Laparoscopic repair of concurrent direct and indirect inguinal, femoral, and obturator hernias on the same side: A case report.

Concurrent direct and indirect inguinal, femoral, and obturator hernias are rare. This case report describes a rare case treated using the laparoscopic approach. A 68-year-old female patient presented with a moving left inguinal lump and pain. Physical examination and abdominal computed tomography scan revealed the coexistence of a left inguinal hernia or Nuck canal hydrocele and a left femoral hernia. The patient underwent laparoscopic transabdominal preperitoneal repair, and all four orifices were covered with one mesh. The patient was discharged on the second postoperative day without any complications. The concurrent presence of four hernias on the same side is rare and has not been previously reported. The laparoscopic approach is useful in such cases because it allows visualization of multiple hernia orifices from the intra-abdominal cavity.

Managing ischemic and necrotic incarcerated femoral hernia contents and their risk factors.

PURPOSE: Incarcerated femoral hernia patients had high risk of hernia contents necrosis. We provide our experience of management ischemia and necrosis of hernia contents in emergency incarcerated femoral hernia patients, and to investigate its risk factors. METHODS: This is a case-control study. Eighty-nine incarcerated femoral patients who underwent emergency surgery from January 2015 to December 2021 were included, and divided into normal group (60 cases) and ischemia/necrosis group (29 cases) according to the intraoperative condition of hernia contents. The surgical methods, intraoperative and postoperative conditions were compared between the two groups. Multivariate logistic regression was used to analyze the risk factors of ischemia and necrosis of hernia contents. RESULTS: Open preperitoneal tension-free repair was the most commonly used surgical methods (68.5%) for incarcerated femoral patients. The utilization rate of laparoscopic repair in the ischemia/necrosis group was lower than that in the normal group (13.8% vs. 20.0%, P = 0.475). The proportion of mesh placement in the normal group was significantly higher than that in the ischemia/necrosis group (98.3% vs 65.5%, P < 0.001). The hernia contents resection rate (55.2% vs 1.7%), operation time (90 vs 40 min), intraoperative bleeding (5 vs 2 ml), ICU admission rate (31.0% vs 1.7%), and hospital stay (7 vs 4 d) were significantly higher in the ischemia/necrosis group than those in normal group. Results of multivariate logistic regression showed that incarceration time more than 9 h (aOR = 19.3, 95%CI: 1.9-192.9) was an independent risk factor for ischemia and necrosis of hernia contents in emergency incarcerated femoral hernia patients. CONCLUSION: Open tension-free repair was the most commonly used surgical methods for emergency incarcerated femoral hernia patients. Ischemia and necrosis of hernia contents will increase bowel resection rate and prolong operation and hospital stay. Long incarceration time is an independent risk factor for ischemia and necrosis of hernia contents.

The Use of CECT in the Diagnosis of Intestinal Obstruction: A Case of Difficult Diagnosis in a Strangulated Left Femoral Hernia.

ABSTRACT: A femoral hernia is an uncommon and acquired hernia in the groin. Its incidence in adults is 2%-8% of all abdominal wall hernias, and it has a female-to-male ratio of 1.8:1. It is usually found in elderly patients and is associated with increased morbidity due to delays in diagnosis leading to a high incidence of incarceration and strangulation. Accurate preoperative diagnosis of femoral hernia is challenging, especially in obese patients in whom a small femoral hernia can be hidden under the groin fat. Unlike an inguinal hernia, it rarely reduces on its own and if asymptomatic and small, is often unnoticed by the elderly obese patient. Femoral hernia is often unsuspected and overlooked in males as it is predominant among females. Delay in diagnosis can lead to intestinal gangrene and high morbidity. We present a case of an incarcerated left femoral hernia in an elderly obese male who presented with acute intestinal obstruction. He was managed with resection of the gangrenous segment and double barrel ileostomy. Although uncommon in males, a femoral hernia has a high incidence of strangulation, and therefore should always be ruled out as a cause of acute intestinal obstruction in elderly patients. Therefore, never forget to examine the groin in case of intestinal obstruction.

De Garengeot Hernia, an acute appendicitis in the right femoral hernia canal, and successful management with transabdominal closure and appendectomy: a case Report.

