Femoral hernia

FEMORAL WITH

SPECIAL

HERNIA

REFERENCE

TO ITS COMPLICATIONS

DAMON B. PPEIPFER, M.D. AND FLETCHERD. SAIN, M.D. Abington, Pennsylvania

S

TRANGULATED hernia is often referred to as a complication fraught with dangers and difficulties but few that cannot be overcome if the case is seen in reasonable time. In order to obtain an understanding of the problem of strangulated femoral hernia we have made a comprehensive analysis of a series of consecutive admissions over a ten-year period according to the fohowing pIan. We shaI1 first review briefly some of the phases of genera1 interest of femora1 hernia, nameIy, incidence, etiology, diagnosis and basic pIan of repair. During this ten-year period IOO cases of femoraI hernia and 1,164 cases of indirect inguinal hernia were seen in the Pfeiffer Surgica1 CIinic. This is within the percentage relationship of the femoral to inguinal hernia reported in other series. This comparatively Iow incidence and the high rate of comphcations of an otherwise simple condition has made femoral hernia an ever live subject in surgical literature. Femoral hernia may be congenital but is more often acquired as a resuIt of weakness of the structures which normally close the femoral canal. The reIativeIy rigid anatomic boundaries of this region are a factor in the frequency of strangujation. The roof of the femora1 cana is formed by the inguina1 Iigament and faIciform margin of the fascia Iata anteriorIy; posteriorIy Cooper’s Iigament, the pectinea1 fascia and pectineus muscIe; Gimbernat’s or the Iacunar ligament mediahy and posteriody and laterally the femora1 vein. Senile atrophic changes, Ioss of fat in the femoral cana1, increase in Iower abdomina1 pressure and use of the inguinal Iigament in repair of inguina1 hernia producing an enlargement of the femoral cana have been mentioned by MueIIerr as factors causing femoral hernia. The diagnosis of femora1 hernia usuaIIy is not diffrcuIt. A mass can be paIpated IateraI and inferior to the pubic spine. Conditions occur when the diagnosis is difficult and the index of suspicion must always be high in obJune,

19~2

scure, compIete or partial bower obstruction. Richter’s type of hernia is sometimes missed and the knuckle of bowe1 becomes gangrenous contributing to the mortaIity in strangulated femora1 hernia. Dunphy2 describes three important circumstances leading to erroneous diagnosis: (I) patient and physician unaware of hernia; (2) hernia of Iong-standing dismissed as possible cause of symptoms because there was no IocaI pain or tenderness in the groin; (3) usual signs and symptoms of intestinal obstruction deveIop sIowIy in approximateIy one-third of the cases because the ileum or coIon is involved low or incomplete circumference of the bowel is caught. These factors Iead to vague gastrointestina1 upsets often erroneously diagnosed as large bowel malignancy. It is therefore axiomatic that compIicated femora1 hernia shouId be suspected in any patient with vague and undiagnosed gastrointestinal complaints. Pain and vomiting are the most common symptoms associated with strangulation. They may be sudden in onset or occasionally chronic Iasting for days or weeks. The distribution of pain is usuaIIy generalized over the abdomen and may or may not be referred to the groin. It wiI1 be pointed out in this study that a very important factor in the complications of femoral hernia is the failure of the patient to seek treatment for a condition known before compIications developed. The treatment of femoral hernia has two principal surgical approaches. The repair is made from beIow the inguina1 ligament through a simpIe incision over the femoral opening or from above the inguinal ligament approached through the inguina1 or abdomina1 incision. It has been stated that over IOO variations in technic have been reported; but with the success of the basic principIe of Bassini5 described in 1893 of obIiterating the cana by suturing its roof or the posterior margin of the inguinal Iigament and the faIciform margin of the fascia Iata to its floor or the pectineus fascia with

