72 - Freie Mitteilung
Bariatry & hernia I
16. Mai 2019, 17:30 - 19:00, Bellavista 3+4, 6. OG
Incarerated femoral hernia – A critical view on approach options
L. Pietrogiovanna, J. Janczak, R. Strahm, N. Pfeifer, W. Brunner, Presenter: L. Pietrogiovanna (St. Gallen/Rorschach)
Recently new literature is in discussion on the best surgical approach to inguinal hernias in women. Our purpose is to present a possible standardization of optimal techniques in incarcerated female hernia approach with a look on femoral ones.
Four female patients (75 - 90 y) with incarcerated inguinal unilateral hernia undergoing repair at our department between 12 2017 and 12 2018 are presented. All patients were admitted with vomiting and abdominal pain. One patient presented with a recurrence after previous Lichtenstein repair two years before and a known asymptomatic hernia on the contralateral side with refusing operation for this side.
In three patients emergency laparoscopy by single port approach confirmed incarceration, bowel respectively omentum was reduced and femoral hernia diagnosed. A TAPP repair with 12x18 cm mesh was performed. In two patients intraoperative a contralateral inguinal and femoral hernia was diagnosed, one (L1 M1 F1) treated with simultaneously TAPP. The other patient as described refused the optionally bilateral operation. After two days this patient presented with incarcerated hernia on the not operated side treated by TAPP. The fourth patient had multiple previous abdominal operations due to anal carcinoma including mesh augmented stoma formation, so laparoscopic approach was not recommended. A transinguinal open approach also showed an incarcerated femoral hernia. Due to massive adhesion inferior epigastric vessels had to be ligated, bowel was reduced. After peritoneal closure a preperitoneal mesh placement was performed with fixation to Coopers and inguinal ligament. Uneventful course for all patients and discharge between 2 and 8 days.
In case of suspected incarcerated inguinal hernia accurate identification of a femoral hernia is necessary especially in female elderly patients. If possible endoscopic approach is preferred and offers exploration of both sides, checking bowel for vitality and fixing the hernia. If bilateral hernia is present, both sides should be addressed. Surgeons not used to TAPP should perform diagnostic laparoscopy with reduction of hernia sac and check of content and switch to TEP if experienced or open procedure. If open approach is necessary checking for femoral hernia is also mandatory and preperitoneal mesh placement is recommended with or without ligation of inferior epigastric vessels.