Laparoscopic Inguinal Hernia Repair for Female Patients: Experience from a High-volume Center in 20 years

BACKGROUND

Although laparoscopic inguinal hernia repair (LIHR) is widely performed worldwide, few studies have focused on the procedure in female patients. This study investigated the characteristics and outcomes of female patients with inguinal hernias who underwent LIHR.

MATERIALS AND METHODS

This study retrospectively analyzed the data of 7380 patients with inguinal hernia admitted to the General Surgery Department of Ruijin Hospital and underwent LIHR from January 2001 to December 2020. The clinical characteristics, surgical outcomes, and complications were assessed.

RESULTS

In total, 572 female patients were enrolled in this study. The proportion of femoral hernias in female patients was higher in women than in male patients (17.4% vs. 0.3%, respectively). Mesothelial cysts of the round uterine ligament (MCURL) were noted in 74 patients. The mean age of patients with MCURL was lower than that of patients without MCURL (46.4 vs. 55.6, P =0.018). Seventy cases (93.3%) of MCURL were resected laparoscopically, and 5 cases were resected through an auxiliary small incision. The round ligament was cut off in 335 patients and preserved in 237. No significant differences were observed in the number of hospitalization days, recurrence rates, or complications between the transection and preservation groups. None of the cases were converted to laparotomy, and no recurrence was noted during follow-up.

CONCLUSION

LIHR is safe and feasible in female patients. Treatment of femoral hernia, MCURL, and the round ligament of the uterus should be carefully considered during LIHR in female patients.

Hip synovial cyst presenting as femoral hernia - case report

We are pleased to introduce this interesting case report. A female patient presented to emergency department with a new lump in her right groin. Although there was quite convincing history for femoral hernia, the clinical findings were not correlating with this completely. The patient underwent ultrasound examination which showed synovial cyst originating from the right hip. This is a rare presentation of hip synovial cyst and we have therefore decided to publish this case report.

Femoral Hernias: Analysis of Preoperative Risk Factors and 30-Day Outcomes of Initial Groin Hernias Using ACS-NSQIP

Femoral hernias are infrequently encountered groin hernias. The purpose of this study was to describe the natural history of femoral hernias by evaluating patient demographics, comorbidities, operative details, 30-day mortality, and risk factors for postoperative complications compared with inguinal hernias and in reducible versus incarcerated hernias. Overall 5360 femoral hernia repairs and 183,173 inguinal hernia repairs were identified using the 2005 to 2015 American College of Surgeon-National Surgical Quality Improvement Program's database. Univariate analysis was used to compare patient characteristics between femoral and inguinal hernias and between reducible and nonreducible femoral hernias. Multivariable logistic regression analyses were used to identify risk factors for 30-day postoperative complications after repair. Femoral hernias accounted for 2.8 per cent of initial groin hernias and 18.9 per cent of all groin hernias in females. A total of 56.5 per cent of initial femoral hernias were nonreducible and these patients were significantly older. Rates of small bowel resection (5.7 vs 0.3%, P < 0.0001), exploratory laparotomy (2.5% vs 0.4%, P < 0.0001), and diagnostic laparoscopy (2.0% vs 0.7%, P < 0.0001) were significantly higher in incarcerated femoral hernias compared with reducible femoral hernias. There were significantly higher rates of unplanned return to the OR, postoperative sepsis, and 30-day mortality in incarcerated femoral hernias versus reducible femoral hernias. Most femoral hernias present incarcerated in older, female patients. Femoral hernias present more commonly incarcerated in patients with significant comorbid diseases and are associated with significantly increased rates of systemic, local, major, and minor complications, return to OR, and mortality. Careful consideration should be given for the evaluation of intestinal viability in the acute setting.

Combined Littre and Richter's femoral hernia: an extremely rare intra-operative finding

Littre hernia is defined as the herniation of a Meckel's diverticulum, while Richter's hernia is the herniation of a portion of the bowel wall. An extremely rare case of a combined Littre and Richter's femoral hernia is reported. An 82-year-old male presented at the emergency department with a painful golf ball-like mass at the right inguinofemoral region. With the diagnosis of incarcerated femoral hernia, he was urgently taken to the operating room. Intraoperatively, an incarcerated Littre, as well as a Richter's hernia were revealed. Enterectomy and side-to-side small bowel anastomosis were performed. The patient made an uneventful recovery. To the best of our knowledge, the present is the first report of a combined Littre and Richter's femoral hernia. Such findings should be reported to raise the awareness of surgeons for complicated cases. It is of utmost importance to have a high suspicion index for strangulated hernias, to minimize the time between admission and surgery.

