53 year old female patient presented for severe abdominal pain, associated with nausea and vomiting diagnosed to have bowel obstruction due to incarcerated inguinal femoral hernia

1. Case presentation
Georges Khalifeh
PGY IV
General Surgery
AL ZAHRAA UNIVERSITY HOSPITAL

2. Case presentation
• 53 y o female patient presented for severe abdominal pain ,associated with
nausea and vomiting
• Pain started 2 days ptp
• Psh : c section (20 y ago )
• Pmh: hypertension

3. Physical exam
• Distended abdomen
• Diffuse tenderness
• Left inguinal bulging mass

5. • Wbc 11200
• Crp 18.38
• Lactate 1.19
• Ldh 223

6. • Ct scan abdo-pelv+ IV contrast

8. Trans inguinal approach
In our case we used a trans inguinal approach for femoral canal
• Dissection of sac
• Reduction/inspection of contents
• Ischemic omentum identified
• bowel not found
• ligation of sac and approximation of inguinal and pectineal ligaments.

10. Midline incision
• Exploration of peritoneal cavity
• Running of bowel
• Identification of constricting ring, anti-mesenteric border
• No sign of ischemia
• No need for resection

11. Richter’s hernia
• A.G. Richter described in 1777 a hernia in which the anti-mesenteric part of
the small intestine was incarcerated

13. Inguinal hernia special types

14. Richter’s femoral hernia
• This type of hernia accounts for 10% of all strangulated hernias.
• The most common :
femoral ring (36–88%)
inguinal ring (12–36%)
abdominal wall (4–25%).

15. Richter’s femoral hernia
• The incidence of Richter's hernia has recently increased because of the
widespread use of laparoscopic techniques.
• The growing popularity of laparoscopic surgery has resulted in Richter's
hernias developing at the trocar site.
• Trocar site herniation following a laparoscopic procedure has been reported
to occur at a rate of 0.2–3%; however, the actual incidence may be higher

16. Decision-making and management strategies
Many times, the strangulated hernia is wrongly diagnosed pre-op
The correct diagnosis often made only at the time of operation
The decision as to which approach is to be adopted depends upon the viability
of the bowel.

17. Management strategies
• Permits resection and anastomosis of bowel
• Allows repair (+/- MESH)without increased risk of infection leading to
decreasing recurrence.
• Avoids unnecessary laparotomy to inspect a loop of bowel slipped into the
abdomen.

18. Goals of emergent repair of a strangulated
hernia
• Unlike elective repair of a reducible hernia where in the primary goal is long-
lasting closure and prevention of hernia recurrence
• The goals of emergent repair of a strangulated hernia may be to alleviate
bowel obstruction, debride devitalized tissue, and/or mitigate the risk of
abdominal catastrophe.
• Repair must often be accompanied by examination of, and sometimes
resection of, bowel or omentum.

19. Surgical incision
• The type of surgical incision varies according to the location of Richter's
hernia.
• This approach affords the surgeon excellent access to repair the hernia defect
and to inspect the bowel through one incision.

20. Classical approaches
Strangulated inguinal hernia can be managed in a routine fashion.
Three Classical approaches are described for an open repair of femoral hernia
Low (Lockwood’s)
inguinal (Lotheissen’s) (1878)
high (Mc Evedy’s) (1950)

22. Disadvantage of inguinal approach
• This approach offers little scope for resection and anastomosis of
gangrenous bowel
• Posterior wall of the inguinal canal is disrupted, which has to be repaired.
• In view of the contamination with the gangrenous bowel, a mesh repair is
not possible.
• Recurrence rate is high (weakens the abdominal musculature)
• False recurrence in the form of a direct hernia

25. If the bowel was found to be gangrenous and
requires resection and anastomosis

26. If the bowel was found to be gangrenous and
requires resection and anastomosis
• inguinal incision can be extended
laterally little beyond the Mc Burney’s
point.
• The extension of incision was done by
dividing only skin and external oblique.
• The internal oblique and transversus
abdominis are split open as that of
gridiron incison (Second Window)

