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Laparoscopic treatment of an incarcerated right femoral hernia in a female patient

Femoral hernia is predominantly a female disorder. Incarcerated femoral hernia is a common surgical emergency condition. Diagnosis is always obvious and straightforward by clinical examination, and open surgical repair was the mainstay of treatment. In the era of minimally invasive surgery, laparoscopic repair of femoral hernia has been shown to be feasible and safe. This video shows the laparoscopic trans-abdominal preperitoneal repair of a right femoral hernia in a female patient who has had an appendectomy and who presented to emergencies with pain in the right inguinal region associated with nausea and vomiting. This procedure was performed by a skilled surgeon fellow telementored by Prof. Leroy, a world-renowned expert in laparoscopic hernia repair surgery.

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Laparoscopic treatment of an incarcerated right femoral hernia in a female patient

作者群

F Costantino, J Leroy, J Marescaux

摘要

Femoral hernia is predominantly a female disorder. Incarcerated femoral hernia is a common surgical emergency condition. Diagnosis is always obvious and straightforward by clinical examination, and open surgical repair was the mainstay of treatment. In the era of minimally invasive surgery, laparoscopic repair of femoral hernia has been shown to be feasible and safe. This video shows the laparoscopic trans-abdominal preperitoneal repair of a right femoral hernia in a female patient who has had an appendectomy and who presented to emergencies with pain in the right inguinal region associated with nausea and vomiting. This procedure was performed by a skilled surgeon fellow telementored by Prof. Leroy, a world-renowned expert in laparoscopic hernia repair surgery.

分類

clinical cases

關鍵字

Laparoscopic treatment, incarcerated right femoral hernia, female patient

媒體類型

手術影片

期間

05'40''

刊物

2009-04

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Apr 2009;9(04).
URL: http://www.websurg.com/doi-vd01en2574.htm

Laparoscopic treatment of an incarcerated right femoral hernia in a female patient

1. Introduction 00'10''

The objective of this film is to show the laparoscopic trans-abdominal preperitoneal repair of a right femoral hernia in a female patient who has had an appendectomy and who presented to emergencies with pain in the right inguinal region associated with nausea and vomiting. After the preoperative work-up (including CT-scan), a laparoscopic exploration is scheduled. The patient is placed in a recumbent position.

2. Peritoneal cavity exploration 00'37''

The laparoscopic exploration helps to identify important right iliac fossa peritoneal adhesions that are sequels of an open appendectomy. In addition, there are omental adhesions that are attached to the abdominal wall.

3. Identification of hernia orifice 00'55''

After navigation between adhesions, the exploration of the inguinal region helps to visualize the hernia orifice as demonstrated by external digital pressure.

4. Dissection of adhesions 01'06''

The first operative step is to free the adhesions at the level of the inguinal region to better expose the internal hernial orifice. A complete adhesiolysis is not necessary. It should simply allow for a better visualization of the hernial orifice. This orifice is not inguinal but femoral. Internal manual traction on the hernia sac allows to reduce the hernia sac and its associated lipoma.

5. Opening of preperitoneal space 01'37''

The next step is to open the preperitoneal space through a peritoneal incision from the internal border of the anterior superior iliac spine to the external border of the ipsilateral umbilical ligament. The adhesions to the peritoneum are preserved. Following the expert’s recommendations, the fellow surgeon dissects the subperitoneal lateral Bogros’ space by parietalization of the subperitoneal structures. This dissection is carried out in contact to the peritoneum in order to avoid deeper injuries at the level of the nerve branches and nerve rami. As we do routinely in female patients, the round ligament is divided in a subperitoneal position. This division may induce a small bleeding and care must be taken to achieve hemostasis of the round ligament using the bipolar electrode. The round ligament is intimately attached to the peritoneum. It is maintained as such to continue parietalization and dissection of the subperitoneal space towards the midline in order to open the Retzius’ space. To do so, dissection of the anterior aspect of the bladder is performed.

6. Identification and reduction of hernial femoral sac 03'28''

The iliopubic branch and the hernial femoral sac are identified. This hernia sac is reduced with traction. No external tactile pressure is necessary here in this case. Then the dissection of the Bogros’ space is continued and here the femoral orifice can be seen underneath the inguinal ligament and above Cooper’s ligament. Parietalization of the retroperitoneal structures is pursued by freeing the peritoneum from subperitoneal structures.

7. Placement of non-absorbable mesh 04'04''

The next step is to place a large piece of non-absorbable mesh, which is tailored to the shape of the preperitoneal space. In the absence of fixation, there is a risk of mesh migration. Therefore 3 tackers are positioned on Cooper’s ligament, then to the internal border of the ipsilateral anterior superior iliac spine in order to recreate the inguinal ligament, and finally to the superior border of the mesh. No tacker is positioned at the level of the triangle of Pain nor at the level of the triangle of Doom.

8. Closure of peritoneal flap 04'52''

Perfect closure is then achieved. To do so, we overlap the peritoneal flaps. The inferior peritoneal flap is grasped in order to cover the superior peritoneal flap. Fixation of the flap is achieved through either Protack® staples or sutures. The sac can also be used to cover the sutured area.