Parietal Strangulation Of Small Intestine In Femoral Hernia Site With Symptoms Of Intestinal Obstruction In Patient With Incidentally Found Small Intestine Tumor--A Case Report

Richter's hernia (partial enterocele) is the strangulation/entrapment of only part of the circumference of the intestinal wall. It is relatively rare, and presents without mechanical obstruction - giving vague, non-specific symptoms and signs, and a threat of intestinal necrosis, gangrene, followed by perforation. A report of a case of entrapment of the jejunum in the femoral ring, which did not cause the gangrene, but symptoms of mechanical obstruction, is presented. Further inspection of the small bowel in this case revealed an extra-luminal tumour, which appeared to be a GIST. The entrapped part of the jejunum has been released and the tumour has been resected.

Increasing Body Mass Index Is Inversely Related to Groin Hernias

Few studies describe the relationship between obesity and groin hernias. Our objective was to investigate the correlation between body mass index (BMI) and groin hernias in a large population. Patients with the diagnosis of inguinal or femoral hernia with and without incarceration or strangulation were identified using the Kaiser Permanente Southern California regional database including 14 hospitals over a 7-year period. Patients were stratified by BMI. There were 47,950 patients with a diagnosis of a groin hernia--a prevalence of 2.28 per cent. Relative to normal BMI (20-24.9 kg/m(2)), lower BMI was associated with an increased risk for hernia diagnosis. With increasing BMI, the risk of incarceration or strangulation increased. Additionally, increasing age, male gender, white race, history of hernia, tobacco use history, alcohol use, and higher comorbidity index increased the chance of a groin hernia diagnosis. Complications were higher for women, patients with comorbidities, black race, and alcohol users. Our study is the largest to date correlating obesity and groin hernias in a diverse United States population. Obesity (BMI ≥ 30 kg/m(2)) is associated with a lower risk of groin hernia diagnosis, but an increased risk of complications. This inverse relationship may be due to limitations of physical exam in obese patients.

Femoral hernia, a rare complication following deep inguinal lymph node dissection

A 72-year-old woman underwent complete deep inguinal lymph node dissection on her right side subsequent to metastasis from malignant melanoma. On the second postoperative day, the patient reported of nausea and vomiting. She presented with a mass in the resected area that gradually increased in size to approximately 15×20 cm. The wound was opened a few hours after onset of symptoms and a large femoral hernia with 40 cm of small intestine was immediately revealed protruding in the groin. Prophylactic suturing of the inguinal ligament and Coopers ligament can reduce the risk of postoperative femoral hernia. Further, the authors argue that drainage for seroma and haematoma should be performed with utmost care, considering other possible causes and, if necessary, guided by ultrasonography.

[Connective tissue dysplasia as a reason of recurrent inguinal hernia]

The examination results of 78 patients with recurrent inguinal hernia revealed presence of systemic connective tissue abnormalities in addition to dysplasia of posterior wall of inguinal canal in 48 (61.6%) patients. Hernial disease was observed in 37 (47.4%) patients including umbilical hernia in 12 cases, femoral hernia in 8 patients, hiatal hernia in 3 patients and bilateral inguinal hernia in 14 cases. Group of other diseases included varicose veins of lower limbs in 15 (19.2%) patients, mitral valve prolapse in 3 (3.8%) patients, violation of skin elasticity (striae) in 6 (7.7%) cases, diverticulum of bladder in 2 (2.6%) patients, diverticulum of esophagus in 1 (1.3%) patient, diverticulosis of small intestine in 2 (2.6%) cases. Our data prove that inguinal hernia is local manifestation of systemic disease.

Aetiology of femoral hernias revisited: bilateral femoral hernia in a young male (two cases)

Bilateral femoral hernias are less common in men than in women and rare in young adults. Only one case of a bilateral femoral hernia in a young man has been reported in the literature before. Three main theories have been postulated for femoral hernias. The theory that they are an acquired disease is the most accepted due to the common occurrence of such hernias in multiparous women but the theory lacks enough evidence. We report two cases in young men. Anatomical variations in the femoral canal could be the primary aetiological factor in these patients. A unilateral femoral hernia in young men with acquired aetiological factors requires a clinical examination of the opposite side.