Incarceration of the appendix within a femoral hernia is a rare condition of abdominal wall hernia about 0.1 to 0.5% in reported femoral hernia [1]. We report a case of a 56-year-old female whose appendix was trapped in the right femoral canal. There are few reports in the literature on entrapment of the appendix within a femoral hernia. The management of this condition includes antibiotics, drainage appendectomy, hernioplasty and mesh repair.

De Garengeot's hernia patients entirely treated laparoscopically: a safe and feasible alternative-a systematic review.

PURPOSE: Less than 450 cases of femoral hernias containing the vermiform appendix have been published since De Garengeot's first description. A laparoscopic treatment option opened 15 years ago seems reliable and safe. A literature review of all the patients who have benefited from this new therapeutic alternative is presented. METHODS: A systematic review using the German Society of Surgery's recommendations was performed for De Garengeot's hernias totally treated laparoscopically. Keywords searched included "De Garengeot hernia" OR "femoral hernia appendix" OR "crural hernia appendix." RESULTS: Only 29 out of 225 De Garengeot hernia's manuscripts were identified describing patients entirely treated laparoscopically: 25 patients by a transabdominal preperitoneal hernia repair (TAPP) and 4 patients by a total extraperitoneal (TEP) procedure; 85.1% were females. The mean age was 71 years. Twenty-two patients had pre-operative imaging tests, sonography (2), computed tomography (14), or both (6). Nevertheless, only 56% had a preoperative diagnosis. Twenty-one cases required urgent treatment, while programmed surgery was possible in 7 instances. An appendix-sparing procedure could be done in 16% of the TAPPs. No postoperative complications occurred. The median hospital stay was 2.5 days. CONCLUSIONS: The best surgical approach for a De Garengeot's hernia is not defined, and many critical questions remain unanswered. A better understanding of the diagnosis and treatment of this peculiar hernia will supply guidelines for clinicians who may encounter it hereafter. A fully laparoscopic approach seems perfectly safe and feasible for this entity, and it could be considered the first-line alternative if enough expertise is available.

Predictive factors of bowel necrosis in patients with incarcerated femoral hernia.

PURPOSE: Intestinal necrosis is a frequent complication in patients with incarcerated femoral hernias (IFH). Knowing the low incidence of IFH, few series with large samples studied predictive factors of intestinal necrosis. The main objectives of our study were to determine the predictive preoperative factors of intestinal necrosis in patients with IFH and to compare its morbidity with that related to incarcerate inguinal hernias (IIH). METHODS: We conducted a retrospective observational cohort study in which we included patients with incarcerated groin hernias (IGH). This is a single-center study between January 2004 and December 2021. Patients were divided into two groups: group A (admitted for IFH) and group B (admitted for IIH). Intestinal necrosis was confirmed intraoperatively. RESULTS: 383 patients with IGH were included in the study: 91 patients had IFH (23.76%) and 282 patients had IIH (76.24%). In patients with IFH, the median age was 67 years. We had 60 females (66%) and 31 males (34%). Bowel ischemia was present in 29 patients (32%). Bowel necrosis was present in 14 patients (16%). We identified three independent variables predicting bowel necrosis in patients with IFH: Duration from symptoms to surgery, NLR (Neutrophil to Lymphocyte ratio), and urea. Bowel ischemia and bowel necrosis were significantly higher in patients with IFH compared to those with IIH. CONCLUSIONS: In summary, we found that duration from symptoms to surgery, NLR, and urea were significantly predictive of intestinal necrosis in patients with IFH.

Formation of Biologic Plug and Patch Mesh for Use in Perforated Femoral Hernia.

Incarcerated inguinal hernias with contamination frequently lead to an open inguinal hernia primary repair. If no contamination is present, a tension-free repair with mesh is a good option. In this case, we encountered an incarcerated femoral hernia with perforation of the small bowel. We will describe and demonstrate via video how to incorporate a tension-free repair with mesh in a contaminated field with formation of a plug and patch made from biologic mesh.

De Garengeot's hernia: A masked abdominal perforation.

