1346 Glassow: Canad. Med. Ass. J. Dec. 25, 1965, vol. 93 Femoral Hernia in the Female FRANK GLASSOW, M.A., M.B., B.Chir.(Cantab.), F.R.C.S.(Eng.), F.R.C.S.[C],* Toronto

ABSTRACT SOMMAIRE A study of 384 consecutive femoral hernior- On a passe en revue 384 herniorraphies rhaphies performed upon female patients crurales, effectuees consecutivement sur des admitted to Shouldice Hospital, Toronto, femmes admises a THopital Shouldice de during a 19-year period was carried out. Toronto, pendant une periode de 19 ans. Its main purpose was to describe the tech¬ Le but principal de ce travail etait de niques used and to evaluate the results decrire les techniques employees et d'eva- obtained. A careful 10-year follow-up plan luer les resultats obtenus. Une periode de for all cases existed. post-observation de 10 annees existait pour Two hundred and ninety-three operations tous les cas. were performed for the repair of simple Du nombre d'operations, 293 ont et£ femoral hernia; 91 were performed for the effectuees pour reparer une hernie crurale repair of femoral hernia which had devel¬ simple; 91 furent effectuees pour reparer oped following an initial ipsilateral inguinal une hernie crurale qui etait apparue apres or femoral repair performed previously, une premiere herniorraphie pour hernie either in this hospital or elsewhere. inguinale homolaterale ou une hernie crurale The basic repair was subinguinal. Four anterieure, soit dans cet hdpital, soit ailleurs. modifications are described, one entirely La technique principale etait subingui- subinguinal and three combined with ex- nale. L'article en d^crit quatre modifica¬ ploration of the . tions, une completement subinguinale et The recurrence rate for simple femoral trois comportant une exploration de canal hernia in the female was 1.3% and for inguinal. "recurrent,, femoral hernia in the female, La proportion de recidives pour la hernie 5.5%. crurale simple chez la femme a ete de 1.3% et pour la hernie femorale "r^cidivante" chez la femme de 5.5%. hernia in the female is un- "I^EMORAL¦*¦ relatively common. In a 21-year period at the Johns Hopkins Hospital from 1925 to 1946 a total of 93 cisional, 284 umbilical, 45 epigastric and 16 miscel¬ females underwent operation for repair of femoral laneous (Table I). Thus in this series inguinal hernia out of a total of 316,525 patients admitted, hernias were three times as common as femoral representing a ratio of one in 3400 hospital admis¬ hernias in the female. During the same period sions.1 In a 20-year period at the Henry Ford Hos¬ inguinal hernias were 50 times as common as fe¬ pital from 1916 to 1936 a total of 36 females un¬ moral hernias in the male. derwent operation for repair of femoral hernia Of these 384 femoral repairs, 293 were per¬ out of a total of 241,037 admissions, a ratio of one formed for simple femoral hernia, 84 for femoral in 6700 admissions.2 Because of this relative rarity hernia which had after an on and because it seemed appeared operation likely therefore that few the same side performed previously in some other had an extensive surgeons personal experience hospital for repair of inguinal or femoral hernia, with the condition, I decided to review and report and seven were for femoral hernia which had our with at experience it the Shouldice Hospital, occurred after an operation on the same side per¬ Toronto, where a large number of hernia repairs formed previously in this hospital for repair of in both sexes have been performed. inguinal or femoral hernia (Table II). Thirty-one In the 19-year period between January 1, 1945 were for obstructed or and 373 repairs performed strangu- January 1, 1964, female patients under¬ lated hernia. This paper deals largely with the un- went 384 femoral hernia repairs at 384 operative obstructed case in which was elective. sessions. During this period 2325 abdominal her- surgery niorrhaphies were performed upon 1912 female TABLE I..Incidence of Abdominal Hernias in Females at 2127 sessions and about patients operative 40,000 Percentage inguinal hernia repairs were performed on males. Type Number of total Inguinal. 1243 53 Incidence Femoral. 384 17 Of the 2325 Incisional. 353 15 abdominal hernias repaired in fe¬ Umbilical. 284 12 males 1243 were inguinal,3 384 femoral, 353 in- Epigastric. 45 2 Miscellaneous. 16 1 *From the Department of Surgery, Shouldice Hospital, Toron¬ to. Total. 2325 100 Canad. Med. Ass. J. Dec. 25, 1965, vol. 93 Glassow: Femoral Hernia 1347

