Femoral hernia repair can be a challenging process, especially when dealing with elderly patients who often present with multiple health issues. Traditional techniques, though effective, may involve cumbersome procedures, general anesthesia, and potential complications. In this blog, we'll explore a simplified and less invasive method – a single-skin incision technique performed under local anesthesia. This approach, developed after years of successful implementation, offers a more straightforward solution to femoral hernia repair.

Understanding the Challenge
Femoral hernias are particularly prone to complications such as bowel strangulation, necessitating access to the abdominal cavity. Conventional methods, while effective, often require laparoscopy, a higher skill set, and general anesthesia – factors that can be challenging for elderly patients with various health conditions.

Exploring Traditional Techniques
Various traditional techniques for femoral hernia repair have been described in medical literature, each with its pros and cons. The low approach of Lockwood, Lotheissen's high approach, and McEvedy's balanced approach provide good access but may involve laparotomy or leave less-than-ideal cosmetic results. Other published single-incision techniques, such as Thomas's and Sorelli’s et al, attempt to address the issue but may still pose challenges and potential complications.

Introducing the Single Skin Incision Technique
Our proposed technique is a straightforward groin crease incision, similar to the standard open inguinal hernia procedure. This approach, performed under local anesthesia, simplifies the process for general surgeons. The lower skin flap is dissected to expose the inguinal ligament, allowing easy dissection of the hernia sac. By opening the sac and draining toxic fluids, the condition of the bowel or omentum can be visualized.

Adapting to Individual Cases
If the bowel or omentum is viable, it can be reduced, and the femoral canal can be sutured with ease after a thorough saline washout. In cases where the bowel is gangrenous, we adopt a technique similar to inguinal hernia repair, involving a horizontal muscle split technique. The peritoneum is accessed carefully, and small bowel resection anastomosis can be performed if necessary.

Ensuring Minimal Complications
Our approach minimizes the risk of complications. The peritoneum is closed with absorbable sutures after lavage, and the muscle layers are approximated with interrupted absorbable sutures. The inguinal canal is closed without the need for reinforcement, reducing the risk of future hernias. Our extensive experience with this technique, involving 165 cases, has shown zero surgical site infections, a 5% incidence of postoperative seroma, and no long-term recurrences for up to two years.

Comparing Approaches
In contrast to historically taught approaches like Lockwood, Lotheissen, and McEvedy's, our technique offers a more tailored solution for cases involving strangulated bowel. The single-incision techniques by Thomas and Sorelli P G, while satisfactory, share similarities with McEvedy's vertical incision, potentially posing risks to the abdominal wall.

Our single skin incision technique for femoral hernia repair provides a simplified, effective, and less invasive alternative, especially for elderly patients with multiple health concerns. With a proven track record of success and minimal complications, this approach offers a promising solution in the realm of hernia repair. As medical practices evolve, embracing techniques that prioritize patient comfort and recovery becomes paramount, and our method strives to achieve just that. 

Source: Femoral Hernia—A New Surgical Technique for Open Repair/Published in the Indian Journal of Surgery/November 2023 (https://doi.org/10.1007/s12262-023-03988-6)

Authors: 
Dr Debkumar Ray, HOD, Dept of GI & Minimal Access Surgery, AMRI Hospital, Salt Lake, Kolkata
Dr Kaushik Bhattacharya, Dept of Surgery, MGM Medical College and LSK Hospital, Kishanganj, Siliguri