HOW I DO IT DIFFERENTLY
|Year : | Volume
| Issue : | Page :
Complicated femoral hernia: Minimally invasive surgery management
Deepa Kizhakke Veetil, Randeep Wadhawan, Naveen Kumar Verma, Shamsu Rehman Tanai
Department of Minimal Access Surgery, Bariatric and Gastrointestinal Surgery, Manipal Hospital, New Delhi, India
|Date of Submission||13-Apr-2022|
|Date of Decision||04-Jun-2022|
|Date of Acceptance||13-Jun-2022|
|Date of Web Publication||08-Jul-2022|
S-18, Greater Kailash-1, New Delhi - 110 048
Source of Support: None, Conflict of Interest: None
Introduction: Complicated femoral hernias can be managed by minimally invasive surgery techniques in the select group of patients. This helps reduce the morbidity of open surgery and enables faster recovery of the patient.
Concerns Addressed: Delay in diagnosis can be reduced by a good clinical examination of the patient with a high index of suspicion for these patients. Imaging helps to confirm the clinical diagnosis and plan the operative intervention. In trained hands, the complicated femoral hernias can be managed by laparoscopy which enables better visualisation. Post-operative recovery is also enabled by the minimally invasive surgery done.
Conclusion: Minimally invasive laparoscopic surgery can be done in the select group of cases of complicated femoral hernia by trained surgeons.
Keywords: Complications, diagnosis, femoral hernia, minimally invasive surgery
| ¤ Introduction|| |
Femoral hernias are known to develop complications such as incarceration, obstruction and strangulation due to the narrow neck of the femoral canal. Delay in diagnosis and missed diagnosis, leading to complications are noted in femoral hernias. Good clinical examination and a high index of suspicion are required for timely diagnosis and intervention.
The standard approach for the management of these cases has been by the open surgical technique. With the development of laparoscopy and the decreased learning curve due to its routine usage, its role in the management of select patients presenting with such complicated femoral hernias is possible as shown in previous studies.,
Minimally invasive surgery has the advantages of improved patient recovery in a shorter duration of time and earlier return to work or previous quality of life. This is especially important for a low- and middle-income country like India where the duration of hospital stay and the number of days lost to disability can be reduced. Here, we report two complicated cases of femoral hernias managed by minimally invasive surgery.
| ¤ Case Reports|| |
Case 1: A rare case of an incarcerated Meckel's diverticulum in the femoral hernia managed by minimal access surgery
A 55-year-old female with no known comorbidities presented with complaints of generalised abdominal pain with features of intestinal obstruction and swelling in the right groin region. She had recurrent symptoms for 5 months. The patient did not have any known medical comorbidities. After evaluation at multiple centres, the patient presented to our hospital. On day 2 of hospitalisation, patient was referred to the surgical department. On clinical examination, evidence of a groin hernia was noted. Ultrasound was done which confirmed the finding.
The patient was planned for laparoscopic surgery under general anaesthesia. Intraoperatively, the right femoral hernia was noted with Meckel's as the content, as shown in [Figure 1]. After the induction of anaesthesia the contents were reduced. The erythema and the constricting band at the base of the Meckels were clearly documented on laparoscopy. The peritoneal flap was raised and the sac was dissected from the round ligament and the vessels. Superficial and deep inguinal rings were normal, but there was an obturator hernia noted on the same side with fat as the contents. 60 cm away from the ileocecal junction Meckel's diverticulum was confirmed with the constricting band noted at its base.
|Figure 1: (Case 1) Intraoperative view of the Meckel's Diverticulum after reducing from the femoral hernia defect|
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Laparoscopic TAPP repair was done on the right femoral and obturator hernia. The peritoneal flap was raised. The hernial sac was dissected from the round ligament and the vessels and the defects were clearly delineated. After the anatomy was identified and haemostasis was ensured, a large 10.3 cm × 15.7 cm anatomical mesh was placed and fixed medially using fixation device. The mesh was placed covering all the hernia defects in the myopectineal orifice, as shown in [Figure 2].
|Figure 2: (Case 1) Prolene mesh placed to cover all the orifices of the Myopectineal Orifice of Fruchau|
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Once the mesh was placed the peritoneum was sutured back using a barbed suture making the area water tight. Once the mesh was placed extraperitoneally only then the Meckel's was tackled to ensure that there was no contamination of the mesh. Meckel's diverticulectomy was done using endostapler 60 mm, as shown in [Figure 3].
