Femoral hernia is a tumor–like protrusion formed when the loops of the intestine and omentum exit the abdominal cavity through the femoral ring. It is manifested by the presence of a sac-like protrusion in the area of the femoral triangle in the vertical position of the body, pain. If a hernia is infringed, intestinal obstruction may develop. Disease is recognized during a surgeon’s examination and additional diagnostics – ultrasound of hernial protrusion, irrigoscopy, herniography, ultrasound of the pelvis and bladder. When a defect is detected, a hernia repair (hernioplasty) operation is performed.
ICD 10
K41 Femoral hernia
Meaning
In modern herniology, femoral hernia (FH) occur in 5-8% of the total number of abdominal hernias. Pathology develops more often in women (the ratio with men is 4:l) due to the anatomical features of the pelvic structure and in children of the first year of life due to the physiological weakness of the connective tissue of the abdominal wall. FH is formed as a result of the exit of the abdominal cavity organs (large omentum, intestinal loops) outside the abdominal wall through the pathological femoral canal. Disease have an insidious course and are quite often infringed.
Causes of femoral hernia
Anatomical and physiological prerequisites for the formation of a FH are factors leading to weakening of the abdominal wall: rapid weight loss, abdominal wall injuries, multiple pregnancies, hereditary weakness of the abdominal wall in children under one year old, postoperative scars, violation of the innervation of the abdominal wall, hip dislocations (including congenital).
The immediate producing factors include situations associated with increased intra-abdominal pressure: physical exertion, difficulty urinating, persistent cough, constipation, prolonged labor, etc. These factors can affect both once (for example, lifting of gravity) and for a long time (prolonged cough with whooping cough, chronic bronchitis).
Pathological anatomy
The components of a femoral hernia are represented by hernial gates, hernial sac and hernial contents. The femoral canal serves as the gate of a FH – a pathological course in the musculofacial space of the femoral triangle. The femoral canal has an internal opening (femoral ring), an external opening (oval fossa) and walls formed by the inguinal ligament, the wide fascia of the thigh, the wall of the femoral vein. The femoral canal is 2-3 cm long and runs in a vertical direction.
The hernial sac of a femoral hernia is formed by preperitoneal fiber, transverse fascia, vascular lacuna fiber, and lattice fascia. The hernial contents of the sac in FH are usually the large omentum and loops of the small intestine, less often the colon (appendix and caecum – on the right, sigmoid – on the left), bladder, ovary with fallopian tube – in women, testicle – in men.
Classification
By localization, disease can be bilateral and unilateral. In accordance with the clinic, FH are divided into correctable, non-correctable and infringed. In case of recoverable defects, the contents of the hernial sac easily return to the abdominal cavity. Unrecoverable form can be set only partially or not at all amenable to reduction into the abdominal cavity. Pinched femoral hernias are characterized by sudden compression of the elements of the hernial contents by hernial gates. When a FH is pinched, dangerous conditions can develop: acute intestinal obstruction, necrosis or gangrene of the intestine, peritonitis.
Depending on the place of formation of the femoral canal, a hernia of the vascular lacuna (lateral, intravaginal, total) and a hernia of the muscular lacuna (Hasselbach’s hernia) are distinguished. During the formation of a femoral hernia, there are three stages: initial, incomplete and complete.
In the initial stage, the hernial sac is located outside the inner femoral ring. At this stage, disease is difficult to distinguish clinically, but may be accompanied by parietal (Richter) infringement. In the incomplete (channel) stage, hernial protrusion is located inside the femoral canal, within the boundaries of the superficial fascia. The full stage is characterized by the exit of a hernia from the femoral canal into the subcutaneous tissue of the thigh, sometimes into the labia in women or the scrotum in men. Usually, aFH is diagnosed already in its full stage.
Femoral hernia symptoms
In the initial and incomplete stages, the pathology is manifested by discomfort in the groin area or lower abdomen, which are aggravated by walking, running and other physical activity. Sometimes in these stages, a femoral hernia is asymptomatic and for the first time manifests itself only in connection with parietal infringement.