767

~. . Pfeltter,

Sain--Femoral

interrupted sutures, many 01’ these variatiruls are surgical fancies and unnecessary. The inguinaI approach of Lotheissen3 described in 1898 cIosed the cana from above. The conjoined tendon is sutured to Cooper’s Iigament to produce a barrier before the femora1 ring. ResuIts TABLE

I

Hernia

series of twenty-five cases with no recurrence. Recurrences are reported but the significant fact here is that Iarge series of femora1 hernias are treated with minimal recurrence rates and no mortaIity, regardIess of age, in the uncompIicated cases. On the other hand, femoral her-

-

T-

-

No. of

Mor-

Operations

Ileaths ; tahty

TABLE II

-

No. of

(%j

Cases Gangrenous

YtXr

Author

l-

Mor-

IIYlthE

taIity (“/‘)

120

34 25 56 34 5o 80

ROWI

Massachusetts Gen. Hospital, Boston Mass. Llncomplicated by obstruction and gangrene. . Complicated by intestinal obstruction; bowe1 viable Comphcated by intestinal obstruction and gangrene Pfeiffer Surgical Clinic, Abington, Pa. Uncomplicated by obstruction and gangrene. Complicated by intestinal obstruction; bowe1 viabIe Complicated by intestinal obstruction, gangrene and intestinal anastomosis.

-

_ 0

0

0

0

IO

$0

r son. G’b Becker. Springer. Frankau McIver. Bowers.

1900 1922 1924 1931 ‘933 1935 I940 1942 1943 1943 ‘95’

Dunphy

65

0

0

23

0

0

I2

)

3

25 -

are reported for this and other technics.” It wiI1 be pointed out that in this series the Bassini plan was preferred, being used in over 80 per cent of cases. The inguina1 or abdomina1 closure was made when the abdomen had to be opened for other reasons or when the surgeon preferred this pIan. The objection to the inguina1 approach is that it may weaken the floor of the canal and predispose to a direct hernia. The record of treatment of uncompIicated femora1 hernia has been a brilIiant one since 1893 when Bassini described the pIan of transfixion and high Iigation of the neck of the sac with obIiteration of the femora1 cana by uniting the roof of the canal with the pectineus fascia. Up until this time the only treatment of femora1 hernia had been excision and closure of the sac with a Iarge percentage of recurrence. In 1893 Bassini5 reported fifty-four cases, of which forty-one were traced severa years postoperativeIy with not a singIe recurrence found. DeGarmo6 in Igo5 reported I IO operations for femora1 hernia with but one recurrence. Over the past fifty years many comparabIe reports have been made. In 1948 MueIIer’ reported a

354 24 16 116 8

McNeaIy . AdeIaide Hay. . Pfeiffer and Sain.

-

6 9 40 4 4 IO 20 8 6

5 20 33 12 6 12

-

50 60 66 100

3 -

25

-

nia complicated by gangrene of the intestine has a very high mortality rate ranging from 25 to IOO per cent in many reported series of cases. (Table I.) In the face of a fifty-year record of poor results without significant improvement in the last category of compIicated gangrenous hernia when compared with consistently good resuIts in uncomplicated femora1 hernia it is regrettable that a11 these patients cannot undergo hernioplasty early. (TabIe II.) Of IOO consecutive admissions to the Abington MemoriaI HospitaI with femora1 hernia eighty-two patients had known this condition existed for a period of a few days to fifty-five years, yet seventy-seven of these had to be driven to seek treatment because the hernia wouId not go back. TweIve of these had progressed to the state of gangrene requiring intestinal anastomosis representing the highly fatal phase of femora1 hernia. The IOO admissions for femora1 hernia up to 1950, covering a ten-year period, are analyzed according to a ten-phase pIan of study. The findings from this pIan of study are very reveaIing. FemoraI hernia is important, particuIarIy from the viewpoint of pitfaIIs in diagnosis, patient inertia and the consequent necessity of American

