Ir. J. Med. Sc. June, 1963, pp. 257-260 Printed in the Republic of Ireland

AN ALTERNATIVE OPERATION FOR STRANGULATED FEMORAL HERNIA By DESMOND K. ~[ULVANY,~I.S., F.R.C.S., F.R.C.P.I. and PATRICK B. KIELu M.B., F.R.C.S.I. H o s p i t a l o f S t . J o h n a n d ,~L~t. E l i z a b e t h , L o n d o n , N W 8

N this discussion of the operative treatment of strangulated femoral hernia we are concerned solely with the " high " type of operation, the " low " operation being considered the procedure of choice when strangulation is absent. ~ A variety of procedures is available and it is proposed to mention those in common use prior to the description of a method which we have found very convenient. Of the high operations using an approach through the inguinal canal the first is thought to have been done by Annandale in Edinburgh 2 in 875, but the method is usually associated with the name of Lotheissen ~ who recorded twelve cases in 1898 which were repaired by this operation. The steps of the procedure are worth recalling as a basis for comparison with the operations employed by Cheatle, H enry and McEvedy and with the operation which we have been using. The skin incision is placed 89 or less above the medial half of the inguinal ligament. After the incision has been deepened, the lower skin flap is mobilised and strongly retracted downwards to expo~e the femoral hernia. The sac is isolated after its coverings have been divided and is then opened at its fundus. Fluid present is carefully removed by suction and bowel or omentum examined. The next step is to open the inguinal canal so as to enable the sac and its contents to be delivered above the inguinal ligament. Accordingly the external oblique aponeurosis is divided and the spermatic cord or round ligament is mobilised to expose the fascia transversalis, the inferior epigastrie vessels and a possible abnormal obturator artery which if found is ligated. An opening in the fascia transversalis is made by blunt dissection and the neck of the hernial sac is then revealed. The conjoined tendon is retracted upwards and the peritoneum above the neck of the sac is opened. At this stage it is usually necessary to divide the lacunar ligament (Gimbernat) so as to facilitate upward delivery of the sac contents. Bowel is then either resected or returned to the abdomen and omentum is similarly dealt with. The sac is then brought up from below and excised after which the opening in the peritoneum is closed. The formal repair of the hernia consists in suturing the conjoined tendon to the pectineal ligament of Astley Cooper, taking care to avoid injuring the external iliac vein. The external oblique is then repaired after which the wound is closed. The chief advantage of the Lothcissen operation is that it allows access to the sac at its highest point and also direct access to the femoral ring. Its main disadvantage is that it

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involves a very wide opening (and therefore weakening) of the inguinal canal. It is not unusual to find a direct inguinal hernia occurring at the site of a previous Lotheissen operation. Lenthal Cheatle 4 was among the first to use an extraperitoneal approach for the radical cure of inguinal and femoral herniae. Although he did not use the operation associated with his name in cases of strangulated herniae, it is worth quoting his opening descriptive sentences : - " Several cases in quick succession presenting difficulties in the efficient excision of the sac led me to devise a new method by which these and other troubles could be easily and successfully dealt with when they arise. I approach and reach the back of the inguinal canal from a middle line incision in the lowest part of the abdominal wall. Unless compelled by some complication I do not open the general peritoneal cavity.* All the work is done in a space made in the sub-peritoneal tissue. I have operated in this way upon 41 patients. I n the first nine I made ~all the incisions longitudinal. In the remainder I have traversed the abdominal wall by Pfannenstiel's method . . . " The late Professor A. K. H enr y ~ also used an extraperitoneal approach to the femoral region employing midline sub-umbilical incision. His first case was the unusual one of bilateral femoral hernia and the approach gave equally good access to both femoral canals. He stripped the unopened peritoneum from the sides of the bladder and from the pelvic wall, and obtained a view of both sacs, which stood out from the peritoneum, as he described it " like horns from a snail ". He closed the canal by turning up a triangular flap of fascia pedieled in front from the pectineus muscle, and sutured it to Poupart's (inguinal) ligament. Jennings, Anson and Wright s were favourably impressed with H e n r y ' s operation and made useful suggestions concerning the operative technique of the extraperitoneal approach for the cure of inguinal and femoral herniae. McEvedy 7 in 1950 described an operation employing a vertical skin incision. The anterior rectus sheath is divided 2 cm medial to the linea semilunaris and the rectus muscle is retracted medially. Next the transversalis fascia is divided to display the peritoneum on which the inferior epigastrie vessels are seen as they r u n upwards and medially. The neck of the hernial sac will then be seen as it enters the femoral canal. In strangulated herniae it will be first necessary to isolate the sac below the inguinal ligament and this requires strong downward retraction of the lower margin of the wound. The sac is then opened at its fundus and its contents dealt with, after which it is drawn upwards through the femoral ring which is then obliterated by suture of Poupart's ligament to Cooper's ligament. Wound closure consists in letting the rectus muscle fall back into place and suturing the anterior rectus sheath. McEvedy's operation has all the advantages of the trans-inguinal approach and gives better access without weakening the inguinal canal. The italics are ours.

