Classification of surgical approaches
The choice of surgical approach determines the course of the entire procedure. Two main approaches are distinguished for femoral hernias:
- Femoral approach. The incision is made directly over the hernia protrusion on the thigh. The surgeon works with the femoral ring (anulus femoralis) from below, via the thigh.
- Inguinal approach. The operation begins by opening the inguinal canal, as in the treatment of inguinal hernias. This allows approaching the defect from above, via the preperitoneal space.
Femoral approach: Bassini repair
A classic operation aimed at closing the hernia ring from the thigh.
- Approach and isolation. A vertical incision of the skin and subcutaneous tissue (10–12 cm) is made just above the inguinal ligament. The surgeon retracts the lymph nodes and the great saphenous vein. The sac is isolated down to the neck. It is critically important to protect the femoral vessels (especially the vein) located lateral to the hernia ring.
- Management of the hernia. Opening the sac, reducing the contents into the abdomen, ligation, and transection of the neck.
- Ring repair. The main goal is to eliminate the defect. To achieve this, the inguinal ligament (lig. inguinale) is sutured to the pectineal ligament (lig. pectineale / Cooper's ligament) with 2–3 stitches using a strongly curved needle. In doing so, the inguinal ligament is pulled upward, and the femoral vein is retracted laterally.
- Closure of the subcutaneous hiatus. At the end of the operation, the outer falciform margin (margo falciformis) is sutured to the fascia of the pectineus muscle, closing the hiatus saphenus.
Inguinal approach: Ruggi and Parlavecchio
This method requires an incision of the skin and the aponeurosis of the external oblique abdominal muscle, opening of the inguinal canal, and retraction of the spermatic cord upward. Then the surgeon incises the posterior wall of the canal (transversalis fascia), enters the preperitoneal tissue, locates the neck of the sac, and pulls the hernia upward.
After managing the sac, the repair is initiated, which has two main variations:
- Ruggi's method. The inguinal ligament is sutured to the pectineal (Cooper's) ligament posterior to the spermatic cord. Disadvantage: the inguinal ligament is displaced downward, widening the inguinal triangle (Hesselbach's). This increases the risk of direct inguinal hernias in the future.
- Parlavecchio's method. An improved variation. Both the inguinal ligament and the lower edges of the transverse and internal oblique abdominal muscles are sutured directly to the pectineal ligament. This eliminates the drawback of Ruggi's method, as it simultaneously obliterates the femoral ring and strengthens the inguinal interval.
Briefly: answers to topical questions
What anatomical structures form the walls of the femoral canal?
The femoral canal has three walls; its medial wall is absent.
- Anterior wall — formed by the superficial layer of the fascia lata.
- Posterior wall — formed by the deep layer of the fascia lata (fascia iliopectinea).
- Lateral wall — formed by the medial semi-circumference of the femoral vein (v. femoralis).
What is the "corona mortis" and which wall of the femoral ring does it border?
The "corona mortis" (corona mortis) is an anatomical vascular variation representing a dangerous anastomosis between the obturator artery and the external iliac or inferior epigastric arteries. The provided sources do not specify which exact wall of the femoral ring this structure borders. It is only noted that it runs near the ring, lying close to the pubic bone and pubic symphysis. The presence of this anastomosis creates a high risk of massive hemorrhage during surgical interventions.
What tissue layers are sequentially incised during the inguinal approach (Ruggi and Parlavecchio methods) to enter the preperitoneal space?
During the inguinal approach for the surgical treatment of a femoral hernia, the tissues are incised in a strict sequence down to the preperitoneal space.
- Skin (cutis).
- Subcutaneous adipose tissue (tela subcutanea).
- Superficial fascia (fascia superficialis).
- Aponeurosis of the external oblique abdominal muscle — its incision allows opening the anterior wall of the inguinal canal.
- Transversalis fascia (fascia transversalis) — a longitudinal incision of this fascia (the posterior wall of the inguinal canal) allows entry into the preperitoneal space.
Which internal organs most frequently comprise the contents of the hernial sac in a femoral hernia?
The sources for femoral hernia explicitly state that with increased intra-abdominal pressure, a loop of the small intestine pushes the parietal peritoneum ahead of it in the area of the femoral ring.
General sources on abdominal hernias state that the hernia contents most frequently consist of the greater omentum and loops of the small intestine; less commonly, other abdominal cavity organs.
To remember the Parlavecchio repair: "Parlavecchio — a PAIR of ligaments and muscles" (in Russian, *PARA*). You suture a PAIR: the inguinal ligament + the edges of the muscles (internal oblique and transverse) to Cooper's ligament.
Class and exam questions
How does the femoral approach differ from the inguinal approach?
In the femoral approach, access to the hernia ring and its closure are performed from below, via the thigh. In the inguinal approach, the surgeon first opens the inguinal canal, enters the preperitoneal space, and pulls the hernia upward.
What is the main disadvantage of Ruggi's method?
When suturing only the inguinal ligament to Cooper's ligament, the former is pulled downward. This increases the height of the inguinal interval, which can provoke the development of a direct inguinal hernia.
To which structure are tissues fixed during femoral hernia repair?
The main "anchor" structure for most types of repair (Bassini, Ruggi, Parlavecchio) is the pectineal ligament (Cooper's ligament / lig. pectineale).
What else to study on this topic
- Topography of the femoral triangle and femoral canal
- Anatomy of the inguinal canal and inguinal interval
- Differences in the technique of handling the hernial sac in oblique versus direct hernias
- Fasciae of the thigh: superficial fascia, fascia lata, margo falciformis
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