not to deploy tacks or suture lateral to
the inferior epigastric vessels.
After ascertaining that the mesh is in a good
position and excellent hemostasis has been
achieved at low insufation pressures, the peritoneal aps may be reapproximated. The edges of
the ap may be apposed using permanent helical
tacks, interrupted suture, or running suture, or
laparoscopic staples or clips. Care should be
taken to achieve a continuous closure without
gaping of the aps between tacks or interrupted
suture to prevent internal herniation of bowel or
exposure of the mesh to the abdomen, particularly when the mesh is not coated. If the operating surgeon should choose not to secure the ap
in place, we recommend repositioning the peritoneum over the mesh and monitoring its position
during desufation. The laparoscopic ports may
then be removed and umbilical fascia closed.
47.5.3 Intraperitoneal Onlay Mesh
Repair
Laparoscopic access to the abdomen is achieved
in the same manner as in the TAPP, with identical
port placement. The patient is placed in
Trendelenburg position, and the myopectineal
areas are inspected bilaterally. The hernia sac
may then be reduced into the abdomen. A large
polytetrauoroethylene (PTFE) or coated mesh is
47 Laparoscopic Femoral Hernia Repair
477
employed with at least 3-cm overlap beyond the
hernia defect(s); generally a 12 × 15-cm sized
mesh is used. A choice of tacks, suture, or staples
are used to secure the mesh medially to Cooper’s
ligament and laterally to the anterior superior
iliac spine, and transfascial sutures should be
placed at the superior edge of the mesh to rectus
abdominis for better xation. Placement of tacks
or suture into the inferior edge of the mesh should
be avoided due to the risk of injury to the iliac
vessels. Again, the lie of the mesh should be
monitored under direct visualization during
desufation of the abdomen to ascertain that it
has not moved in position.
Of note, this technique is not recommended
due to high recurrence rates, but it is historically
described. Moreover, by not dissecting the peritoneum out of the defect, an occult femoral hernia may be missed or misdiagnosed. Some
surgeons may defer to it as a last resort if the preperitoneal space cannot be accessed for hernia
repair due to brosis from previous radiation or
other procedures. If chosen, the surgeon may opt
to perform a hybrid IPOM/TAPP repair to tuck
the inferior edge of the mesh within a preperitoneal pocket.
47.5.4 Robotic Femoral Hernia
Repair
Patient positioning may depend on the robot platform being used due to the variation in the array
and maneuverability of the robot arms. Generally,
the patient is placed supine, in Trendelenburg
position, with the robot docked at the patient’s
hip, though the Xi platform provides greater exibility for positioning about the patient.
Abdominal access is obtained based on surgeon
preference, and three ports are placed transversely at the level of the umbilicus: one 10-mm
umbilical port, an 8-mm port to the right in the
midclavicular line, and a 5-mm port (or 8-mm, if
using the Xi) to the left in the midclavicular line.
The case should proceed in the same fashion
as described in the TAPP section, with the following modications for the robot system.
Monopolar scissors should be used to make a
curvilinear incision in the peritoneum above the
myopectineal orice between the anterior superior iliac spine and the medial umbilical ligament
as the start of the ap. After development of the
preperitoneal pocket, the assistant at the bedside
should place the mesh into the abdomen via the
8-mm trocar and the operator at the console can
unroll it and position it within the dissected preperitoneal space. After the mesh is xated
smoothly in place, the peritoneal ap should be
closed, as it would be during a laparoscopic
TAPP repair. An advantage of using the robot in
this instance is the increased ease of intracorporeal suturing compared to the laparoscopic
procedure.
47.6 Postoperative Complications
andConsiderations
Complications after laparoscopic hernia repair
include hematoma due to injury to one of the vessels traversing the myopectineal orice, inguinodynia from nerve injury or mesh irritation, mesh
or surgical site infection, urinary retention or
complications due to bladder injury, port site hernia, small bowel obstruction or internal herniation, and hernia recurrence.
Chronic pain is the most frequent adverse outcome after inguinal hernia repair [20], with rates
reported as high as 25% [21]. Laparoscopic
repair of inguinal hernia is associated with
decreased chronic pain compared to open techniques [22, 23], and type of technique performed
(TAPP versus TEP) carries an equivalent risk of
postoperative pain after laparoscopic femoral
hernia repair specically [24].
