Femoral hernia pathophysiology
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: M. Khurram Afzal, MD [2]
Overview
A femoral hernia is the protrusion of the hernia sac through the femoral ring into the femoral canal. The anatomy of the femoral canal is such that the neck is made up of rigid structures that predispose the herniated bowel to strangulation and/or incarceration. The hernia sac contains small bowel which can predispose to intestinal obstruction. Some connective tissue diseases predispose the patient to developing femoral hernia. Malignancy is very rarely associated with femoral hernias, thus, histopathological analysis is done routinely following a repair but shows incarcerated bowel on most occasions.
Pathophysiology
Anatomy
 Source: Henry Vandyke Carter via Wikimedia Commons[1] |
- Pelvicrural interval, an opening from the abdomen to the thigh, is divided into two spaces:[2]
- Lacuna musculosa (lateral space), as the name suggests the iliopsoas muscles pass through this space.
- Lacuna vasculosa (medial space), as the name suggests, is the passage for the femoral vessels.
- In the pelvis, along the anterior surface of the iliopsoas muscles run the external iliac vessels.[3]
- The external iliac vessels pass between the iliopubic tract and Cooper's ligament, and then under the inguinal ligament to become the femoral vessels.[3]
- As the external iliac vessels pass along the lacuna vasculosa, they are covered by the transversalis fascia forming the femoral sheath.[3]
- The femoral sheath extends 4cm caudally to become the adventitia of the femoral vessels.[3]
- The femoral sheath has a medial compartment that is known as the femoral canal.[3]
- The femoral canal is less than 2 cm in diameter and it contains lymphatics and glands.[3]
- The true opening of the femoral canal is a musculoaponeurotic ring that consists of:[4]
- The medial boundary of the femoral ring is made up of the lateral edge of the transversus abdominis muscle aponeurosis insertion with the transversalis fascia onto the pubis.[4]
- The true inner ring of the femoral canal is bounded by:[5]
- The iliopubic tract anteriorly and medially
- The Cooper's ligament posteriorly
- The distal orifice (neck of the femoral canal) has a rigid boundary which is usually less than 1 cm in diameter and is surrounded by:[6][7]
- The lacunar ligament medially
- The inguinal ligament anteriorly
- Fascia of the pectineal muscle posteriorly
- The rigidity of the structures forming the boundary of the neck of femoral canal results in femoral hernias' strangulation.
Pathogenesis
- A femoral hernia is the protrusion of the peritoneal sac through the femoral ring in to the femoral canal, posterior and inferior to the inguinal ligament, and it is medial to the femoral vessels.[8]
- The hernia sac may contain preperitoneal fat, omentum or small bowel.[8]
- Femoral hernias typically have a narrow neck, which predisposes them to incarceration and the need for emergent surgery.[8]
- De Garengeot hernia is a type of femoral hernia that contains the appendix.[9]
- Littre hernia is an uncommon type of femoral hernia that contains a Meckel's diverticulum.[9]
Genetics
- First degree relatives of patients with inguinal hernia are more susceptible to developing femoral hernia.[10][11]
Associated Conditions
- Ehlers-Danlos syndrome[10][12][13]
- Appendicitis[9][14][15][16]
- Meckel's diverticulum[17][9][18]
- Intestinal obstruction[18]
- Intestinal volvulus[18]
- Intussusception[18]
Gross Pathology
Microscopic Pathology
- It is recommended that femoral hernia specimens should be submitted for microscopic histopathological analysis, though it is very rare to find a malignant lesion in a femoral hernia sac.[19]
References
- ↑ "upload.wikimedia.org".
- ↑ Panton JA (1923). "Factors bearing upon the Etiology of Femoral Hernia". J. Anat. 57 (Pt 2): 106–46. PMC 1262989. PMID 17103962.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Lichtenstein, Irving (1986). Hernia repair without disability : a surgical atlas illustrating the anatomy, technique, and physiologic rationale of the "one day" hernia and introducing new concepts : tension-free herniorrhapies. St. Louis: Ishiyaku EuroAmerica. ISBN 0912791306.
- ↑ 4.0 4.1 McVay CB (1974). "The anatomic basis for inguinal and femoral hernioplasty". Surg Gynecol Obstet. 139 (6): 931–45. PMID 4278445.