TABLE II..Type of Femoral Hernia Encountered in was examined even Female Patients guinal region always clinically in the presence of an obvious femoral hernia. The Number of type of surgical procedure used was Type offemoral hernia cases Percentage subsequently variable and occasionally depended upon this clin¬ Simple. 76293 ical observation. Following initial repair elsewhere. 84 22 Following initial repair in this hospital 2 7 Total. 384 100 Anesthesia and Follow-up Data These have been described elsewhere.3 In adults infiltration anesthesia ade¬ The youngest female patient was 13 years, al¬ regional preceded by the hernia had been since quate preoperative sedation was used. Children though present infancy. had anesthesia. In adults bilateral The incidence of femoral to inguinal hernia in chil¬ general opera¬ dren is but is of the order of tions were staged two days apart. A comprehensive variously reported a minimum of 10 for each one to four per 1000 in most large series. There is follow-up lasting years patient was in and was considered of much difference of opinion regarding the sex inci¬ operation dence of femoral hernias in children. In 760 her- great importance. It enabled the great majority of to be examined or contacted in this on children patients annually niorrhaphies performed hospital this it was below the of 10 the re¬ during postoperative period. Moreover, age years during period that the undocumented viewed, one case of femoral hernia, in a thought probable remaining only boy cases successful rather than of 5 years, was encountered. Of the three represented repairs teenage unsuccessful ones in view of the care taken with one a of hernia girls operated upon gave history the system. A accurate statis¬ since infancy and in one the hernia had been pres¬ follow-up relatively tical analysis of the long-term results obtained was ent since early childhood. In Lloyd's5 series of 715 therefore cases of both sexes from Great Ormond St., London, possible. Seven different the same one femoral hernia was encountered. However, in surgeons using general series there were female children techniques performed the great majority of these Fergusson's0 eight on females with below the of 10 out of a total of 347 females operations femoral hernia. Eighty- age five were and five male children below the age of 10 out of performed personally. a total of 153 males with femoral hernias. Neverthe¬ less, because of its rarity, no surgeon has much ex¬ Technique perience with this condition in childhood and most An oblique inguinal incision was used. The femoral have not seen a case.7 The oldest patient in this region was entered immediately below the inguinal series was 89. ligament by incising the deep of the about 1 cm. below and parallel with the medial part of the Definition ligament. At this level the falciform edge of the sa¬ phenous opening and the saphenous vein lying distally In this series a femoral hernia was defined as a were rarely seen. The hernia was usually obvious as a hernia seen at operation to be protruding through diffuse vague swelling beneath the fascia even before an orifice of exit in the .8 It was this had been incised. Sometimes, however, it was but not It difficult to find and careful search was always made. usually always diagnosed clinically. It was covered a of consisted of a sac which typically by layer extraperitoneal nearly always peritoneal fat which was excised. the hernia was covered with fat. Much separately Freeing usually extraperitoneal usually demonstrated a relatively narrow neck. Accurate less often it was small entirely fatty. Very fatty freeing around the neck was considered important. In femoral protrusions or fat tabs are commonly en¬ most cases this revealed the orifice of exit as a small countered in the male but they are much less com¬ oblique opening on the medial wall of the femoral mon in the female and are not included within the sheath measuring 0.5 to 1.0 cm. in its long axis. This definition given. In three cases a different prob¬ opening had a firm edge and was sometimes almost lem in definition occurred. In each the femoral under the overlying . Occasionally it region was intact when examined from below the was much larger, destroying most or all of the medial inguinal ligament. Examination from above, how¬ wall of the . In a few cases it came the anterior of the sheath as a rare ever, from within the femoral canal after the in¬ through part pre- vascular femoral hernia. Its medial was canal had been revealed a true upper margin guinal opened, usually