Incidence of small bowel obstruction after
laparoscopic herniorrhaphy is 0–0.1%, though
may reach up to 2% of cases [25]. Intraperitoneal
repair holds a higher risk than TEP repair due to
the formation of peritoneal adhesions and the
potential for tacks to cause a nidus for obstruction or volvulus. Furthermore, TAPP repair has
the risk for viscera to herniate through defects
from incomplete peritoneal ap closure, unlike a
TEP repair, unless the peritoneum is violated
[26, 27].
478
E. D. Kane and B. P. Jacob
Femoral hernia recurrence is also a known
potential event following repair, though true
long-term recurrence rate is uncertain. Multiple
randomized controlled trials and large retrospective studies have reported recurrence rates
between 0% and 5% after laparoscopic groin hernia repair up to 10years postoperatively [21, 28].
Compared to open femoral hernia repairs, rates
of recurrence requiring reoperation in a large prospective nationwide analysis were much lower
after laparoscopic repairs, with a 2.2% recurrence after elective laparoscopic repair versus
7.1% for open techniques [6]. Of note, this study
also demonstrated nearly a twofold increased risk
in need for reoperation for recurrence for female
patients over males. Because femoral hernias are
so challenging to identify preoperatively and
many are missed during open repair due to lack
of exposure of the femoral canal, a laparoscopic
approach is optimal to minimize the risk of ipsilateral hernia recurrence, particularly in female
patients.
Conclusion
Femoral hernias can be repaired safely using
open or laparoscopic techniques. Laparoscopic
approaches to the groin provide the advantage
of nding both inguinal and femoral defects
during the same dissection. Surgeon comfort
with the anatomy and understanding of the
surgical technique is critical to safe and appro-
priate repair. The use of the robot as an adjunct
to laparoscopic repair remains in evolution
although concerns with cost and training
persist.
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Results andComplications
ofFemoral Hernia Repair
SergioAleri, CaterinaCina, andGermanaSavi
48
48.1 Risk Factors
The most important risk factors which adversely
affect the outcomes of hernia repair for groin hernia are:
– Female gender
– Old age
– Severe pain at hernia site and signs of
mechanic bowel obstruction
– Presence of coexisting cardiopulmonary
diseases
– High ASA score
– Femoral-type hernia
– Late admission
Several authors analyzed a series of patients
operated for groin hernia (series including femoral hernia) and dened risk factors correlated
with unfavorable outcome in patients who underwent elective (majority) or emergency surgery.
Incarceration and strangulation are usually more
frequent in women and ASA 3 and 4 group.
Tension-free hernioplasty is the most common
procedure. Content of the hernia can be ileum
only, omentum only, ileum with omentum, sigmoid colon, cecum, appendix, and preperitoneal
S. Aleri (*) · C. Cina · G. Savi
Department of Digestive Surgery, Fondazione
“Agostino Gemelli” General Hospital, Catholic
University of Sacred Heart, Rome, Italy
e-mail: sergio.aleri@unicatt.it
fat in most of cases. Ovary and fallopian tubes
were rarely found. Necrotic bowel resection or
omentectomy are rarely required (0.3–1%) [1].
Major complications generally occur in
patients with severe coexisting diseases.
Emergency hernia repairs in elderly patients carry
a high morbidity and mortality risk in the presence of coexisting cardiopulmonary problems.
48.2 Emergency Vs. Elective
Surgery
Emergency episodes were related to higher incidences of visceral and small bowel involvement,
increased small bowel resection rate, longer hospital stay, and higher mortality [2–4].
The femoral hernia has a rate of strangulation
between 40 and 60%, tenfold the inguinal hernia,
so it often requires emergency repair [5–7].
Incarceration and strangulation carry a sevenfold higher risk of postoperative overall mortality
rate in high-risk patients and increase a 20-fold in
case of concomitant emergency resection (9.3–
5.3%), occurring in 9.3–46.44% of cases [8].
Data from the Swedish Hernia Register [9]
showed a 30-day mortality rate of 4.4% following emergency surgery for femoral hernia, compared with 0.2% for elective repair.
Alhambra-Rodriguez de Guzman et al. [8]
analyzed the effect of bowel resection on morbidity and mortality. They retrospectively analyzed a
cohort of 86 patients undergoing emergency
© 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_48
481
482
ab
treatment for incarcerated femoral hernia
between 1995 and 2009. In all cases the hernia
repair was made with polypropylene mesh, and
in 8 patients (9.3%), ischemia-related bowel
resection was necessary. They found intake of
oral anticoagulants and a maximum of 3 days’
duration of the symptoms as the independent risk
factors for bowel resection. 5 of the 8 patients
resected (62.5%) developed wound infection in
the 50% of cases with a complication rate of
10.5%.