Journal

of Surgery

Pfeiffer,

Sain--Femoral

the family physician and surgeon recommending treatment in all cases as soon as diagnosed. It is important, also, because of its reIationship to other phases of surgery and the medica profession in generaI, nameIy, the probIem of intestina1 obstruction and gangrene, the wideIy discussed diagnostic ciinic, medical survey, radio and television heaIth programs on a national scaIe. The ten phases of the 100 consecutive cases admitted for femora1 hernia reveaIed: (I) age of patient, one month to ninety-two years; (2) sex, females sixty-six and males thirty-four; (3) known by patient (few days to many years), eighty-two patients; (4) irreducibIe preoperatively, seventy-seven patients; (5) diagnosed by family physician, ninety-three patients; (6) diagnosed preoperativeIy (as femoral or inguinal), ninety-eight patients; (7) contents-small bowel twenty-eight (dark viability returned sixteen, gangrene twelve), omentum thirty-six, omentum and smaI1 bowel seven (incIuded in smaI1 bowel), Iarge bowe1 five, tube and ovary one, appendix one, Meckel’s diverticuIum (previously reported) one, urinary bladder one, sac empty seventeen; (8) spontaneous reduction under anesthesia fourteen; abdomen opened in two of these, bowel found viable; others recovered uneventfuIIy; (9) procedure-high ligation of sac, cIosure of femoral cana1, wire preferred eighty-six, closed through abdomen fourteen; (IO) anesthesia-spinal sixty-nine, genera1 twenty, local seven, local and general four. AGEDISTRIBUTIO\ L$

I-20..

ZI-30............................. 3’-4O...,..............__.__..,... 4I-50_._..._......_....._.._...... 51-60.. br-70............................. 71~80.......................... 8x-()0..... .. .. .. gr-IOO............................

..

4 14 24 r9 18 12 4 I

The youngest patient in this series was a little gir1 one month of age who had the right tube and ovary incarcerated for ten days before operation. The oldest patient was a ninety-two year oId femaIe who had 20 cm. of discoIored bower in her hernia. It had been irreducibIe for only three hours. Both of these patients had uneventfu1 ConvaIescence. There were patients in all age groups with the majority coming in the middle decades. According to our records the age of the patient was not a significant factor in the recovery except in the group compli-

June,

195~

Hernia

cated by gangrene of the intestine. The three deaths occurred in this Iatter group in patients aged seventy-seven, seventy-nine and eightyone, respectiveIy. Table III shows the ages and summary of the group of twelve requiring intestina1 anastomosis. TABIF.

Age

!

Sex

No. of i

III

Known by Patient

Chart

__I_~/__ F M F F

81

65 79 74 81

10161 11136

hl F

15279 6067 20376

i,” 46

F F F F

7503 23003 26015

77

F

9217

I

59 / F

I

/ 4523

I !

1

-___-

Many yr.

2571 19214

Kc-

suit

55 yr. 5 yr. Not mentioned Few months Two months Unknown Four months Two days Unknown (symptoms of obstructions I day) Not mentioned (symptoms of obstruction I day) Unknown (not diagnosed preoperatively) operated for bowel obstruction; I da,y duration

Good Good Good Good Death Good Death Good Good Good Death

Good

I

1

I

The seventy-nine year oId man who died had been sick for one day with symptoms of boweI obstruction. At operation the small howeI was distended and fissured; gangrenous knuckle of bowel was inverted and side-to-side anastomosis made. Autopsy showed the small bowe1 perforated 90 cm. proxima1 to the anastomosis which had held without Ieaking. The eighty-one year old femaIe who died represents one of the pitfalts in diagnosis of femoral hernia which is mentioned in many reports on this subject. Dunphv reporting from the Peter Bent Brigham HospitaI in Boston, emphasizes this point. This patient was sick and under care of her doctor for nine days before coming to the Hospital. She was complaining of abdomina1 discomfort, flatulence and nausea becoming progressively worse, to coIic and vomiting. She was admitted to the Hospital with a diagnosis of partia1 intestina1 obstruction, etioIogy probabIy maIignancy, a common error when femoral hernia diagnosis is missed. Five days after admission, diagnosis was made when a mass appeared in the groin. The fact that the patient continued to move her boweIs and pass fIatus unti1 the day before diagnosis _”