Inguinal hernia repair

In excess of 100,000 inguinal hernia repairs are performed in the UK each year (Devlin & Kingsnorth 1998). It is the most commonly performed general surgical procedure and is routinely undertaken in patients receiving local anaesthesia in the day case setting. The Royal College of Surgeons has recommended that > 50% inguinal hernias are undertaken on day cases, although at present this figure is only 30% (RCSE 1993). This article defines hernias and describes the aetiology and surgical treatment of inguinal and femoral hernia. The differences between the traditional and laparoscopic repair of hernias are explored as well as the use of materials such as polypropylene mesh to enhance the repair. The need for thromboprophylaxis and antibiotic therapy are outlined together with patient discharge advice.

Femoral hernia repair with mesh-plug in children

PURPOSE

Femoral hernias (FH) are rarely seen in children, so there is no consensus on the age and sex distribution or the optimum method of repair. Recently, repair of the femoral hernias with mesh-plug has gained wide popularity in adults. The authors used this method in 4 children with FH and discuss its utilization in children.

METHODS

Four consecutive children with femoral hernia were treated using mesh-plug. Patients' characteristics and operative technique was described.

RESULTS

Plugging femoral defect with a mesh-plug was applied successfully in children. No complications were seen after a follow-up period for 2 years (range, 8 to 30 months).

CONCLUSION

Repair of femoral hernias with mesh-plug is performed easily and successfully in children.

Accidental small bowel perforation after antegrade femoral artery access for percutaneous thromboembolectomy and angioplasty

PURPOSE

To report a rare complication of antegrade femoral access for percutaneous aspiration thromboembolectomy and transluminal angioplasty.

CASE REPORT

A 73-year-old obese woman underwent antegrade femoral aspiration thromboembolectomy for lower limb arterial embolism. Fifteen hours later, she presented with acute abdomen and decreased hemoglobin. Computed tomography showed small bowel obstruction, incarcerated femoral hernia, and free peritoneal air and fluid suggesting bowel perforation. Emergent laparotomy revealed an incarcerated, perforated femoral bowel loop and 4-quadrant peritonitis.

CONCLUSIONS

Femoral hernia injury is an exceptional complication of vascular interventions. Knowledge of this potential hazard may help to avoid its occurrence.

Risk of femoral hernia after inguinal herniorrhaphy

BACKGROUND

Small case series have suggested an increased risk of femoral hernia after previous inguinal herniorrhaphy, but no large-scale data with complete follow-up are available.

METHODS

Data were extracted from the Danish Hernia Database covering the interval from 1 January 1998 to 1 July 2001, and included 34 849 groin hernia repairs.

RESULTS

Of 1297 femoral hernia repairs, 71 patients had previously had an operation for inguinal hernia within the observation period. These 71 femoral hernias represented 7.9 per cent of all reoperations for groin hernia recorded in the database. The median time to reoperation for a 'recurrent' femoral hernia after previous inguinal herniorrhaphy was 7 months, compared with 10 months for inguinal recurrences. The risk of developing a 'recurrent' femoral hernia after previous inguinal herniorrhaphy was 15 times higher than the rate of femoral hernia repair in the general population.

CONCLUSION

This study of 34 849 groin hernia repairs demonstrated a 15-fold greater incidence of femoral hernia after inguinal herniorrhaphy compared with the spontaneous incidence. These femoral recurrences occurred earlier than inguinal recurrences, suggesting that they were possibly femoral hernias overlooked at the primary operation.

[Incarcerated and strangulated hernias--surgical approach and management]

Acute symptomatic groin hernias with potential or definite ischemia represent a special group of all the groin hernias. The method of choice to treat these hernias has to fulfill the following criteria: 1. Easy reduction of the hernia sac and its contents without causing damage. 2. Good exposure and easy access for possible resection. 3. Safe hernia repair through the same access. According to our experience with 44 incarcerated and strangulated groin hernias operated between 1993 and 1997 and after a literature review, we took the following procedure as our routine: Posterior approach and mesh repair. We do not use a meshgraft only in the presence of colonic necrosis or peritonitis.

