Keywords: Femoral hernia, peritonitis

 

 

 

 

Abstract :Femoral hernia contribute to the second most common abdominal hernia though it represents only a small 4% [1] incidence when compared to inguinal hernia. It is most commonly seen among females more in multiparous and elderly individuals. The peculiar feature of this hernia is high incidence of complication ( obstruction and strangulation) to the extent of 30 to 80%[2]. The case presented here is a untreated femoral hernia which led to frank fecal peritonitis, prerenal failure , burst abdomen ,wound infection and ileostomy repositioning.

Keywords: Femoral hernia, peritonitis

Introduction :

Femoral canal is a narrow space with rigid boundaries of pectineal ligament posteriorly , inguinal ligament anteriorly , femoral vein laterally and lacunar ligament medialy. The cumulative probability of femoral hernia being complicated is 22% in the first 3 months and rising to 45% in the next 2 years[3,4].Thus a femoral hernia repair is mandatory. The primary etiology of femoral hernia appears to be natural loss of tissue strength and tissue elasticity. There is no evidence of underlying embryonic etiology which contrasts with inguinal hernia.

Case report:

50 year old female was admitted in the emergency department in early morning with history of (h/o)

swelling in the right groin [Fig.1] for 1 week. She was experiencing lower abdominal pain for 1 week. She hadvomiting, 5 episodes per day for a week. She had no constipation. The patient gives h/o swelling in

the right groin 1week ago which was reducible and now irreducible. Examination on arrival revealed a

thin built women who was in distress due to abdominal pain and distention . She was dehydrated, pale ,

tachypneic and tachycardic  with hypotension. Per abdomen examination showed distended abdomen with diffuse tenderness and swelling in the right groin 4 × 3cm . Diagnosis of femoral hernia was made.

Rest of the examination was normal. Patient was resuscitated with intravenous fluids and higher

antibiotics was instituted. After adequate resuscitation femoral hernia release was attempted and once the sac was opened, only a part of the wall of small intestine was found to be gangrene without any

contamination [Fig 2]. As the contents could not be completely freed , lower midline incision was made and exploratory laparotomy was done. About 2 litres of fecopurulent peritoneal fluid with extensive

fecal matter contamination was present and perforation of size 2 X 2cm was found adjacent to the

gangrenous bowel wall in the ileum through which intestinal contents were seeping into the peritoneal

cavity [Fig.3].The gangrenous bowel was 50cm from ileocecal junction . Resection of gangrenous

segment was done and ileostomy was constructed in right iliac fossa .Thorough peritoneal lavage was

given and abdomen was closed after keeping drainage tube in hepatorenal pouch and pelvis. Femoral

hernia was repaired with prolene stitch [Fig 4]. Patient was managed in ICU. Patients haematological

parameters were reduced as the patient was in frank sepsis. Patient had hypoproteinemia which was

corrected with albumin . Patient was started on oral diet on the 6th POD(post operative day). During the 7th POD haematological parameters improved but patient started developing generalised edema but

her renal parameters were normal. In spite of correction of hypoprotinemia and normal renal

parametersgeneralised edema worsened. During 9th POD midline wound dehiscence was made out. A

diagnosis of burst abdomen was made in 10th POD and emergency tension suturing was done

approximating the skin alone without approximating the linea alba , as it was under tension and

ileostomy was repositioned [Fig.5] . During 12th POD renal parameters started rising and a diagnosis of

acute kidney injury was made and was treated with high dose of diuretics . From 13th POD generalised

edema started decreasing. During the course of illness right groin wound was infected which was

managed conservatively . After adequate resuscitation and nutritional supplementation patient

recovered well and patient was eventually discharged on 32nd POD after suture removal. Patient was

reviewed 1month later for ileostomy closure and the procedure was done without opening the midline wound . Patient recovered uneventfully and was discharged on 10th POD. Patient is in follow up for the past 6 months and has not  developed any complications [Fig.6].