_

770

Pfeiffer,

Gin---Femoral

was made confused the issue greatly. At oper:Ltion the mass was found to be an abscess from a gangrenous knuckle of sigmoitl colon caught in the left femoral canal. The gangrenous knuckIe of bowel was excised Ieaving viabIe coIon on the mesenteric side. A No. 36 T tube was fastened into the sigmoid and the abscess cavity was drained. The patient improved and a colostomy was estabIished. About the fifth postoperative day a feca1 vesicaI fistula developed and she died the tenth postoperative day from sepsis. The third death occurred in a seventy-seven year oId woman who had had symptoms of bowe1 obstruction for one day. At operation the gangrenous bowe1 was resected, and an end-to-end anastomosis was made. Her general condition was very poor and she died the second postoperative day. No autopsy was obtained. One patient in this group with gangrene of the bowe1 illustrates the pitfalIs in the prognosis of a patient with femora1 hernia. A sixty-five year old maIe (192 14) had his hernia for fiftyfive years and it had been irreducibIe for many years. There are many such patients who are toId by their doctors to forget it. This patient pushed a knuckle of small bowel behind the omentum which had phrgged the femoral cana for many years. The omentum was firmly adherent and the smaI1 bowel behind it was gangrenous. There are many such cases to ihustrate that this highIy IethaI potentia1 is ever present in femora1 hernia and that patients shouId all be operated upon as soon as the condition is diagnosed. Furthermore, public health education should urge the Iaity to seek surgica1 repair of a11 hernias as soon as discovered since hernia is a leading cause of bowel obstruction, a highly fata condition. The ninety-three cases diagnosed correct19 by the famiIy physician in&de al1 cases in which diagnosis of hernia was made. A few of these were diagnosed as inguinal hernia and a few as “inguina1 or femora1.” The ninety-eight diagnosed preoperativeIy aIso incIude the few cases in which a differentia1 could not be made with certainty between femoral and inguina1 hernia before operation. OccasionaIIy a mass is found lying over the inguina1 region and its hernial orifice cannot be determined with certainty until operation is performed. However, this in no way deters action for correction. Of the two cases missed one was disgnosed preoperatively as smaII bowel obstruction, and at

Hernia

abdominal exploration the undiagnosed kuucklc of a small bo\veI was found strangulated in the femoral ring requiring intestinal anastomosis. The other undiagnosed cast was uncomphcated and found incidental to an operation for an indirect inguinal hernia. Contents of the sac reveaIed omentum alone in thirty-six patients and smaI1 bowel in twenty-eight, of which seven contained omenturn aIong with the smaII bower. In tweIve patients the intestine was devitalized requiring bowel surgery. In six of these twelve patients the gangrenous knuckIe of bowe1 was inverted by siIk mattress sutures. It is beIieved that this method of handhng the gangrenous bowel is Iess shocking to these seniIe, poor risk patients than resection and anastomosis. This simpIe inversion of the devitaIized bowe1 shouId be performed in the Richter’s type of hernia or in the cases in which the area of gangrene does not compIeteIy encircle the bowe1 and the involvement of the mesentery is minima1 in this region. It is suggested that this simphfied plan is a factor in the reIativeIy Iow mortahty in this group of comphcated cases. In sixteen of the twenty-eight cases in which small bowel was found in the sac the intestine was darkened and discoIored indicating impaired circuIation, but vitaIity returned. In a11 questionabIe cases the bowe1 was either wrapped in warm, moist gauze packs or returned to the abdomen for a minimum of ten minutes by the clock. MuscIe stimmation by gentIe pinching or flicking with the finger is important to determine bowel viability. This maneuver wil1 ehcit muscIe contraction in the viabIe boweI. Five times the Iarge bowel was found in the sac and seventeen times it was found to be empty. The folIowing organs were found once: tube and ovary, appendix, Meckel’s diverticuIum and the urinary bladder. In fourteen patients the irreducibIe hernia reduced spontaneousIy under anesthesia. Only twice was it thought necessary to open the abdomen to determine viability. In both of these patients the bowe1 was found viabIe. AI1 of this group made uneventfu1 convaIescence. The procedure preferred in the majority of femora1 hernioplasties in the Pfeiffer SurgicaI Clinic is high ligation of the sac with transfixion and closure of the femora1 cana by suturing the inguinal and Gimbernat’s Iigaments to the pectineus muscIe. Mattress No. 32 to 28 wire sutures were used in 86 per cent of these American