closely related to the free edge of the under- sac within the femoral peritoneal lying completely surface of Gimbernat's ligament.8 Omentum was the canal. sacs were with These dealt routinely but, structure most commonly found within the sac, being in accordance with the definition above, were not present in 25$ of cases, and frequently adherent to the classified as femoral hernias. sac. These adhesions were freed and the sac was ex¬ cised from below in the great majority of cases. The Diagnosis ligated stump retracted out of sight into the inguinal region or was usually easily reduced gentle The clinical characteristics of a femoral hernia upwards by pressure or further freeing. are well known and is the diagnosis usually easy. At this stage of the operation a decision to open the Nevertheless, it was misdiagnosed as an inguinal inguinal region or to leave it intact had to be made. hernia in 8% of the cases in this series. The in¬ Several advantages resulted from opening it. An in- Canad. Med. Ass. J. 1348 Glassow: Femoral Hernia Dec. 25, 1965, vol. 93 guinal hernia found clinically or suspected at operation the femoral ring from above as well as the routine could be dealt with. An obstructed or strangulated closing from below. In a few cases these two separate hernia was sometimes better treated from above. Mo¬ closures were combined into a simultaneous synchron- bilization of an adherent femoral stump was sometimes ous above-and-below technique. The femoral ring was only possible after opening the inguinal region. A closed or narrowed by attaching Cooper's ligament to closure of the femoral ring could be carried out under the transversalis fascia or to the back of Poupart's direct vision. The disadvantages were that quite often, ligament where the transversalis passed downwards in retrospect, it was unnecessary. The posterior wall behind it, using a continuous No. 34 stainless steel of the inguinal canal in the female is typically a strong suture line. In Types 3 and 4 a routine inguinal repair structure3 and the incidence of direct inguinal hernia was then performed. in females is low. Hence an accurate clinical assess¬ ment of the inguinal region should always be made Simple Femoral Repairs.293 Cases even when an obvious femoral hernia is In present. Two hundred and femoral a poor-risk patient the shorter time needed to perform ninety-three repairs the easier subinguinal repair could be a deciding were performed upon 288 female patients, since in factor. There is also the added risk of inguinal recur¬ 10 (3%) the hernia was bilateral. Bilateral femoral rence if the inguinal region is opened. hernia is uncommon in both sexes. Two hundred The basic repair used in this hospital was a closure and nine cases were on the right side and 84 on of the orifice of exit performed from below the in¬ the left. guinal ligament. Each repair, however, fell into one of four modifications of this basic These four sub- repair. TABLE III..Simple Femoral Repairs in Female Patients types (Types 1-4) are classified as follows: Number Percentage Number of operations % of Total. 293 100 total Right side. 72 209 performed Left side. 29 84 (a) External oblique not opened. Type 1 151 39 Bilateral. 103 (b> External oblique opened. 233 61 Peritoneal sac present. 95 275 (a) posterior wall of inguinal Entirely fat. 185 canal examined but not Recurred later as femoral. 1.3 4 opened, repair below only; Type 2 24 6 (/3) posterior wall of inguinal canal opened. 209 55 In 18 of these cases the hernia was entirely (i) repair performed from In 15 of the 18 there was also below only. Type 3 162 43 fatty (Table III). (ii) repair performed from an associated inguinal hernia, which was the only above and below in¬ hernia Therefore a fe¬ Type 4 47 12 diagnosed clinically. fatty guinal ligament. moral hernia was clinically diagnosed on only three occasions, in each of which it was unaccompanied In 39% of cases (Type 1) the orifice was closed an hernia, and was never 34 stainless by inguinal clinically entirely from below using two lines of No. diagnosed on the 15 occasions on which it was. steel wire sutures. The first line carried the lower edge If a femoral hernia in a female is to the to fasten it on the clinically diag¬ upwards deep upper high nosed, it is almost certain to contain a true sac. or on the or to pectineus, pectineal line, directly In the 275 cases the femoral Cooper's ligament if that structure could be reached. remaining hernia The medial part of this continuous suture