The inguinal rings

The inguinofemoral area constitutes the frontier between the abdomen and the lower limb. Because of the human standing position, the inguinal region is a zone supporting the abdominal thrust, and is weakened by the orifice of the inguinal and femoral passages. Peritoneal diverticula may externalize into these orifices, leading to the formation of hernias. This article reviews the anatomic constituents of the inguinofemoral region and the anatomic basis for the treatment of hernias.

Saved by a hernia: an unusual presentation of ovarian cancer

A lump in the groin of a 75-year-old woman co-existed with a single ovarian cyst. It was eventually diagnosed as a solitary necrotic omental metastasis from a cystadenocarcinoma of the ovary which had herniated through the femoral canal.

Femoral hernia: a complication of laparoscopic pelvic lymphadenectomy after groin node dissection

Groin node dissection was done in an 80-year-old woman who had bilateral groin metastasis from squamous cell carcinoma of the vulva. After this procedure, laparoscopic pelvic lymphadenectomy was performed because of bilaterally positive groin nodes. Postoperatively, a strangulated femoral hernia occurred.

Pseudo-synovial cyst arising at the pubic bone region and forming a large femoral-inguinal mass

We describe a patient with rheumatoid arthritis who presented a large femoral-inguinal mass. The mass proved to be a synovial cyst-like structure communicating with rigid cystic lesions at the pubic bone. No obvious communication between the cystic lesions and the hip joint or bursae was seen by hip arthrogram or in surgery. Pathological examination of the cystic lesion at the pubic bone revealed infiltration of multiple rheumatoid nodules with marked fibrinoid necrosis into the bone, with synovium-like tissue on it. However, no synovial tissue was observed in the femoral-inguinal mass. These findings suggest that the femoral-inguinal mass was not a true synovial cyst but can be called a pseudo-synovial cyst arising at the pubic bone region.

Exacerbation of groin hernias after laparoscopy

The incidence of pneumoperitoneum-related complications of laparoscopy is quite low. The more common complications are due to improper placement of the needle during insufflation and those related to the cardiorespiratory system. We describe two cases who underwent prolonged laparoscopic surgery and presented postoperatively with hernia.

Laparoscopic femoral hernia repair using a mesh dart

We report 2 patients with femoral hernias (1 incarcerated) that were encountered during laparoscopic hernia repair for symptomatic direct inguinal hernias. The femoral hernias were readily repaired using the BARD dart that has been described previously for use during open femoral herniorrhaphy. We believe that this is the first report using the dart for laparoscopic femoral herniorrhaphy.

[Crural hernia after inguinal hernia repair. A technical note]

A case of femoral hernia following repair of an inguinal hernia with the Shouldice method is presented. The authors discuss the pathogenesis, suggest the use of ultrasound for a precise preoperative diagnosis, and propose the "plug" technique of Lichtenstein as the method of choice for the repair. This method offers a minimally invasive approach, without disturbing the previous inguinal repair and it is very simple to perform.

The cause, prevention, and treatment of recurrent groin hernia

At present, groin hernia repair is associated with a 10% recurrence rate. Despite innumerable modifications of the Bassini technique, this depressing figure remains essentially unimproved. This article documents the two major reasons for failure and presents techniques that are simple, can be performed under local anesthesia in an outpatient setting, allow patients to return home within hours of their surgery, encourage rapid return to unrestricted activity, and are associated with a recurrence rate approaching 0%.

An unusual complication of laparoscopic cholecystectomy

An unusual series of complications of laparoscopic cholecystectomy is presented. The complications occurred after use of laparoscopic technique in the treatment of acute cholecystitis. The authors feel that this is a problem that points up the need for experience and caution in the use of laparoscopic cholecystectomy in the setting of acute cholecystitis.

The Henry operation for incarcerated and strangulated femoral hernias

Selection of a subinguinal, inguinal, or preperitoneal approach permits the surgeon flexibility in managing femoral hernias. A 20-year experience is reviewed, with 44 incarcerated or strangulated femoral hernias corrected using the preperitoneal Henry operation. It is an effective and safe method of repair. Examination of the contralateral side revealed an unsuspected femoral hernia in seven (16%) of the cases.