A complete femoral hernia is characterized by the appearance of a visible hernial protrusion in the inguinal-femoral fold. Hernial protrusion, as a rule, has a small size, smooth surface, hemispherical shape; it is located under the inguinal fold. Hernial protrusion appears in a standing position or when straining; after reduction it disappears, which is accompanied by a characteristic rumbling.
If there are intestinal loops in the hernial sac during percussion, tympanitis is determined. An important differential diagnostic criterion for a reversible FH is a positive symptom of a cough shock. In rare cases, with a femoral hernia, swelling of the lower limb on the corresponding side may occur due to compression of the femoral vein, a feeling of “crawling goosebumps” and numbness. When entering the hernial sac of the bladder, dysuric disorders develop.
Complications
Complications of a femoral hernia include its inflammation and infringement, coprostasis. Inflammation of the femoral hernia can occur in serous and purulent type. Usually, the hernial contents are inflamed first (appendix, intestine, uterine appendages, etc.), less often the inflammation passes to the hernial sac from the skin. An inflamed femoral hernia becomes edematous, skin hyperemia occurs, pain increases, and body temperature rises. In some cases, peritonitis develops.
With a strangulated femoral hernia, an acute violation of blood supply and innervation of the organs that make up the hernial contents develops. At the same time, the hernia increases in size, becomes unrecoverable, dense, sharply painful on palpation. There are severe pains in the area of infringement or in the entire abdomen, a delay in stools and gases develops. Prolonged infringement of the femoral hernia can lead to organ necrosis and the development of intestinal obstruction. In this case, hiccups, nausea, repeated vomiting, cramping pains appear.
Diagnostics
The absence of bright manifestations in the initial stages of a femoral hernia complicates the early diagnosis of a FH. When recognizing the disease, the abdominal surgeon takes into account the typical symptoms (the presence of spherical protrusion in the femoral triangle area in an upright position and vertibility in the supine position, a symptom of cough shock, etc.), auscultative data (listening to peristaltic noises), percussion determination of tympanitis, etc. During the palpation of the hernial sac, it is possible to determine the nature of its contents, to clarify the size of the hernial canal and the setability of the FH.
Femoral hernia in the process of diagnosis is differentiated from inguinal hernia, lipoma, lymphadenitis, leaky abscess, varicose veins, thrombophlebitis, femoral artery aneurysm, metastases of malignant neoplasms. To determine the contents of the hernial sac, ultrasound scanning of hernial protrusion, irrigoscopy, ultrasound of the bladder and pelvis is performed.
Treatment for femoral hernia
There are no conservative approaches to the treatment of pathology; when the disease is detected, surgical intervention is indicated – herniation with defect plastic surgery (hernioplasty). In surgery, many methods and modifications of surgical interventions have been developed, which, depending on the access used, are divided into inguinal (the method of Ruggi, Parlavecchio) and femoral (the method of Bassini, Lockwood, Herzen, etc.), and according to the method of closing the hernial gates can be simple and plastic.
Hernioplasty of a femoral hernia involves opening the hernial sac, examining its contents, if necessary, resection of the altered omentum, reduction of the hernial contents into the abdominal cavity, ligation and excision of the hernial sac and hernial canal plastic. The operation can be performed using the patient’s own tissues or synthetic materials (polymer meshes). With a pinched femoral hernia, it may be necessary to perform a median laparotomy with resection of a non-viable part of the intestine.
Prognosis and prevention
In most cases, the prognosis is good for a non-pinched FH. The greatest number of relapses is observed with femoral herniation methods. In the absence of treatment, an unrecoverable femoral hernia may form, in 82-88% of cases, infringement occurs. Prevention of the development of a femoral hernia consists in strengthening the muscles of the anterior abdominal wall, limiting physical exertion, wearing a bandage during pregnancy, proper nutrition, and eliminating a nagging cough. The earliest possible radical treatment of a femoral hernia allows to prevent life-threatening complications.
Literature
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