INTRODUCTION: de Garengeot's hernias occur when an inflamed appendix is encased within a femoral sac. This is a relatively rare type of femoral hernia. As a result, there are currently no guidelines for the management of these hernias. CASE: We present a 90-year-old woman with a de Garengeot's hernia complicated with strangulation and perforation. The diagnosis was made intraoperatively, and it was managed with hernia repair and an appendicectomy. There were no postoperative complications. DISCUSSION: The presentation of de Garengeot's hernias is non-specific. Enclosure of the bowel content within the hernia sac may mask systemic systems of disease. Rarely, septic signs or symptoms are identified on presentation. It is typically diagnosed intraoperatively, thus prompt emergency surgery should not be delayed by clinicians awaiting precise knowledge of the sac content via imaging. Prompt surgery with a single McEvedy incision enables treatment for both the appendicitis and abdominal wall defect, an appendectomy and hernia repair, respectively. In patients that present with an irreducible femoral hernia and biochemistry suggestive of an acute inflammatory process, there should be a high clinical suspicion for de Garengeot's hernia due to the risk of perforation being masked by an anatomical encasement around the perforated bowel content.

Comparison of mesh repair and suture repair for the treatment of incarcerated femoral hernia: a retrospective, single-center study.

BACKGROUND: Femoral hernias often present with incarceration or strangulation that requires emergency surgery. However, recommendations vary regarding optimal approaches for incarcerated femoral hernia. The aim of this study is to compare clinical efficacy between mesh repair and suture repair for the treatment of incarcerated femoral hernia. METHODS: Retrospective, single-center analysis of the clinical data from 48 patients with incarcerated femoral hernia, including 16 patients who underwent mesh repair (mesh repair group) and 32 patients who underwent traditional suture repair (suture repair group). RESULTS: The mean age, body mass index, incarceration duration, hernia sac size, operation duration, and the rates of postoperative incision infection, recurrence, chronic pain, and mortality were not significantly different between the suture repair and mesh repair groups (P > 0.05 for all). In contrast, the female/male ratio; the rates of bowel obstruction, coexisting diseases, and nighttime operation; and the American Society of Anesthesiologists grade were higher and the rate of prophylactic antibiotic use and the mean cost of hospitalization were lower in the suture repair group than in the mesh repair group (P < 0.05 for all). CONCLUSION: The surgical approach should be chosen based on the patient's condition. Mesh repair for the emergency treatment of incarcerated femoral hernia is safe and effective, whereas suture repair is suitable for elderly patients, those with more coexisting diseases, and those with limited life expectancy.

Open preperitoneal vs. open anterior repair for the treatment of emergency femoral hernia: a bicentric retrospective study.

PURPOSE: The aim of this study is to compare the postoperative results, in terms of complications and recurrence, between the anterior and open preperitoneal approaches in emergency femoral hernia. METHODS: This bi-centric retrospective cohort study included patients who underwent emergency femoral hernia repair between January 2010 and December 2018. Postoperative complications and recurrence were analyzed comparing anterior and open preperitoneal approaches. The predictors of complications, mortality and recurrence were investigated using multivariate logistic regression. RESULTS: A total of 204 patients met the inclusion criteria. Open anterior approach was performed in 128 (62.7%) patients and open preperitoneal was performed in 76 (37.3%). Open preperitoneal approach was associated with lower rates of recurrence (P = 0.033) and associated midline laparotomies (P = 0.006). Multivariable analysis identified patients with chronic nephropathy (OR, 3.801; 95%CI, 1.034-13.974; P = 0.044), preoperative bowel obstruction (OR, 2.376; 95%CI, 1.118-5.047; P = 0.024) and required midline laparotomy (OR, 12.467; 95%CI, 11.392-102.372; P = 0.030) as risk factors for complications and ASA ≥ III (OR, 7.820; 95%CI, 1.279-47.804; P = 0.026), COPD (OR, 5.064; 95%CI, 1.188-21.585; P = 0.028), necrotic contents (OR, 36.968; 95%CI, 4.640-294.543; P = 0.001), and required midline laparotomy (OR, 11.047; 95%CI, 1.943-62.809; P = 0.007). as risk factors for 90-day mortality. Male gender (OR, 4.718; 95%CI, 1.668-13.347; P = 0.003) and anterior approach (OR, 5.292; 95%CI, 1.114-25.149; P = 0.036) were risk factors for recurrence. CONCLUSION: Open preperitoneal approach may be superior to anterior approach in the emergency setting because it can avoid the morbidity of associated midline laparotomies, with a lower long-term recurrence rate.

Emergency groin hernia: outcome after mesh and non-mesh repair.