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One disadvantage of the approach is that a vertical incision through the rectus sheath has the mechanical defect of dividing aponeurotic layers across their line of stress; however, it can be guarded against by careful suture; interrupted mattress sutures of linen thread are satisfactory. Sir Heneage Ogilvie s modified McEvedy's method by using a crease incision for the skin and a muscle-splitting approach for the deeper layers. The operation which we have employed for cases of strangulated femoral hernia is simple to carry out and with attention to a few important points of technique, is capable of giving gratifying results. Its main advantage is in providing optimum conditions for bowel resection, should this be necessary. The skin incision is a vertical one placed medial to the linea semilunaris and prolollged downwards over the summit of the hernial swelling. In the upper part of the incision the peritoneal cavity is entered via a para-rectal approach. It is then a simple matter to see what is entering the femoral ring. Through the lower part of the incision the sac is displayed by dividing its coverings. It is then opened carefully so as to permit accurate suction removal of infected fluid. The contents are visualised and their upward delivery into a peritoneal pack is facilitated by dividing under vision the lacunar ligament. Non-viable small bowel or omentum is now resected, employing judicious packing to prevent contamination of the general peritoneal cavity. If the bowel is adjudged to be viable it is returned to the general peritoneal cavity. The sac is now removed from below after ligation of its neck. Repair of the hernia is achieved by the standard sutures between Poupart's ligament and Cooper's ligament. The wound is then closed in layers, particular care being taken with the suturing of the anterior rectus sheath. The method just described may be particularly suitable for those patients whose history and physical examination both point to the presence of non-viable bowel in their strangulated femoral herniae. These patients, often aged, are in special need of quick and accurate surgery because of coincidental cardio-respiratory ailments. The central idea of the operation is that bowel resection is best done via an abdominal incision. Few surgeons would object to the idea that a gut resection performed below the inguinal ligament carries with it increased technical difficulties, but the same may be true of a resection done above the inguinal ligament through a relatively narrow peritoneal opening as in the Lotheissen operation. A possible objection to our operation-that it opens tissue planes in the abdominal wall to potential or actual infection--is probably more theoretical than practical in view of the efficacy of local antibiotic sprays and general antibiotic cover. Furthermore these hazards do not unduly attend such operations as resection of small or large bowel volvulus, or even a gangrenous intussusception. The central theme is perhaps worth reiterating. Bowel resection in cases of non-viability is best done from within the abdomen where tension can be easily avoided and adequate scrutiny of adjoining bowel loops and the accompanying mesentery carried out. This is surely important in view of the fact that the patient's survival depends, inter alia, on the soundness of the anastomosis.

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References 1. Farquharson, E. L. (1962). Textbook of Operative Surgery. E. & S. Livingstone Ltd. p. 760. 2. Annandale. (1875). Edinb. M. J., 21, 1087. 3. Lotheissen, G. (1898). Zentrabl. Chit., 25, 548. 4. Lenthal Cheatle. (1921). Proc. Roy. Soc. Med., 15, 3. B. M. J., 2, 1025. 5. Henry, A. K. (1936). Lancet, 1, 53I. 6. Jennings, Anson and Wright. (1942). Surg. Gynaec. and Obst., 106, 74. 7. McEvedy. (1950). Ann. Roy. Coll. Surg. Eng., VII, 484. 8. Ogilvie, Sir Heneage. (1959). Hernia. Edward Arnold Ltd. p. 98.