Postoperatively, the patient was started on a liquid diet 6 h after the procedure. Following the ERAS protocol, the patient was ambulated out of bed and allowed orally with no drains placed. The patient recovered well and was discharged on the 2nd post-operative day.
On day 7 of follow-up, the patient was comfortable, she had resumed a normal diet and had returned to routine activities of daily living [Table 1].
|Table 1: Timeline of events in the two cases of complication femoral hernia|
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Case 2: A case of obstructed femoral hernia in an elderly lady
A 74-year-old female presented with the complaints of severe epigastric pain and repeated episodes of vomiting of 2 days. The patient was admitted and evaluated by the medical gastroenterologist and was referred to the surgical department on day 2 of hospitalisation. The patient was detected to have obstructed left-sided femoral hernia. The patient was taken up for emergency surgery. Laparoscopic left femoral hernia anatomical repair was done. Intraoperatively, the antimesenteric border of a part of the jejunum was noted to be the incarcerated content, as shown in [Figure 4]. The ring was divided and the contents were reduced. The bowel was then subjected to 100% oxygen which helped relieve the ischaemia and improved the colouration of the involved bowel. This was assessed subjectively by looking at the return of the colour of the involved segment of the bowel and also by noting the peristalsis of the involved segment of the bowel. There was an area of impending perforation which gave way during the examination of the bowel. This area of perforation was closed in two layers intracorporeally using interrupted vicryl 00 sutures, as shown in [Figure 5].
|Figure 4: (Case 2) Obstructed femoral hernia with part of the circumference of the jejunum as the contents|
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|Figure 5: (Case 2) Area of perforation closed using interrupted vicryl sutures|
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As the bowel was repaired, it was decided to only perform an anatomical repair of the femoral hernia defect and placement of a mesh was abstained, as shown in [Figure 6].
Anatomical repair of the femoral defect was done using a nonabsorbable barbed 0 suture followed by the closure of the peritoneal flap with absorbable sutures. No drains were placed. As there was an enterotomy which required repair, the patient was started on the oral diet after the passage of flatus.
Postoperatively, the patient was discharged on day 4 on a soft diet.
On follow-up on day 7, she was comfortable, ambulated and on a normal diet [Table 1].
| ¤ Discussion|| |
The two cases of complicated femoral hernia presented here underwent minimal invasive surgical management and had a good post-operative outcome and a faster discharge from the hospital.
In the first case of Littres hernia, the importance of having a high index of suspicion and a good clinical examination to diagnose the condition needs to be highlighted. Intraoperatively, after reduction of the contents, handling of the hernia defect and mesh repair is done. Following which the peritoneal flap undergoes a water-tight closure before dealing with the Meckel's diverticulum. This was done to ensure there was no contamination to the area of the mesh repair. In the second case, as the bowel was opened and there was a contained spill of enteric contents, anatomical repair was done. This practice is supported by other studies as done and mentioned by Smith et al.
The advantages of laparoscopic repair in both cases were the excellent visualisation of all the possible defects of the myopectineal orifice and adequate coverage of all the potential sites along with the hernia defect using a prolene mesh. It was also useful for the adequate examination of the involved segment of the bowel including the adjacent bowel and document the improvement in vascularisation following the release from the hernia ring.
Patient selection is important. In patients where the abdominal distention is not significant and ports can be placed safely, laparoscopy definitely has a role in the management of these patients. In such cases, morbidity of laparotomy can be avoided.
| ¤ Conclusion|| |
Minimally invasive laparoscopic surgery can be done in the select group of cases of complicated femoral hernia by trained surgeons.
The patients have given consent to use their de-identified information for improving the scientific literature.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The authors would like to thank Department of Anaesthesiology and Operation theatre staff at Manipal Hospital.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| ¤ References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]