BACKGROUND: Emergency inguinal and femoral hernia repair can be done by suture or mesh repair, there is still scepticism around using mesh. We aim to evaluate the usage of mesh and the outcome of emergency groin hernia repair after mesh and suture repair. METHODS: Retrospective cohort study of adult patients who underwent emergency inguinal and femoral hernia repair from 1st January 2018 to 31st July 2020. Electronic data and case notes were reviewed and outcome data were collected. RESULTS: Eighty-nine emergency groin hernia repairs were carried out. Sixty-two were males, 60 inguinal hernia and 29 femoral hernia. Median age was 72 years (range 20-95). 74 (83.1%) were primary hernia and 15 (16.9%) recurrent hernias. 67 (75.3%) mesh and 22 (24.7%) suture repairs were carried out. Eleven cases required bowel resection and of those 10 had suture repair. Inguinal hernia was more likely to have mesh repair as compared to femoral (P-value 0.002). Median length of stay was significantly lower in mesh group 2 days (1-5 IQR) versus 7.5 days (5-11 IQR) in suture repair group (P-value <0.0001). Five cases (6.74%) had wound complications (3 wound infections, 2 haematoma). With median 20 months (range 6-36 months) follow-up, 1 recurrence each in both mesh and suture repair groups, no mesh infection and 2 (2.2%) 30-day mortality recorded. Wound infection, recurrence and reoperation were not statistically different in two groups. CONCLUSION: Emergency groin hernia are amenable to mesh repair and in case of bowel resection or gross contamination non- mesh repair is recommended.

De Garengeot Hernia: A Total Extraperitoneal Approach to a Femoral Hernia Repair.

Introduction: A de Garengeot's hernia is a femoral hernia containing the appendix and accounts for approximately 0.8% of all femoral hernias. Presentation of the Case: This paper describes a case of an 84-year-old female who presented with abdominal pain, believed to have an incarcerated femoral hernia. Patient underwent a hernia repair and was found to have a femoral hernia involving the appendix, a de Garengeot's hernia. The femoral hernia was repaired using a total extraperitoneal (TEP) approach. Discussion: There are a variety of reported ways to repair a de Garengeot hernia. In this case, we discuss the successful use of the TEP approach to repairing a de Garengeot hernia. Conclusion: Although rare, a de Garengeot hernia must remain on the differential when evaluating a patient for an incarcerated femoral hernia. A TEP approach provides the surgeon the ability to perform a variety of hernia repairs, regardless of what is encountered during the operation.

Point-of Care Ultrasound in Stratifying Clinically Evolving Inguinal and Femoral Hernias.

BACKGROUND: Point-of-care ultrasound (POCUS) is an optimal imaging modality for the risk stratification of patients presenting to the emergency department (ED) with inguinal and femoral hernias, allowing for better evaluation of clinical presentations and guiding appropriate treatment. The lack of ultrasound classification for inguinal and femoral hernias has led to inconsistent use and often underuse of POCUS in this patient population. Several groin hernia classifications are available, but most are complex and often targeted toward surgical management. OBJECTIVES: The objective of this study is to review the use of POCUS in the diagnosis of inguinal and femoral hernias, providing a synopsis of critical ultrasound findings in determining signs of incarceration, strangulation, and small bowel obstruction, and suggesting a simple and educative sonographic classification for inguinal or femoral hernias. DISCUSSION: POCUS can reliably confirm the presence of groin hernias and can uniquely identify specific ultrasound findings predictive of complications, such as aperistaltic nonreducible bowel loops, free fluid in the hernia sac, and lack of color doppler in the entrapped mesentery and bowel walls. POCUS can also aid in determining the presence of small bowel obstruction by detecting dilated loops of bowel >25 mm adjacent and proximal to the hernia site. CONCLUSIONS: In the ED, POCUS can confirm the presence of a hernia sac and identify and predict surgical emergencies, such as bowel incarceration or strangulation, which are the most important elements in the management of patients presenting with possible inguinal or femoral hernias.

Management of appendicitis in a De Garengeot hernia: Lockwood approach.

A De Garengeot hernia is a femoral hernia containing the vermiform appendix. This extremely rare hernia is associated with appendicitis and the risk of perforation and abscess formation. Given limited data, it poses both diagnostic and management difficulties. While management is generally surgical, questions remain about the best operative approach, indications for appendicectomy and optimum hernia repair technique. We describe a case of acute appendicitis within a De Garengeot hernia that was managed with an open appendicectomy via a Lockwood incision. This case helps to illustrate the management considerations present for this rare clinical pathology and describes a method to effectively identify the hernia and resect the appendix.