Journal

of Surgery

Pfeiffer,

Sain-Femoral

IOO patients. In 14 per cent the hernioplasty was performed from the abdominal side using the McVey technic or a modification of it. It was necessary to enIarge the femoral ring fourteen times. This was done with the herniotome by the stepcut pIan upward and inward to facihtate an easier cIosure of the ring. There shouId be no hesitancy in cutting the femora1 ring when the hernia is not readiIy reducibIe. The cut shouId be upward and inward away from bowel and vessels. Spinal anesthesia was used in sixty-nine patients, genera1 anesthesia in twenty, IocaI in seven and IocaI with genera1 four times. The genera1 anesthesia was sodium pentotha1 or ether, or a combination of sodium pentothal, gas and ether. COMMENTS It is significant that 82 per cent of these patients had known of their hernia previous to hospitaIization. The vast majority of these 82 per cent had known of it for a period of severa months to many years. The fact that 77 per cent waited unti1 the hernia became irreducible indicates that the Iaity and the medica profession shouId be better informed regarding the high mortality of compIicated femora1 hernia as compared to the absent or Iow mortaIity associated with the operation for simple femora1 hernia, with mortaIity ranging from 25 to IOO per cent in reported series of cases of the a11 too frequent compIication of devitaIized intestine requiring anastomosis, a compIication which is nearIy aIways preventable. It is suggested that the now commonIy used press, radio and teIevision for transmitting information to the pubIic shouId come to the aid of this poorly understood subject. Just recentIy WGN-TV Chicago received a gold medal award by popular vote for its service of disseminating public heaIth information. There are important phases of a subject which are not reveaIed in a statistical anaIysis. Statistics may be misIeading, but vaIuabIe generaI knowIedge can be gained from such a study when the student is aware that despite statistical indications he must recognize the necessity of individuaIization tempered with generaIization. This point is specihcaIIy illustrated by an individua1 case management which Ieft a Iasting impression since the days of my internship. A white, middIe-aged male with vague abdominaI pain and nausea was referred without a

June,

1932

Hernia

77’

definite diagnosis to the surgical ward of Abington Memorial HospitaI by a thoroughly competent family physician. Past history revealed nothing more than recent persistent abdominal pain and nausea. Physical examination was essentiahy negative. SurgicaI intervention by one of the authors (D. B. P.), motivated by surgica1 judgment, consideration experience, and knowIedge of the pitfaIIs in the diagnosis and management of this type of case, led to the confirmed diagnosis and early cure of a stranguIated femoral hernia of the Richter type. Sixty-four cases were followed up two to nine years postoperatively. Two recurrences were found, a rate of 3 per cent. One of these recurrences was in a patient who had had numerous injection treatments for femora1 hernia; the other had been repaired through the superior approach. Both of these patients were reoperated upon and foIIowed up over five years showing no evidence of recurrence. SUMMARY I. One hundred cases of femoral hernia have been analyzed. 2. Seventy-seven per cent sought treatment because of irreducibIe hernia. 3. TweIve per cent progressed to a compIication requiring anastomosis in this series with a 25 per cent mortaIity. 4. SimpIe inversion of gangrenous bower and anastomosis is recommended in preference to resection and anastomosis when devitahzation is not extensive as is frequentIy the case in compIicated femoral hernia. 5. The modified Bassini technic was the procedure for hernioplasty used in 86 per cent of this series. 6. PubIic heaIth education on hernia is suggested. 7. FolIow-up recurrence rates are reported. REFERENCES

