Laparoscopic Femoral Hernia Repair

Abstract

The most prominent concern of a femoral hernia is the increased risk of bowel strangulation, as they are often missed or misdiagnosed on initial physical exam. For this reason, all patients with a femoral hernia diagnosed in the elective setting should be offered prompt intervention. The choice of technique utilized is based on the surgeon’s experience and comfort level, the patient’s physical exam, and their previous surgical history. Laparoscopic approaches are well suited for inguinal and femoral hernia repair and hold the benefit of being able to visualize and diagnose concurrent inguinal hernias which were not identified preoperatively. Minimally invasive techniques for repair of femoral hernias include total extraperitoneal (TEP), laparoscopic transabdominal preperitoneal (TAPP), intraperitoneal onlay mesh (IPOM), and robotic TAPP approaches. Key steps of the procedure include exposure of the entire myopectineal orifice, a wide peritoneal dissection to make room for mesh placement, sweeping back the peritoneal reflection to prevent a recurrence of a peritoneal hernia from under the lower edge of the mesh, exposure of the lacunar ligament, and blunt reduction of the hernia contents, avoiding the use of electrosurgery near the iliac vessels. If the contents remain incarcerated, a relaxing incision of the femoral ring may be made by incising the lacunar ring medially. The surgeon should inspect thoroughly for hemostasis after reduction of the hernia contents. While femoral hernia recurrence is a known complication, rates of recurrence requiring reoperation have been reported to be lower after laparoscopic repairs compared to open. Surgeon comfort with the anatomy and understanding of the surgical technique is critical to safe and appropriate repair.