Indications
- All femoral hernias (high risk of strangulation)
Landmarks: inguinal ligament (anteriorly), pectineal ligament (posteriorly), lacunar ligament (medially), femoral vein Procedure: Low / crural approach If any doubt as to bowel viability, laparotomy recommended
- Dissect down to hernia
- Groin incision directly over inguinal ligament
- Identify, dissect superficial fascia down to sac
- Expose neck of hernia
- Open hernia, inspect, reduce hernial contents
- If necrotic bowel, resect and perform laparotomy
- Close hernie defect
- Carefully retract femoral vein
- close defect (suture inguinal ligament to pectineal ligament - use J-shaped needle)
- Close subcutaneous tissue with interrupted sutures + skin with subcuticular
High inguinal approach Extraperitoneal approach Useful if unsure hernia is inguinal or femoral
- Dissect down to hernia
- Supra inguinal incision (Pfannenstiel, midline)
- Skin, blunt dissect superficial tissues to gain access to hernial sac
- Open rectus sheath + retract rectus
- Open up pre-peritoneal space with blunt dissection
- Continue process down towards inguinal ligament + identify hernia
- Identify and reduce hernia
- If sac empty, reduce back to abdomen: pull above, push below
- If bowel present, stretch femoral ring (with haemostat), transfix sac + excise tissue
- If irreducible, open peritoneum from above + inspect contents +/- bowel resection
- Close femoral canal with interrupted non-absorbable sutures between pectineal + inguinal ligament
Intestinal Stenosis of Garre
- Strangulated hernia causes mucosal ulcer
- Intestinal mucosa more vulnerable to ischaemia rather than overlying seromuscular layer - heals by fibrosis
- Annular stenotic stricture of small bowel
- Causes small bowel obstruction