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CASE REPORT – OPEN ACCESSInternational Journal of Surgery Case Reports 17 (2015) 85–88

Contents lists available at ScienceDirect

International Journal of Surgery Case Reports

journa l homepage: www.caserepor ts .com

aparoscopic repair of an incarcerated femoral hernia

agan Pillay ∗

epartment of General Surgery,Victoria Hospital, Prince Albert Parkland Health Region, 1521 6th Avenue West Prince Albert, SK S6V5K1, Canada

r t i c l e i n f o

rticle history:eceived 17 September 2015ccepted 25 October 2015vailable online 30 October 2015

eywords:emoral herniaaparoscopic hernia repairernia incarceration

a b s t r a c t

INTRODUCTION: A femoral hernia is a rare, acquired condition, which has been reported in less than 5%of all abdominal wall hernias, with a female to male ratio of 4:1.PRESENTATION OF CASE: We report a case in a female patient who had a previous open inguinal herniorrha-phy three years previously. She presented with right sided groin pain of one month duration. Ultrasoundgave a differential diagnosis of a recurrent inguinal hernia or a femoral hernia. A transabdominal preperi-toneal repair was performed and the patient made an uneventful recovery.DISCUSSION: Laparoscopic repair of a femoral hernia is still in its infancy and even though the outcomesare superior to an open repair, open surgery remains the standard of care. The decision to perform alaparoscopic trans abdominal preperitoneal (TAPP) repair was facilitated by the patient having previous

open hernia surgery. The learning curve for laparoscopic femoral hernia repair is steep and requires greatcommitment from the surgeon. Once the learning curve has been breached this is a feasible method ofsurgical repair. This is demonstrated by the fact that this case report is from a rural hospital in Canada.CONCLUSION: Laparoscopic femoral hernia repair involves more time and specialized laparoscopic skills.The advantages are a lower recurrence rate and lower incidence of inguinodynia.

© 2015 The Author. Published by Elsevier Ltd. on behalf of IJS Publishing Group Ltd. This is an openhe CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

access article under t

. Introduction

A femoral hernia while a rare occurrence can be problematics they often present with symptoms of incarceration or strangu-ation. It is more common in females and the type of repair cane controversial. While open surgery remains the standard of care,

aparoscopic surgery has lower recurrence rates and post operative

Fig. 1. Incarcerated omental contents in the femoral hernia (blue arrow).

∗ Fax: +1 3067643091.E-mail addresses: yagan2pillay@yahoo.ca, yaganpillay@yahoo.ca

ttp://dx.doi.org/10.1016/j.ijscr.2015.10.031210-2612/© 2015 The Author. Published by Elsevier Ltd. on behalf of IJS Publishing Greativecommons.org/licenses/by-nc-nd/4.0/).

Fig. 2. Release of the omentum from the hernial defect.

pain (Fig. 1). This type of repair however has a steep learning curveand still presents a challenge for surgeons.

2. Case report

A 45 year old female presented with right groin pain of onemonth duration. There was no history of trauma. Past history: Open

right inguinal herniorrhaphy three years previously Clinical examrevealed a swelling in the right groin below the inguinal ligament(Fig. 2). The swelling could not be completely reduced. There was noerythema or fluctuance around the swelling. The rest of the abdom-

roup Ltd. This is an open access article under the CC BY-NC-ND license (http://

CASE REPORT – OPEN ACCESS86 Y. Pillay / International Journal of Surgery Case Reports 17 (2015) 85–88

i(n(

Fig. 4. Femoral canal (blue arrow), pubic bone (double arrow) and broad ligament

Fig. 3. Incidental ovarian cyst and hernial defect (blue arrow).

nal examination was uneventful. The patient was well systemicallyFig. 3). Ultrasound of the pelvis showed a recurrent inguinal her-ia or a differential diagnosis of a femoral hernia on the right sideFig. 4). The patient was operated upon laparoscopically as she had

Fig. 5. Diagrammatic representation

(curved arrow) after peritoneal flap creation.

of the relevant anatomy [6].