line picked consisted of a peritoneal sac. In 33 of these there up Gimbernat's ligament. It was usually impossible was an associated ipsilateral inguinal hernia. These technically to avoid including the undersurface of 33 cases form a complicated group. In eight of Poupart,s ligament with the medial part of this suture the cases a clinical diagnosis of inguinal hernia line. The second line of continuous sutures brought was made, and in five a clinical diagnosis of both the upper free edge of the orifice downwards and inguinal and femoral hernia was made, i.e. in 13 of medially over the first. This repair strengthened the the 33 cases an hernia was cli¬ and dimin¬ inguinal diagnosed whole medial aspect of the femoral canal and in the 20 it was discovered at its size. Sometimes the dead nically remaining ished remaining space At the hernia was between the medial of the femoral sheath and operation. operation inguinal aspect found to consist of a true sac in 14 cases and was the pectineus was separately closed. in 19 In it was In 61% of cases the inguinal canal was opened for the entirely fatty (Table IV). five de¬ reasons indicated. In 6% (Type 2) the external oblique scribed as very small. In only two cases was a direct was closed without opening the posterior wall of the inguinal hernia encountered, each described inguinal canal because it was strong and because no as a tiny fatty hernia. Direct inguinal indications for its division were present. In 43% (Type hernia in the female is rare and the asso¬ 3) the posterior wall was opened and a femoral repair ciation of femoral hernia with direct inguinal her¬ then performed entirely from below the inguinal liga¬ nia rare. Of the 14 cases ment. This method allowed the orifice of exit to be particularly consisting of a true indirect sac and associated with a fe¬ demonstrated by a finger inserted from above the in¬ through the femoral ring into the moral hernia the clinical diagnosis of inguinal guinal ligament hernia was made in in of femoral canal, as well as affording protection to the correctly nine, five which femoral vessels during the repair. In 12% (Type 4) the femoral hernia was also diagnosed and in four the femoral ring was judged large and the femoral of which the femoral hernia was itself only discov¬ canal wide enough to justify an additional closure of ered at operation. In only five cases therefore was Canad. Med. Ass. J. Dec. 25, 1965. vol. 93 Glassow: Femoral Hernia 1349

TABLE IV..Female Patients with a Diagnosed Simple TABLE V..Age Incidence in Female Patients with Femoral and an Associated Ipsilateral Inguinal Hernia Simple Femoral Hernia Total. 33 Age Number Percentage Inguinal hernia diagnosed preoperatively. 13 Inguinal hernia undiagnosed preoperatively. 20 0- 10. Inguinal hernia indirect. 31 11 -20. Inguinal hernia direct. 2 21-30. Inguinal hernia containing peritoneal sac. 14 31 -40. Inguinal hernia fat. 19 41 -50. entirely 51 -60. 61-70. a true indirect inguinal sac not diagnosed clinical¬ 71 -80. ly, and in two of these it was described as small 81 -90. when discovered at operation. These figures sug¬ 293 100 gest that the risk involved in missing an inguinal hernia by not exploring the inguinal region in a years, 13 between 20 and 30 years, 57 between female patient who has a femoral hernia and in 30 and 40 years, 75 between 40 and 50 years, 46 whom no clinical evidence of an inguinal hernia between 50 and 60 years, 62 between 60 and 70 is present is of the order of 1 to 2%. This may be years (Table V), 28 between 70 and 80 years and important when a surgeon is considering whether nine were more than 80 years old, i.e. 82% were to perform a repair of a femoral hernia entirely aged between 30 and 70 years. In 117 (40%) the from below the inguinal ligament or not. hernia was partially or totally irreducible. Two- Of 1243 repairs performed in female patients thirds of the patients weighed less than 130 lb. with inguinal hernia, a femoral hernia with a peri¬ and one-quarter less than 115 lb. Antibiotics were toneal sac, undiagnosed clinically, was found in used in 15 cases (5% ). There were three cases of four instances, and in 15 an unsuspected fatty postoperative wound infection, a rate of 1%. femoral hernia was found. If the femoral region Four recurrences, a recurrence rate of 1.3%, are had not been these 19 cases routinely explored, known. These patients were aged 42, 62, 71 and might subsequently have represented a 1 to 2% 77 at the first One recurred within rate femoral years