 

 

 

 

 

 

 

 

Discussion :

Diagnosis of femoral hernia is often missed in setting of acute abdomen because of failure to examine the region below inguinal region. Differential diagnosis of lymph node, lipoma and saphena varix which are benign conditions interferes with early diagnosis[5].The patient in the above setting ,though she had vomiting was taking  diet till the evening prior to her arrival to hospital and was having bowel movements. The late presentation could be due to the fact that she was tolerating oral diet to some extent. Except for x ray abdomen erect no other imaging modality was carried out. Patient with severe peritoneal contamination should be resuscitated adequately before taking up for surgery. Resuscitation and adequate post operative nutritional support forms a mainstay in the management of intra abdominal sepsis. Burst abdomen by conventional method is closed by tension suturing involving the entire abdominal wall[6,7]. But it was not possible in the above case because of risk of abdominal compartment syndrome and ileostomy site was under tension due to abdominal wall edema. So it was decided to just  approximate the skin by tension suturing. The procedure was attended without any complication.

Various procedures available for repair of femoral hernia includes Lockwood method, Lotheissen method and McEvedy method. Traditional teaching of repair for femoral hernia is low approach of Lockwood for elective surgery and high approach of McEvedy for emergency surgery.  But systematic review of literature does not support this method. However transinguinal approach of Lothessien results in higher recurrence rate[8]. In elective surgery for femoral hernia plug repair is preferred because of low recurrence rate, however migration of mesh and infection has to be considered.  Recently laproscopic approach to femoral hernia is tried but it warrants extensive dissection.

Conclusion :

Thus an high index of suspicion and adequate exposure to examine the patient  is required in those presenting with acute abdomen. With adequate resuscitation pre operatively both the mortality and morbidity can be brought down but still remains higher in persons undergoing emergency femoral hernia repair[9,10].

 

Acknowledgement:

Prof. Dr.V.Palani ., M.S(Gen Surg)

Saveetha Medical College and Hospital

Saveetha Nagar

Thandalam,

Chennai.

 

References:

1.Oxford Textbook of Surgery ,2nd Edition, Chapter 31.1, Inguinal and Femoral hernia, Femoral hernia , Introduction , Clare Cheek and Andrew Kingsnorth

2. Oxford Textbook of Surgery ,2nd Edition, Chapter 31.1, Inguinal and Femoral hernia, Femoral hernia , Presentation and diagnosis , Clare Cheek and Andrew Kingsnorth

3.Maingot’s Abdominal Operation,Mc Graw Hill, 11th Edition, Chapter  5, Femoral hernia, Anatomy and Etiology

4.Outcomes of emergency and elective femoral hernia surgery in four district general hospitals: a 4- year study , Suppiah A, Gatt M, Barandiaran J, Heng MS, Perry EP.

Hernia. 2007 Dec;11(6):509-12. Epub 2007 Jul 13.

 

5. Oxford Textbook of Surgery ,2nd Edition, Chapter 31.1, Inguinal and Femoral hernia, Femoral hernia , Differential Diagnosis

6. Interrupted abdominal closure prevents burst :  randomized controlled trial comparing interrupte-x and conventional continous closures in surgical and gynaecological patient. Agrawal CS, Tiwari P, Mishra S, Rao A, Hadke NS, Adhikari S, Srivastava A.

Indian J Surg. 2014 Aug;76(4):270-6. doi: 10.1007/s12262-012-0611-8. Epub 2012 Aug 24. PMID:25278649

 

 

7.A study of the factors related to abdominal wound dehiscense. Roy SB, Acharya AN, Sarkar A, Roy SB. J Indian Med Assoc. 2013 Dec;111(12):847-9. PMID ;25154160

 

8. Oxford Textbook of Surgery ,2nd Edition, Chapter 31.1, Inguinal and Femoral hernia, Femoral hernia , Treatment , Clare Cheek and Andrew Kingsnorth

 

9. Femoral hernia: mortality and morbidity following elective and emergency surgery. Brittenden J, Heys SD, Eremin O.J R Coll Surg Edinb. 1991 Apr; 36(2):86-8

10. Emergency femoral hernia repair: a study based on a national register. Dahlstrand U, Wollert S, Nordin P, Sandblom G, Gunnarsson U.Ann Surg. 2009 Apr; 249(4):672-6.

 

Authors:

Godwin Devadhas Packiaraj.,M.S(Gen Surg) , FMAS

Assistant Professor , Department of General Surgery

Saveetha Medical College and Hospital

Saveetha nagar

Thandalam

Chennai – 602105

Ph.no. 9841204436

drgodwin80@gmail.com

 

B.S.Sundaravadanan., M.S(Gen Surg), FRCS , FIAGES

Associate professor , Department of General Surgery

Saveetha Medical College and Hospital

Saveetha nagar

Thandalam

Chennai- 602105

Ph.no.9841073832

bss_nimmu@hotmail.com

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