CASE REPORT – OPEN ACCESSY. Pillay / International Journal of Surgery Case Reports 17 (2015) 85–88 87

Fig. 6. Lacunar ligament (blue arrow) medial to femoral canal (double arrow).

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Fig. 8. Superior mesh fixation to the anterior abdominal wall.

Fig. 9.

Fig. 7. Mesh fixation to coopers ligament medially.

previous open repair. She had a trans abdominal pre-peritonealTAPP) mesh repair. Her post operative recovery was uneventfulnd she was discharged home on post operative day one (Fig. 5).

. Discussion

Femoral hernias are relatively uncommon (Fig. 6). They accountor less than 5% of all hernias. Femoral hernias occur just belowhe inguinal ligament, when abdominal contents pass through aaturally occurring weakness called the femoral canal. They areore common in females because of the wider bone structure of the

emale pelvis by a ratio of 4:1 (female:male) [1]. Femoral hernias areore common in multiparous females as compared to non-parous

emales (Fig. 7). Approximately 60% of femoral hernias are foundn the right, 30% on the left, and 10% bilaterally [2]. An enlargedemoral ring is thought to be the cause of the femoral hernia [7].he lacuna vasorum increases in size as a person ages and is thoughto be the reason for the increased incidence in the elderly [8]. Threepproaches have been described for open surgery: Lockwood’snfra-inguinal approach, Lotheissen’s trans-inguinal approach and

cEvedy’s high approach (Fig. 8). The infra-inguinal approach ishe chosen method for elective repair while McEvedy’s approach isreferred in the emergency setting when strangulation is suspecteds this approach allows better access for visualisation of bowelnd possible resection if needed [3]. Laparoscopic repair involveshe extraperitoneal (TEPP) or transabdominal preperitoneal (TAPP)pproach (Fig. 9).

While there is good evidence for this method of repair it is stillot the standard of care. This is in part due to the abnormally steep

earning curve for surgeons (Fig. 10). It involves more time and spe-ialised laparoscopic skills. The advantages are a lower recurrence

Fig. 10. Mesh reperitonealisation.

rate and post operative pain [3,5]. Once the learning curve has beenbreached this repair is eminently feasible as evidenced by the repairof this patient’s hernia in a rural hospital in Saskatchewan, Canadaby a surgeon with no formal training in minimally invasive surgery.

Conflict of interests

Not applicable.

Funding

No funding.

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CASE REPORT8 Y. Pillay / International Journal of

onsent

I have consent from the patient. I submitted the incorrect formreviously. That form was for another case report already pub-

ished.Research registry UIN is 554.

uthor contribution

Yagan Pillay—only author.

cknowledgement

None.

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pen Accesshis article is published Open Access at sciencedirect.com. It is distribermits unrestricted non commercial use, distribution, and reproductredited.

PEN ACCESSry Case Reports 17 (2015) 85–88

References

1] R.T. Kochupapy, G. Ranganathan, S. Dias, D. Shanahan, R. Ann, Coll. Surg. Engl.95 (2013) e14–e16.

2] A. Mahajan, A. Luther, Incarcerated femoral hernia in male: a rare case report,Int. Surg. J. 1 (2014) 25–26.

3] N. Stoikes, E. Mangiante, G. Voeller, Laparoscopic repair of a man with massivebilateral femoral hernias, Am. Surg. 75 (2009) 1189–1192.

5] R.C. Read, Crucial steps in the evolution of the preperitoneal approaches to thegroin: an historical review, Hernia 15 (1) (2011) 1–5.

6] George A. Sarosi Jr., Kfir Ben-David, Laparoscopic inguinal and femoral herniarepair in adults, in: T. Post (Ed.), UptoDate, UptoDate, Waltham, MA, 2015(Reference for Figure 5).

7] C.B. McVay, L.E. Savage, Etiology of femoral hernia, Ann. Surg. 154 (1961)25–32.

8] T. Hachisuka, Femoral hernia repair, Surg. Clin. North. Am. 83 (2003)

1189–1205.

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