- ↑ MCVAY CB (1965). "INGUINAL AND FEMORAL HERNIOPLASTY". Surgery. 57: 615–25. PMID 14275790.
- ↑ Lytle WJ (1974). "The inguinal and lacunar ligaments". J. Anat. 118 (Pt 2): 241–51. PMC 1231505. PMID 4280996.
- ↑ Papanikitas J, Sutcliffe RP, Rohatgi A, Atkinson S (2008). "Bilateral retrovascular femoral hernia". Ann R Coll Surg Engl. 90 (5): 423–4. doi:10.1308/003588408X301235. PMC 2645754. PMID 18634743.
- ↑ 8.0 8.1 8.2 Doherty, Gerard (2010). Current diagnosis & treatment : surgery. New York: Lange Medical Books/McGraw-Hill. ISBN 978-0071635158.
- ↑ 9.0 9.1 9.2 9.3 Phillips AW, Aspinall SR (2012). "Appendicitis and Meckel's diverticulum in a femoral hernia: simultaneous De Garengeot and Littre's hernia". Hernia. 16 (6): 727–9. doi:10.1007/s10029-011-0812-2. PMID 21442431.
- ↑ 10.0 10.1 Liem MS, van der Graaf Y, Beemer FA, van Vroonhoven TJ (1997). "Increased risk for inguinal hernia in patients with Ehlers-Danlos syndrome". Surgery. 122 (1): 114–5. PMID 9225924.
- ↑ Jorgenson E, Makki N, Shen L, Chen DC, Tian C, Eckalbar WL, Hinds D, Ahituv N, Avins A (2015). "A genome-wide association study identifies four novel susceptibility loci underlying inguinal hernia". Nat Commun. 6: 10130. doi:10.1038/ncomms10130. PMC 4703831. PMID 26686553.
- ↑ Harrison B, Sanniec K, Janis JE (2016). "Collagenopathies-Implications for Abdominal Wall Reconstruction: A Systematic Review". Plast Reconstr Surg Glob Open. 4 (10): e1036. doi:10.1097/GOX.0000000000001036. PMC 5096520. PMID 27826465.
- ↑ Lei W, Huang J, Luoshang C (2012). "New minimally invasive technique for repairing femoral hernias: 3-D patch device through a femoris approach". Can J Surg. 55 (3): 177–80. doi:10.1503/cjs.030710. PMC 3364305. PMID 22630060.
- ↑ Kalles V, Mekras A, Mekras D, Papapanagiotou I, Al-Harethee W, Sotiropoulos G, Liakou P, Kastania A, Piperos T, Mariolis-Sapsakos T (2013). "De Garengeot's hernia: a comprehensive review". Hernia. 17 (2): 177–82. doi:10.1007/s10029-012-0993-3. PMID 22983696.
- ↑ Snoekx R, Geyskens P (2014). "De Garengeot's hernia: acute appendicitis in a femoral hernia. Case report and literature overview". Acta Chir. Belg. 114 (2): 149–51. PMID 25073217.
- ↑ Sinraj AP, Anekal N, Rathnakar SK (2016). "De Garengeot's Hernia - A Diagnostic and Therapeutic Challenge". J Clin Diagn Res. 10 (11): PD19–PD20. doi:10.7860/JCDR/2016/21522.8871. PMC 5198391. PMID 28050438.
- ↑ Zacharakis E, Papadopoulos V, Athanasiou T, Ziprin P, Zacharakis E (2008). "An unusual presentation of Meckel diverticulum as strangulated femoral hernia". South. Med. J. 101 (1): 96–8. doi:10.1097/SMJ.0b013e31815d3c83. PMID 18176301.
- ↑ 18.0 18.1 18.2 18.3 Wu SY, Ho MH, Hsu SD (2014). "Meckel's diverticulum incarcerated in a transmesocolic internal hernia". World J. Gastroenterol. 20 (37): 13615–9. doi:10.3748/wjg.v20.i37.13615. PMC 4188914. PMID 25309093.
- ↑ 19.0 19.1 Wang T, Vajpeyi R (2013). "Hernia sacs: is histological examination necessary?". J. Clin. Pathol. 66 (12): 1084–6. doi:10.1136/jclinpath-2013-201734. PMID 23794497.
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