[Strangulation of the appendix in an inguinal hernia sac in children]. / Ushchemlenie cherveobraznogo otrostka v gryzhevom meshke u detei s pakhovymi gryzhami.

OBJECTIVE: To study the features of the clinic and treatment of children with infringement of the appendix in inguinal hernias in children. MATERIAL AND METHODS: We observed 12 children with the localization of the appendix in the right inguinal hernia. Four of them had an infringement of the appendix: two with inguinal hernia, two with sliding inguinal and femoral hernias. To verify the diagnosis, we used clinical and laboratory examinations of children with restrained inguinal hernia, ultrasound and Doppler examination of the groin and scrotum, X-ray, morphological examination of surgical materials. 4 clinical observations are presented. RESULTS AND DISCUSSION: Difficulties in diagnosing acute appendicitis in case of infringement of the appendix in inguinal hernias in children are associated with an atypical clinical picture, which proceeds under the mask of OZO. Testicular infarction was found in 2 children with strangulated inguinal hernia and necrosis of the appendix. Combined surgery with abdominal and herniatomical access for sliding restrained hernias in 2 children made it possible to perform a radical operation and avoid severe postoperative complications. CONCLUSIONS: 1. Infringement of the appendix in inguinal hernias in children is rare. 2. The clinical picture of the restrained appendix in the hernial sac proceeds under the mask of OZJ. 3. Operative access in the groin area when the appendix is infringed in the hernial sac is the operation of choice. 4. In case of infringement of the appendix with sliding hernias (inguinal and femoral), the operation of choice can be abdominal and herniatomical approaches.

[Laparoscopic totally extraperitoneal repair of strangulated groin hernia]. / Laparoskopicheski assistirovannaya total'naya ekstraperitoneal'naya plastika (laparoscopic assistant total extraperitoneal plastic ­ latep) v lechenii ushchemlennykh gryzh pakhovoi oblasti.

OBJECTIVE: To study the possibility of totally extraperitoneal repair combined with diagnostic laparoscopy in the treatment of strangulated groin hernias (Laparoscopy-Assisted Totally Extraperitoneal Plasty, LATEP). MATERIAL AND METHODS: We analyzed the results of laparoscopic totally extraperitoneal hernia repair. The trocar placement technique was modified. There were 38 patients with strangulated groin hernia. The sample included 26 patients with strangulated inguinal hernia, 9 ones with strangulated femoral hernia and 3 patients with recurrent strangulated inguinal hernia. RESULTS: LATEP was attempted in 38 patients and successful in 37 (97.3%) cases. In 1 (2.6%) patient, correction of small bowel strangulation was failed and conversion to open surgery was required. In 29 patients (76.3%), correction of strangulation was performed after laparoscopy-assisted external manipulations and careful traction from abdominal cavity. In 8 (21%) cases, strangulation spontaneously regressed before laparoscopy. Laparoscopy confirmed viability of strangulated organs in 36 patients. One (2.6%) patient required bowel resection due to small intestine wall necrosis. Later, all patients underwent totally extraperitoneal repair. We were able to prevent the contact of hernia sac fluid with the implant in all cases. At the stage of preperitoneal repair, local damage to peritoneum occurred in 9 patients. Nevertheless, sealing was not required since hernia fluid was previously removed from abdominal cavity. There were no signs of implant infection and hernia recurrence within 6-14 months. CONCLUSION: Totally extraperitoneal repair combined with diagnostic laparoscopy is possible for strangulated groin hernias.

Feasibility of modified-TEP technique for large inguinoscrotal and large femoral hernia and its advantages.

PURPOSE: To describe the feasibility of modified-TEP technique in reducing dead space in large inguinoscrotal and large femoral hernia to prevent seroma, reduce recurrence and complications. METHODS: This is a case series of patients who have completed a minimum of 9 months follow-up after undergoing elective endo-laparoscopic inguinal hernia repair with modified-TEP technique for large inguinoscrotal and large femoral hernia in a single institution from June to October 2020. RESULTS: 14 large inguinoscrotal hernia and 4 large femoral hernia were repaired using the modified-TEP technique in 15 patients. These patients reported minimal pain after surgery. There were no reported seroma, complications or recurrences up to 9 months follow-up period. CONCLUSION: Modified-TEP technique for large inguinoscrotal and large femoral hernia has shown good outcomes and patients reported minimum levels of pain. In experienced hands, it is safe, feasible and effective in reducing seroma formation and hernia recurrence.