The femoral canal: the key to femoral herniorrhaphy

It is conceded by many Authors that femoral hernias not uncommonly result from a previous inguinal herniorrhaphy. Why? A clear visualization of the femoral canal is hampered by the confusing structure of two of its components, the iliopubic tract and the lacunar ligament. Both entities have horizontal as well as vertical extensions. Therefore, a clear understanding of the femoral canal anatomy requires an appreciation of its three dimensional character. The various approaches to femoral hernia are documented. Obliteration of the entire canal by means of a "plug" prosthesis which occludes both the entrance and exit of the canal offers a simple and very effective means of correction. The results of the surgery are documented.

Onchocerciasis and acquired groin hernias in Ecuador

A prevalence of 4.3% (52) groin hernias were observed in 10 communities in the hyperendemic areas of onchocerciasis in Ecuador. Of the 31 patients in whom herniorrhaphy was performed, 87.1% presented with the acquired type of hernias; 15 (48.4%) with direct inguinal and 12 (38.7%) with femoral hernias, while only 12.9% (4) presented with indirect inguinal or the congenital type of hernias. This is in sharp contrast to the usual preponderance of indirect inguinal hernias reported in surveys of other population groups. Mechanisms for this association are discussed.

[Femoral hernia following inguinal hernioplasty]

Study of 194 cases with femoral hernias showed that in 8.25% they developed after inguinal hernioplasty. The anatomical features of the zone of the inguinofemoral junction were studied in 15 operations. The anatomical elements were weak in more than 50% of patients, triangular inguinal spaces and interligamentary spaces more than 4 cm in width were found in two thirds of patients. Operative treatment for plastic repair was accomplished with the strongest anatomical elements of this zone with restoration of their physiological directions and application of autologous dermoplasty.

Postoperative starch granuloma revealed as femoral herniation. A case report

A rare case of postoperative starch granuloma in a 55-year-old woman, revealed as femoral herniation, is reported. A small, finger-tip-sized tumor showing femoral herniation was noticed 3 weeks after cholecystectomy for cholelithiasis, and no content in the hernia sac was noticed. Histologically, the granuloma situated in the wall of the hernia sac was diagnosed as a starch granuloma consisting of starch granules, which were clearly revealed by polarized light microscopy. These granules were detected in the cytoplasm of macrophages including multinucleated types, some showing a positive immune reaction with antibodies to the alpha-subunit of S-100 protein, vimentin and lysozyme. Starch granules from surgical gloves showed identical features by polarized light microscopy, thus proving the histogenesis of this granuloma. This is the first reported case in the Japanese literature of starch granuloma manifested as femoral herniation.

[Hernia recurrence--study of 100 case history]

One hundred cases of recurrent inguinal or femoral hernia are reviewed in order to find out some common causes of this important problem. The delay of recurrence is usually short and frequently technical errors are responsible for this surgical failure. Considering their own results, the authors propose a few easy solutions in order to lower the recurrence rate. A prospective study now in progress will help us to appreciate our present results.

[Symptomatic hernia (author's transl)]

A symptomatic hernia (most inguinal or femoral hernia, seldom epigastric, umbilical or post-operative hernia)--appeared a little while ago--originates from a preexisting, so far unknown or long since known illness. All patients with a hernia--especially those over 40 years old--are to be carefully asked for preexisting illnesses. Barium-enema and rectoscopy are not indicated at each inguinal or femoral hernia as a screening-method to exclude a symptomatic hernia; however, both methods must be employed in suspicious cases. 320 Patients with a histologically verified carcinoma of the rectum and colon had no inguinal or femoral hernia. From 387 patients with an inguinal or femoral hernia 318 patients were over 40 years old; at these patients polyps were found in five cases by rectoscopy, but never by barium-enema, and two carcinoma of the colon transverse appeared by barium-enema. A 23-years old patient with a great intraabdominal malignant tumor must be added to the sum total.

The inguinal and lacunar ligaments

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The surgical repair of inguinal and femoral hernias

This paper is based on 15,000 hernia repairs performed by the author at the Shouldice Hospital, Toronto. Experience with more than 75,000 consecutive herniorrhaphies performed in this hospital from 1945 to 1970 is reviewed in four parts - statistics, including recurrence rates; the management of the patient with a primary uncomplicated hernia, emphasizing in particular the preoperative phase, the sedation given, the local anesthetic used in 95% of cases and the postoperative phase; the technique of repair of a primary inguinal hernia; and a review of experience with primary and recurrent femoral hernias, emphasizing the different problems in men and women, and describing the technique of femoral repair.