Calik et al. [2] analyzed 80 patients who
underwent surgical femoral hernia surgery
between 2009 and 2013. 43 patients (53.8%)
required emergency surgery to treat incarceration
(omentum in 51% of the cases, small bowel
32.6%, small bowel + omentum 9.3%, sigmoid
colon 4.7%, and right tuba 2.3%). 18 of them
(41.9%) showed strangulation and underwent
resection (of the omentum in 12 patients, of the
small bowel in 5 patients, and of the omentum +
small bowel in 4 patients). Plug mesh was used in
the 73.8% of the procedures, McVay herniorrhaphy in 20%, primary repair in 2.5%, and Stoppa
technique in 2.5% of the cases, and 1 patient was
treated laparoscopically. The overall complication was developed in 11 patients (13.8%):
wound infection (5 patients, 6.3%), pneumonia
(4 patients, 5%), hematoma (1 patient, 1.3%),
and cerebrovascular occlusion (1 patient, 1.3%).
2 patients died of pneumonia and cerebrovascular
occlusion (2.5%). Recurrence occurred in 1
patient (1.3%) treated with McVay method. The
authors concluded that risk factors predicting
morbidity after surgical repair of femoral hernia
are need of emergency surgery with bowel resection and interval between symptoms onset and
surgery. Age, gender, comorbidity, ASA score,
type of anesthesia, and surgical methods are considered controversial risk factors.
48.3 Surgical Technique Repair
Some series reported several types of complication related to mesh plug repair like foreign body
feeling, chronic pain, migration of the mesh plug
toward the scrotum or pelvis, intestinal obstruc-
S. Aleri et al.
Fig. 48.1 Schematic representation of the abdominal
wall with femoral hernial orice. (a) The hernial defect
has been lled with mesh plug. (b) Plug placed in the preperitoneal space and the intra-abdominal pressure is distributed in the femoral ring
tion, recurrence, or seroma [10–14]. Preperitoneal
patch is located deep into the preperitoneal space,
so it is xed by the intra-abdominal pressure and
it is not easy to displace it (Fig.48.1). The sutures
used to x the plug to the tissue around the femoral ring produce tension, responsible of the foreign body feeling. Seroma formation is common
when a synthetic material like polypropylene is
used over fatty tissue. It increases effusion of uid
from tissues, while the patch placed deeply in preperitoneal space is not in contact with the subcutaneous fat [15, 16]. Preperitoneal repair also does
not treat the femoral ring directly, so it avoids
compression or injury to the femoral vein [17].
Chen etal. [18] in 2010 published a prospective study in which 85 patients undergoing primary, unilateral femoral hernia repair surgery
(enrolled between 2002 and 2008) were randomized in two arms: 45 patients were placed in a
preperitoneal group (pre-PG—in 20 cases a
medium-sized patch was used and in 25 cases an
easy-prosthesis mesh) and 40in mesh plug group
(MPG). There were no perioperative deaths. No
recurrence occurred in the pre-PG, while it
occurred in 4 patients of MPG (10% with
p=0.0451); wound infection was recorded in 1
patient (2%) of pre-PG vs. 3 of MPG (7% with
p=0.3383); seroma occurred in 2 patients (4%)
vs. 8 of MPG (20% with p = 0.0490); foreign
body feeling was declared only in 6 patients of
MPG (15% with p=0.0088). Concerning complication and recurrence rate, the authors found
preperitoneal herniorrhaphy superior to the mesh
plug technique for repair for femoral hernia
(Fig.48.2).
48 Results andComplications ofFemoral Hernia Repair
483
Fig. 48.2 (a) Hernia
mesh; (b) hernia plug
a
b
Fig. 48.3 Structure of ULTRAPRO Plug
Song et al. [19] used an ULTRAPRO Plug
(25% polypropylene, 75% monocryl, partially reabsorbable) (Fig.48.3) as hernia repair device in
a cohort of 121 patients that underwent electively
surgical operation of femoral hernia repair
between 2009 and 2013. Median follow-up was
at 26months. No mortality, recurrence, or major
event is declared. The overall rate of morbidity
was 8.3% (10 patients: 1 with wound dehiscence,
2 with supercial infection, 1 with subdermal
hematoma, 2 with postoperative chronic pain, 1
with sensory loss, 3 with foreign body feeling).
