A Novel Laparoscopic-Assisted Approach to the Repair of Pediatric Femoral Hernias

Introduction

Femoral hernias are rare and often misdiagnosed in the pediatric population. They are reported to account for less than 1% of all groin hernias in children.^1–5 Unlike indirect inguinal hernias, which are thought to protrude through a congenitally patent processus vaginalis, the etiology of femoral hernias is unclear. The most popular hypothesis is that of McVay and Savage, ⁶ who postulated that a congenitally narrow insertion of the posterior inguinal wall onto Cooper's ligament results in enlargement of the femoral ring. However, others have suggested that femoral hernias may be acquired via an increase in intraabdominal pressure or previous inguinal hernia repair.^4,7,8

The repair of femoral hernias has traditionally been undertaken in an open fashion via either an inguinal or crural incision,^5,8–10 with just a few reports utilizing laparoscopic techniques.^11–14 Recurrence rates can be high, perhaps because femoral hernias may involve a fascial defect of significant size.^1,4,7 Thus, the typical approach of simple high ligation of the hernia sac used for indirect inguinal hernias may be inadequate for permanent femoral hernia repair. Here, we describe a laparoscopic-assisted technique that is buttressed by a small cigarette of mesh and requires only two incisions for the repair of this uncommon pediatric entity.

Patients and Methods

Surgical technique

After induction of general anesthesia, all patients received a dose of a prophylactic antibiotic. A 5-mm, 30° laparoscope was placed in the umbilicus to visualize the inguinal area bilaterally. A right-sided femoral hernia was identified in all 3 patients (Fig. 1). The laparoscope was advanced and placed into the femoral hernia sac in order to transilluminate the abdominal wall above the sac. A 1-cm skin incision was made with a 15-blade scalpel over the defect. Via the skin incision, the sac was grasped, dissected free of the surrounding tissue, twisted 360°, suture ligated with 3-0 Vicryl™ suture (Ethicon, Cincinnati, OH), and divided. A 2-×3-cm piece of monofilament polypropylene mesh (Prolene™; Ethicon) was rolled into a cigarette and sutured into shape with a 3-0 polypropylene stitch (Prolene) (Fig. 2). This piece of mesh was then stitched to the pectineal and inguinal ligaments with 3-0 Prolene in order to completely close the hernia defect (Fig. 3). Absorbable suture was used to close the subcutaneous tissue (interrupted 3-0 Vicryl) and skin (subcuticular 4-0 Monocryl™; Ethicon). The umbilical fascial incision was closed with a figure-of-eight 2-0 Vicryl stitch, and the skin was closed with simple plain gut stitches.

OPEN IN VIEWER

FIG. 1.

Right femoral hernia, laparoscopic view.

OPEN IN VIEWER

FIG. 2.

A 2-×3-cm piece of monofilament polypropylene mesh (Prolene; Ethicon) rolled into a cigarette and sutured into shape with a 3-0 polypropylene stitch (Prolene).

OPEN IN VIEWER

FIG. 3.

Right femoral hernia after repair, laparoscopic view.

Results

Our technique was used successfully to repair right femoral hernias in 3 patients: two boys and one girl between 8 and 9 years of age (mean, 8.5 years). Ipsilateral indirect inguinal hernias were present in 2 patients: one had been repaired previously, and one was identified during laparoscopic exploration of the right inguinal area. The indirect inguinal hernia identified intraoperatively was repaired in the laparoscopic-assisted fashion described by Dutta et al. ¹⁵ No left-sided hernias, inguinal or femoral, were found. Patients were ready for discharge on the day of surgery and had uneventful recoveries. Follow-up at 6 months revealed excellent cosmesis, without recurrence.

Discussion

Femoral hernias, which make up only approximately 1% of all pediatric hernias in the groin,^1–4 pose a twofold challenge for surgeons. First, femoral hernias are prone to misdiagnosis because of their relative rarity. Indirect inguinal hernias are a much more common cause of reducible groin masses in children and may occur simultaneously with femoral hernias,^4,8 as noted in 2 of our 3 patients. Thus, as the less likely diagnosis, femoral hernias may easily be missed in favor of repair of an indirect inguinal hernia, particularly when an open technique is used. Second, unlike pediatric indirect inguinal hernias, femoral hernias have an associated fascial defect that requires closure. Therefore, techniques that consist of hernia sac ligation alone may not be sufficient for long-term repair and might contribute to the high recurrence rates, which may range from 2% to 13%, for femoral hernia repair, whether open or laparoscopic.^3,12

Although a standard approach to femoral hernias would necessarily involve narrowing the femoral canal to close the abdominal wall defect, there is still no consensus on what the simplest, most efficacious, and durable approach would be.

Recent reports have focused primarily on techniques that include laparoscopic groin exploration with femoral hernia repair.^11–14 Although laparoscopy may help reduce the rate of missed diagnoses, closure of the fascial defect must still be addressed. Thus far, the reported laparoscopic and laparoscopic-assisted approaches mainly describe ligation of the femoral hernia sac with use of the proximal portion as a “plug” for the abdominal wall defect.^11–14 The use of a natural biologic plug caused by the scarring of a ligated hernia sac or umbilical ligament to repair a hernia defect has been reported elsewhere as well.^16,17 However, follow-up in these cases is insufficient to determine whether scarring from the native tissue will provide a long-term durable repair. Instead, we suggest that the addition of a mesh plug, as has been described for open repairs, ⁹ will provide the most permanent seal for a femoral hernia defect.

In our approach, we combine a laparoscopic exploration to evaluate both inguinal regions with the use of an infrainguinal incision for direct dissection of the femoral hernia sac and closure of the defect with a permanent plug of mesh. The external dissection, when coupled with laparoscopic guidance, reduces the size of the incision and the risk of injury to adjacent structures such as the femoral vessels. It also obviates the need for the additional incisions that would be required for a purely laparoscopic dissection of the sac. ¹³ Furthermore, the “cigarette” we form out of polypropylene mesh provides a more permanent plug for the abdominal wall defect. We hope that this will reduce the likelihood of recurrence of the hernia. Because the defect is directly visualized both internally and externally, it can be evaluated and palpated so that our plug can be tailored to fit the size of the fascial gap. In this way, only a modest size of mesh need be used to reduce concerns of foreign-body placement in pediatric patients.

Conclusions

We have described a laparoscopic-assisted approach to pediatric femoral hernia repair that is straightforward, safe, efficacious, and efficient. The addition of laparoscopy to a traditional open approach aids in the diagnosis and localization of the femoral hernia sac, as well as provides the ability to examine the contralateral groin for hernias. Because dissection of the hernia sac is performed externally, only two incisions are required, for the camera and the hernia itself. The addition of a small mesh plug buttresses and secures the remaining abdominal wall defect, which is associated with a femoral hernia. More patients and longer follow-up are essential to accurately judge the long-term implications of this novel technique.