28. The Thomas Repair of the strangulated
femoral hernia -one skin incision for all

29. INCISION IN RECTUS SHEATH

30. EXTENSION FOR LAPROTOMY

31. SURGICAL APPROACHES—
LAPAROSCOPY

34. SURGICAL APPROACHES—
LAPAROSCOPY
• One systematic review including 7 articles published between 1996 and 2007
reported on the use of laparoscopy for the management of incarcerated and
strangulated inguinal hernia.
• Most incarcerated and strangulated hernias were reduced using a
combination of manual and laparoscopic manipulation under general
anesthesia

35. 328 patients
6 conversions to an open procedure
34 complications (mostly minor)
17 bowel resections

36. Conversion to open
The reasons for conversion
iatrogenic bowel injury
need for omentectomy
bowel distention making visualization difficult
dense intraperitoneal adhesions

37. Complications
Complications related to a laparoscopic approach :
 left colon injury during Veress needle insufflation
3 intraperitoneal mesh infections(2 of which required reoperation)

38. Mesh infection
• A recent study of patients undergoing laparoscopic bowel resection and
concomitant repair of acutely incarcerated inguinal hernia showed a low rate
of mesh infection when the mesh was placed in the preperitoneal space.

39. Benefits of laparoscopy
• Ability to detect and simultaneously repair a contralateral patent processus
vaginalis or hernia.
• In addition, the ability to identify and manage intra-peritoneal contents
reduced from the hernia sac may be improved with laparoscopy.

40. Recommendation
• laparoscopic approach to incarcerated and strangulated inguinal hernia is
feasible, facilitates bowel resection as needed, and exhibits an overall
morbidity similar to an open approach
• Deeba S, Purkayastha S, Paraskevas P, et al. Laparoscopic approach to incarcerated and strangulated inguinal hernia. JSLS 2009;13:327–31
• Poelman MM, van den Heuvel B, Deelder JD, et al. EAES Consensus Development Conference on endoscopic repair of groin hernias. Surg Endosc
2013;27:3505–19

41. Recommendation
• In the case of strangulated inguinal hernia, diagnostic laparoscopy is
preferred to open exploration
spontaneously reduced inguinal hernia via hernia sac laparoscopy: preliminary results of Sgourakis G, Radtke A, Sotiropoulos G, et al. Assessment
of strangulated content of the a prospective randomized study. Surg Laparosc Endosc Percutan Tech 2009;19:133–7.
Poelman MM, van den Heuvel B, Deelder JD, et al. EAES Consensus Development Conference on endoscopic repair of groin hernias. Surg Endosc
2013;27:3505–19

42. Recommendation
• The use of synthetic mesh in the pre-peritoneal space is possible with a
relatively low risk of morbidity in clean contaminated situations such as
bowel resection
• Atila K, Guler S, Inal A, et al. Prosthetic repair of acutely incarcerated groin hernias: a prospective clinical observational cohort study. Langenbecks Arch
Surg 2010;395:563–8.

43. Take home message
• Do not give muscle relaxant during induction

44. Take home message
• Manual reduction attempts should be avoided prior to directly inspecting and
evaluating the viability of the intestine.
• Early operative intervention is central to the successful management of
Richter's hernia.

45. What if ,we combined 2 types of surgery
laparoscopic + open
• Laparoscopic approach for exploration ,resection of bowel if needed
(preserving peritoneum intact )+ open inguinal repair +/- Mesh

47. What if ,we combined 2 types of surgery
USING SAME INSICION
• Open inguinal repair
• Same strategy
• Sac identified, strangulated omentum,
• Bowel not found
• LAPAROSCOPIC TRANSINGUINAL TRANSABDOMINAL
RETRIAVIAL OF AFFECTED BOWEL
• Trocar inserted into hernia sac ,insuflation of abdomen

48. Thank you