operation. "recurrence" of hernia following in¬ four because a second had been in female days component guinal herniorrhaphy patients. missed, one recurred in a month and the other two There were cases of three prevascular femoral within one In one the was hernia in which the hernia the year. original operation protruded through for a strangulation. Two have undergone a second femoral sheath anterior to the femoral vessels. in this for the of the fe¬ In two cases operation hospital repair other the hernia involved the antero- moral recurrence. medial of the sheath. part This recurrence rate for In in contradistinction to the femoral herniorrhaphy general, therefore, in females to re¬ male, in whom the association of hernia appears be lower than in most multiple corded series. In series it was on one side is common, the female Fergusson's6 10% types relatively recurrences in 347 female and in But- tends to have a hernia, either indirect in¬ (34 repairs) solitary ters'S) series it was 6% recurrences in 66 guinal or femoral in type. A direct hernia (four inguinal female Birt10 stated that the recurrence is uncommon and uncommon in asso¬ repairs). particularly rate for for femoral hernia varied from ciation with another hernia on the same side. operations 5 to in various series. The low re¬ This lends on the one hand to 10% reported justification surgical currence rate obtained in this series that treatment directed towards the cure of the suggests only the low or femoral of as indirect a type repair modified de¬ inguinal hernia, with less emphasis in scribed and female on the of the of carefully performed gives good results. repair posterior wall the and all the canal than in a and on the Butters,9 Lytle8 Wakeley11 preferred inguinal male; other, low i.e. closure of the orifice from below to the treatment of a femoral hernia in a female operation, patient from below the the ligament only, although their analyses consid¬ entirely inguinal ligament. ered males as well as females. It may be opportune to speculate at this point that the reason females femoral hernia develop Femoral Hernia Previous proportionately more than males is be¬ Following Ipsilateral frequently or Femoral cause in females the inguinal region is stronger. Inguinal Herniorrhaphy Performed Indirect inguinal hernia in the female is usually in Some Other Hospital.84 Cases small, and sliding inguinal hernia and direct in¬ These 84 cases presented with a femoral hernia guinal hernia are both rare. It is probable that the when first seen in this hospital. The initial repair femoral region is also stronger in the female and or repairs had been performed elsewhere for an that the small weak area in the medial wall of the inguinal or a femoral hernia. Since the operation femoral canal gives way reluctantly with a greater notes were not available, the type of the original risk of obstruction or strangulation because of the hernia was not known. If the time interval be¬ firm edges of the orifice of exit. tween the repair and the appearance of the fe¬ The average age at operation was 52 years. The moral hernia was very short, it seems likely that a youngest patient was 13 years old and the oldest femoral hernia may have been missed originally. 89 years. Three patients were between 10 and 20 A longer interval suggested either a new hernia or 1350 GLASSOW: FEMORAL HERNIA Canad.25,Med.1965,Ass.vol. J.93 a hernia developing as the result of a previous Of these 10 cases, seven have undergone a sec- inguinal or femoral repair. In 64 cases the hernia ond operation in this hospital for the repair of the had recurred after one operation previously on the "recurrent" femoral hernia. Four of the 10 cases affected side, in 15 after two operations, in four developed a femoral hernia following a simple after three operations and in one case after four femoral herniorrhaphy performed here, and two of previous repairs. No case of bilateral femoral "re- these have undergone a further repair. One devel- currence" was encountered in a female. oped a femoral hernia following a simple inguinal repair performed in this hospital and a further re- TABLE VI. FEMALE PATIENTS ADMITTED WITH FEMORAL pair has been performed. The remaining five de- HERNIA Fotiowixo REPAIR (INGUINAL OR FEMORAL) veloped a femoral hernia following a repair per- ELSEWHERE formed here for a femoral hernia which itself had Percentage developed following a simple inguinal or femoral Number of previous operations Number of total herniorrhaphy performed elsewhere. Four of these 1.64 76 five have undergone a second repair here. 2.15 18 3. 