R. F. Femoral hernia. Arch. Surg., 56:229-237, 1948. DUNPHY, J. E. Diagnosis and surgical management of strangulated femoral hernia. J. A. M. A., 114: 394. 1940. LOTHEISSEN, G. Zur Radikaloperation der Schenkelhernien. Central. f. Cbir., 25: 548-550, 1898. LINDAH, 0. Surgical therapy of crural hernia with special consideration of frequency of recurrences. Nord. med., 30: 1220-1222, 1946. BASSINI, E. Mono Metodo Operation per Ia Cura Radicale delI’Ernia Crurale. Padova, 1893. A. Draghi.

I. MUELLER,

2.

3. 4.

5.

Pfeiffer,

772

Sain-Femoral

6. DE GAHMO, W. B. Cure of femora1 hernia; resuIt of I IO operations by a single method. Ann. Surg., 42: 209-214, 1905. 7. FIIANKAN, C. Strangulated hernia. hit. J. Surg., 19: 176, 1931. 8. GATCH. W. D. and MONTGOMERY. W. F. Treatment of externa1 hernias containing gangrenous bowel. J. A. M. A., 129: 736-739, 1945. g. BIIAJEKAH, M. V. StranguIated hernia. Arch. Suw., 54: 41-47. 1947. 10. PARK, W. D. Treatment and after treatment of strangulated hernia. M. Press, 2 I7: 89-c) I, I 947. I I. JONES, T. E. and KEHM, R. W. Obscure incarcerated or strangurated hernia as cause of intestina1 obstruction. Cleveland Ch. Quart., 13: 9-10, 194.6.

Hernia LV. B. Radical cure of femora1 hernia. I’r. Am. S. A., 24: 402, rgo6. JENS, J. StranguIated femora1 hernia-review of 100 cases. Lancel, r : 705-707, 1943. HARKINS, I-1. N. and SMENSAN, S. A. Cooper’s ligament herniotomy. S. Clin. Nortb America, 23: 1279-1297, 1943. MCVEY, C. B. InguinaI and femora1 herniopIasty: anatomic repair. Arch. Surg., 57: 524-530, 1948. RICE, C. 0. and STRICKLER, J. H. Repair of hernia with specia1 appIication of principIe evoIved by Bassini, McArthur and McVey. Surg., Gynec. Ed Obst., 86: 169-176, 1948. PATTERSON, F. M. S. Incarceration of Meckel’s diverticuIum in a femora1 hernia. North Carolina .M. J., 7: 59-60, 1946.

12. COLEY,

13. 14.

15. 16.

r7.

ACCORDING

to various statistical studies, from 3 to 20 per cent of women uncomphcated uterine retroversion are sterile. When endocervicitis, uterine tixation and adnexitis are aIso present, the incidence of steriIity increases greatIy and these require adequate surgery. Before resorting to therapy for steriIity due to uncompIicated retroversion, the surgeon shouId make sure oligospermia or azoospermia is not aIso present. If not some form of Iigamentopexy is justified and is folIowed by the desired pregnancy in about one-haIf of the cases; many, however, remain steriIe after surgery, probabIy because other factors are aIso present even though unrecognized. Surgery is rareIy successfu1 in patients with advanced peIvic disease such as tuba1 pathoIogy. (Richard A. Leonardo, M.D.) with

American

Journal

of Surgery