From the Guidelines
Femoral hernia repair can be performed through several open surgical approaches, including the low approach (Lockwood), the high approach (McEvedy), and the inguinal approach (Lotheissen), with the choice of approach depending on the specific case and the surgeon's preference. The low approach involves an incision below the inguinal ligament directly over the hernia, providing direct access to the femoral canal but limited exposure for complex repairs 1. The high approach uses a vertical incision above the inguinal ligament, offering excellent exposure for strangulated hernias requiring bowel resection. The inguinal approach accesses the femoral hernia through an inguinal incision, similar to an inguinal hernia repair, allowing good visualization of the femoral ring from above.
Key Considerations
- All techniques involve identifying the hernia sac, reducing its contents, excising or inverting the sac, and closing the femoral canal.
- Closure typically uses non-absorbable sutures to approximate the inguinal ligament to Cooper's ligament (pectineal ligament), though mesh reinforcement is increasingly common to reduce recurrence rates, as supported by the 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias 1.
- The use of mesh in clean surgical fields is associated with lower recurrence rates without an increase in wound infection rates, making it a recommended approach for patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection.
- In contaminated or dirty surgical fields, biological mesh prosthetics may be used for repair, offering a low-morbidity alternative to prosthetic mesh products in complex settings.
Postoperative Care
- Postoperative care includes pain management with acetaminophen and NSAIDs, activity restriction for 2-4 weeks, and wound care.
- These open approaches remain valuable options, particularly for emergency repairs or when laparoscopic approaches are contraindicated, though minimally invasive techniques are becoming more prevalent for elective repairs.
- The choice between different surgical approaches and the use of mesh or biological prosthetics should be based on the individual case, taking into account factors such as the size of the defect, the degree of contamination, and the patient's overall health status.
From the Research
Surgical Options for Femoral Hernia Repair
The following are different surgical open options for femoral hernia repair:
- Lockwood's infra-inguinal approach 2
- Lotheissen's trans-inguinal approach 2, 3
- McEvedy's high approach 2, 3
- Open tension-free Cooper ligament repair 4
- Infrainguinal plug technique 5
- Complete groin repair (CGR) 5
- Preperitoneal mesh repair 5
- Mini-mesh repair 6
Characteristics of Each Approach
- Lockwood's approach: involves a separate skin incision and dissection to access the femoral sac 2
- Lotheissen's approach: involves a separate skin incision and dissection to access the femoral sac 2
- McEvedy's approach: may be superior when entry into the peritoneum is anticipated, but may be associated with longer operation time and hospital stay 3
- Open tension-free Cooper ligament repair: applies the principles of the tension-free method of McVay's Cooper ligament repair by covering all potential hernia sites in the myopectineal orifice with a mesh 4
- Infrainguinal plug technique: has gained popularity in recent years, but evidence supporting this repair is sparse 5
- Complete groin repair (CGR): a tissue-based repair that can be performed for specific indications 5
- Preperitoneal mesh repair: can be performed for specific indications, such as recurrent femoral hernias or inguinofemoral hernias 5
- Mini-mesh repair: a new technique that involves securing a small mesh to the Cooper's ligament with 2/0 polypropylene suture 6