4 5 In all, therefore, 10 femoral hernias have devel- 4. 11 oped following 1620 repairs performed in this hos- Right side.62 74 Left side.22 26 pital upon female patients admitted with an ingui- Bilateral.0 0 nal (1243 cases) or a femoral (377 cases) hernia. Developed further femoral hernia after repair of femoral hernia here 5 6 SUMMARY In 62 cases the hernia was on the right side and A series of 384 consecutive femoral herniorrhaphies in 22 on the left (Table VI). The average age at in females performed in a 19-year period in one hos- years. pital is reviewed. operation when performed here was 51 Two hundred and ninety-three repairs were per- The youngest patient was 13 years old and the formed for simple femoral hernia. Eighty-four repairs oldest 81 years. In six cases a history of a wound were performed for femoral hernia which had followed infection was given following a previous repair one or more previous repairs on the same side for an but no case developed a postoperative wound in- inguinal or femoral hernia performed in some other fection following the repair performed here. Anti- hospital. Seven repairs were performed for femoral biotics were administered in 45% of cases (38 out hernia which had followe.d one or more previous re- of 84) but these drugs are prescribed less frequent- pairs on the same side for an inguinal or femoral re- ly now than a few years ago. pair performed in this hospital. A Type 1 repair was performed in 31 cases, The basic repair was performed below the inguinal Type 2 in 14, Type 3 in 26 and a Type 4 repair ligament. in 14 (see earlier description of types). Four different modifications of this basic repair are described. In Type 1, 151 (39%) of the operations were In this group of cases some very difficult re- performed without opening the external oblique. In pairs were encountered. Considerable experience Types 2, 3 and 4, the external oblique, was opened. and familiarity with the area was necessary for a There were 24 (6%) of Type 2 cases in which the good repair to be accomplished when the hernia inguinal canal was not opened further, 162 (43%) of was large. In such cases the orifice of exit and the Type 3 cases in which the posterior wall of the in- femoral ring had become coincidental and in some guinal canal was divided and the low repair controlled of these it was possible to effect a very satisfactory from above and 47 (12%) of Type 4 cases in which closure entirely from below the inguinal ligament. the fernoral ring was closed from above in addition to Five, i.e. 6¼, of these patients are known to the low repair. have developed a further recurrence. This figure The technique in each of the four types is described represents our own recurrence rate of "recurrent" fe- and the indications are given. The results are discussed and analyzed. The recurrence rate for simple femoral moral hernia in females. All occurred following a herniorrhaphy in the female was 1.3%. single operation elsewhere and then a femoral re- The results obtained in this series of 384 consecutive pair here. The only accurate report of the recurrence femoral repairs in female patients suggest that the low rate of true recurrent femoral hernia discovered in operation modified in the majority of cases by open- the literature was in Wakeley's series.'1 He gave ing the inguinal canal gives good results associated an operative recurrence rate of less than 2¼ for with a low recurrence rate. the low operation for the repair of simple femoral hernia in males and a recurrence rate of more than R.'FEP'.NCES 60 % for the repair of recurrent femoral hernia. 1. KOONTZ, A. R: A.M.A. Arch. Sury., 64: 298, 1952. 2. McCLURE, R. D. AND FALLLS, L. S.: Ann. Sing., 109: 987, 1939. 3. (Th..ssow, F. Surg. Gynec. Obstet., 116: 701, 1963. Femoral Hernia, Following Previous ipsilateral 4. Idern Canad. J. Sury., 7: 284, 1964. Inguinal or Fen.oral I-Ierniorrh aph y Performed 5. LI.oxi, K I. Brit. J. Sury., 18: 657, 1930. 6. FERGUSSON, J. D.: St. Thorn. Hosp. Rep., 2: 209, 1937. in this Hospital-JO Cases4 7. FOSBURO, R. (1. AND MAHIN, M. P.: Amer. J. Sing., 109: 470, 1965. Some of these cases have already been discussed 8. LYTLE, W. J. Ann. Roy. Coil. Sing. Eng., 21: 244, 1957. 9. BUTTERS, A. (V Brit. Med. J., 2: 743, 1948. but it was thought best to consolidate the group 10. BIRT, A. B. Practitioner, 159: 362, 1947. in a single section. 11. WAKELEY, C. P. (1.: Lancet, 1: 822, 1940.