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Monthly Surgery
Tips
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Mr Maurice Brygel
Melbourne Hernia Clinic
Sir John Monash Private Hospital
Cabrini Hospital
Masada Hospital
Melbourne, Australia
Sydney Hernia Centre
www.hernia.net.au
www.haemorrhoids.com.au
Correspondence to: mbrygel@netspace.com.au
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This
is the first in a series of surgical tips provided
by General Surgeon Mr Maurice Brygel of Melbourne
Australia. He has extensive experience in education
using multimedia and information and communications
technology. He has designed two websites which
are widely used by both patients and doctors
as a global medical education resource. He founded
the video-book of surgery.
His
areas of surgical interest include hernia repair
under local anaesthetic with experience of over
9,000 cases. His other areas of interest
include all aspects of office skin surgery and
anorectal conditions. Future tips will cover
all these different areas as well any interesting
cases that arise in the course of his or his
colleagues' practise. They will not necerssarily
be limited to those areas.
All
tips will be published in an annual volume.
He would still like to
emphasise and will be concetrating on, the history
and examination of any lump or bump or surgical
problem. This will usually lead to the correct
diagnosis and approporiate management.
This
series of photos is interesting in that the
patient presented six years following a right
inguinal hernia repair with a painful swelling
and felt that his hernia had come back.
However an ultrasound was carried out
which suggested that he had a femoral hernia
and not a recurrence.
Clinical examination verified the femoral
hernia.
Hernias
can be difficult to diagnose clinically because
they are often present in overweight patients
and can be difficult to find.
In this case the lump was readily palpable.
The
next question is usually, is it an inguinal
or femoral hernia? In this case it was felt to be a femoral
hernia because these
present usually below and lateral to
the pubic tubercle. However confusion can arise because femoral
hernias ride up over the abdominal wall as they
expand due to the covering of the deep fascia
(scarpas) and thus can appear to be higher. Thus during the examination one should
attempt to move it down as well.
The
femoral hernia can be reducible or irreducible.
In
this case it was an irreducible painful femoral
hernia.
It
is important in considering the diagnosis and
operation to consider the anatomical landmarks.
In
this case the femoral hernia presents through
the femoral ring, which is medially bounded
by the lacuna ligament and laterally by the femoral vein. Anteriorly is the inguinal ligament and
posteriorly the pubic bone.
In
all cases of abdominal pain the groin should
be examined to exclude inguinale and femoral
hernias. The femoral canal should be examined
to ensure there is no femoral hernia because
of the higher risk of strangulation.
Surgery
can be performed with a variety of approaches.
In this series one sees the low approach
directly over the femoral canal.
For further information find attached
link to Melbourne Hernia Clinic
http://www.hernia.net.au.
| LEFT FEMORAL HERNIA |
RIGHT FEMORAL
HERNIA |
 
Courtesy of Dr Gerry Ahern, Monash Univeristy
This is the clinical examination
- demonstrates a right femoral hernia, following
a right inguinal hernia operation previously.
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The patient is examined standing. A bulge in the right groin can be seen
and the scar of the inguinal hernia repair
is seen.
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CLINICAL
TIPS:
All patients
with a hernia should be examined
standing up then lying down.
Both sides
must be examined.
All possible
hernia sites should be examined
The patient
is asked to cough with their head
turned away from the examiner and
any cough impulse is noted.
Then the
hernia or swelling is palpated to
confirm whether it is a hernia.
Reduction is attempted by gentle
pressure.
In overweight
patients the hernia may be difficult
to see or even palpate. Both the
external ring and the femoral canal
can be examined withg the tip of
the fingers and the patient coughing.
Sometimes an squelch can be felt.
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Lateral view.
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CLINICAL
TIPS:
A differential
diagnosis should be considered.
FEMORAL
HERNIAS
- Inguinal
hernia
- Lymph
nodes
- Lipomata
- Abscess
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Close-up of the scar.
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CLINICAL
TIPS:
Femoral and
inguinal hernias can occasionally
occur together therefore must examine
both sites, the inguinal canal and
the femoral canal.
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Patient in theatre recumbent and the surface markings
shown. Transverse upper line is the previous
incision.
Triangle is the external ring.
The swelling is outlined and the
vertical lines are the femoral nerve,
artery and vein. Note that the swelling overlies the vein.
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CLINICAL
TIPS:
Note: The
large femoral hernia expands and
actually appears to be anterior
to the femoral vein as well. This
is important when making a surgical
incision.
Differential
diagnosis of a strangulated femeral
hernia is an abscess in the groin.
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The hernia is exposed.
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SURGICAL
TIPS:
The femoral
hernia looks just like a lump of
fat. To expose the hernia the deep
fascia of the thigh is divided.
There may be venous tributaries
of the long sapnenous vein or branches
of the femoral artery such as the
superficial epigastric. Lymph nodes
may also be encountered.
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Exposed.
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Narrow neck demonstrated. Sac has been dissected
free.
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SURGICAL
TIPS:
Femoral hernias
are very commonly irreducable and
may easily strangulate.
To reduce
the hernia the surrounding fat is
excised so that the sac can be gently
manipulated back in.
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Sac being demonstrated. Fat being dissected free. Sac is transfixed
and excised or even maybe just reduced.
Fat is excised.
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SURGICAL
TIPS:
Femoral hernias
are very commonly irreducable and
may easily strangulate.
To reduce
the hernia the fat is removed and
the sac is narrowed down.
The contents
must be reduced. The sac is then
opened and by this stage the henria
can be readily reduced. The sac
is then transfixed and excised.
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Mesh plug placed into femoral canal.
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SURGICAL
TIPS:
Previously,
femoral hernias were repaired by
suturing. However, this causes tension
with a higher rate of reccurence.
There was also the risk of narrowing
or injuring the femoral vein. Now
a popular technique described by
Lichtenstein is to insert a rolled
up mesh like a cigarette. Commonly
polypropylene. This avoids tension
and is readily fixed into position
with a low recurrence rate.
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Mesh
plug fixed into position.
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Thus, femoral hernias are not common compared
to inguinal hernias. They occur relatively more
frequently in females. Because of the narrow
rigid walls of the femoral ring they are commonly
irreducable and may readily strangulate. Thus,
they should be repaired in most cases to avoid
the risk of strnagulation and emergency surgery.
They are sometimes confused with inguinal hernias
and other lumps which may occur in the femoral
triangle.
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