What are the types of femoral hernia repair?

Types of Femoral Hernia Repair

Femoral hernia repairs can be performed using various approaches, with the choice between open and laparoscopic techniques depending on patient factors, hernia characteristics, and surgeon expertise.

Open Surgical Approaches

There are three classical open surgical approaches for femoral hernia repair:

1. Lockwood's Infra-inguinal Approach:

   • Involves a skin incision below the inguinal ligament directly over the femoral hernia
   • Provides direct access to the femoral sac
   • Best suited for uncomplicated femoral hernias
   • Limited access if bowel resection is needed 1

2. Lotheissen's Trans-inguinal Approach:

   • Involves an incision through the inguinal canal
   • Allows access to the femoral hernia from above
   • Provides better visualization of the femoral defect
   • Can address concurrent inguinal hernias 1, 2

3. McEvedy's High Approach:

   • Uses a higher vertical incision above the inguinal ligament
   • Provides excellent access to the peritoneal cavity
   • Preferred when strangulation is suspected and bowel resection may be needed
   • Significantly reduces the need for additional laparotomy (2.6% vs 33.3% for Lotheissen's and 43.2% for Lockwood's) 2

A modified approach using a single skin incision 1 cm above the medial half of the inguinal ligament has been proposed, allowing flexibility to use any of the three classical approaches based on intraoperative findings 1.

Mesh-Based Repair Techniques

• Mesh Plug Technique:

  • Involves placing a mesh plug into the femoral canal
  • Further developed by Gilbert and Rutkow
  • Associated with shorter operating time and reduced postoperative pain
  • Recommended as first choice in elective and non-infected cases 3

• Flat Mesh Repair:

  • Standard flat mesh is recommended over plug repair
  • Evidence suggests higher erosion rates with plug versus flat mesh 4
  • Mesh should have adequate overlap (1.5-2.5 cm) 4

Laparoscopic Approaches

1. Totally Extraperitoneal (TEP) Repair:

   • Becoming the preferred approach for femoral hernias
   • Allows visualization and repair without entering the peritoneal cavity
   • Associated with low conversion and complication rates
   • Particularly beneficial for bilateral hernias 5

2. Transabdominal Preperitoneal (TAPP) Repair:

   • Provides excellent visualization of the hernia defect
   • Allows inspection of the contralateral side
   • Recommended to inspect the contralateral side during TAPP for potential bilateral hernias 4
   • Uses a triangular or diamond configuration of 3-4 trocars 4

Mesh Fixation and Selection

• Mesh fixation is generally unnecessary in TEP repair except for large medial (M3) hernias 4
• In both TEP and TAPP, mesh fixation is recommended for large medial hernias to reduce recurrence risk 4
• Low-weight mesh may provide slight short-term benefits like reduced postoperative pain and shorter convalescence
• Mesh selection should not be based on weight alone 4, 6

Special Considerations

• For emergency repairs of incarcerated/strangulated femoral hernias:

  • McEvedy's approach may be superior when entry into the peritoneum is anticipated 2
  • Mesh repair is still recommended over primary tissue repair even in emergency settings 4
  • Synthetic non-absorbable mesh for clean fields, biologic or biosynthetic meshes for contaminated/dirty fields 4

• For women:

  • Laparoscopic repair is suggested to decrease the risk of chronic pain and avoid missing a femoral hernia 6
  • Female gender has an 8:1 predominance in femoral hernias 5

Pitfalls and Complications

• Delayed diagnosis significantly increases mortality in strangulated hernias 4
• Time from symptom onset to surgery is the most important prognostic factor 4
• Early intervention (<6 hours from symptom onset) reduces the incidence of bowel resection 4
• Bowel resection is required in approximately 13.7% of cases 4

The choice of approach should be tailored to the surgeon's expertise, patient characteristics, and hernia presentation, with laparoscopic approaches generally offering faster recovery times and lower chronic pain risk when resources and expertise are available 4, 6.