Wenzhang et al. [20] performed 72 elective
femoral hernia repairs with herniorrhaphy with
Prolene 3-D patch device (Fig.48.4) in a period
Fig. 48.4 Prolene 3-D patch
of 5years (2004–2009). After a median followup of 39months, they did not record any postoperative complications like seroma, wound
infection, edema, or recurrence. Postoperative
pain assessed by VAS score was 6.3 after 7days
of surgical repair.
In 1999 the MRC Laparoscopic Groin Hernia
Trial Group [21] conducted a randomized trial:
928 patients undergoing hernia repair for groin
hernia (inguinal and femoral hernia) were randomized in two arms, laparoscopic repair (468 patients)
and open hernia repair (460 patients of which 433
underwent tension-free mesh repair). In this large
multicenter randomized trial, the overall surgical
484
S. Aleri et al.
complication rate was 5.6% for laparoscopic group
and 1.4% for open group. Laparoscopic hernia
repair was related to earlier return to usual activities and less persistent groin pain 1year after the
surgery, but it is also related to serious surgical
complications (lateral cutaneousnerve of the tight
damage, bladder injury and trocar injury to the left
common iliac artery), hernia recurrence (1.95 vs.
0% in open repair group), and higher estimated
cost for the healthcare system.
Nilsson et al. [22] used the Swedish Hernia
Register and the Sweden National Patient
Register to nd surgical adverse events within
30 days of groin hernia surgery in a total of
143,042 patients registered between 2002 and
2011. The main complications investigated were
severe cardiovascular complications, severe
adverse surgical events, and intraoperative complications. In this study laparoscopy and suture
repair were related to increased risk in per-operative complications compared to open anterior
mesh technique.
Chia etal. [23] compare three different open
surgical approaches (Lockwood’s or LW,
Lotheissen’s or LT, and McEvedy’s or ME) in
190 patients who have undergone emergency
femoral repairs in a period of 13years.
All three approaches appear safe and effective
in femoral hernia repair in emergency surgery.
McEvedy’s procedure is related to a lower rate of
laparotomy but also to a longer operation time
and hospital stay.
48.4 Surgical Site Infection
Supercial and deep surgical site infections are
most commonly related to mesh infection.
Infected mesh as a postoperative complication of
hernia surgery affects up to 13.6% of patients
[24], with wound-related complications affecting
33% of patients postoperatively [25]. Mesh infections have been reported from 2 to 39 months
postoperatively [26], and the most common
organisms cultured by wound infection are
Staphylococcus aureus, methicillin-resistant
Staphylococcus aureus, and vancomycin-resis-
tant Enterococcus [27, 28].
Risk factors related to mesh infections
included smoking, the American Society of
Anesthesiologists (ASA) score of C3, age, duration of surgery, obesity, and emergency operations [24, 25].
Risk factors related to surgical site infection
include age, comorbidities/underlying illness,
obesity, smoking, wound classication and site,
and complexity of procedure [29].
At the same time, the nonuse of mesh in hernia repair is related to an increased risk of hernia
recurrence [30]. It has been shown that the use of
mesh signicantly reduces the rate of hernia
recurrence by an average of 30% compared to
suture repair [31, 32].
Mesh grafts may be biologic (absorbable) or
synthetic (nonabsorbable). Biologic grafts are
derived from either human or porcine dermis, and
they act as a collagen and extracellular matrix
scaffold, where the host broblasts can create
angiogenesis and lay down new collagen. They
have been advocated for their use in contaminated elds because of their greater resistance to
infection compared to synthetic mesh, but they
are also more expensive.
Polypropylene (monolament, nonabsorbable, inert, sterile, and porous, approximately
0.44-mm thick) and polytetrauoroethylene
(1-mm thick, strong, soft inert, and conformable
with a structure that ensures early xation) are
the most commonly used mesh materials.
Infected mesh wounds have traditionally been
treated by surgical removal of the mesh, but it is
potentially difcult and related to high recurrence. Stremitzer etal. [33] advocated the conservative management for the cases of infection in
the presence of absorbable mesh grafts and recommended the surgical removal of infected nonabsorbable ones. Meagher et al. [34] treated
successfully wound infection caused by nonabsorbable and absorbable meshes conservatively
using e.v. antibiotic therapy and VAC
medication.
Efcacy of antibiotic prophylaxis for prevention of surgical site infection (SSI) in the open
tension-free hernia repair remains controversial.
Mazaki et al., in a review and meta-analysis on
1920 patients who received antibiotic prophylaxis