Page 47 - World Journal of Laparoscopic Surgery

CASE REPORT
Femoral Hernioscopy: A Minimally Invasive Procedure to

Evaluate Bowel Viability

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1
Shafquat Zaman , Mona Kamal , Peter Waterland 3
AbstrAct
We highlight an important surgical technique that can be utilized to prevent unnecessary laparotomies in patients undergoing emergency
femoral hernia repair. A 79-year-old female presented to our unit with an increasingly painful left-sided groin swelling. She was subsequently
taken to the operation theater for an emergency operation and found to have a spontaneously reduced femoral hernia after induction of
anesthesia. Femoral hernioscopy was performed successfully with the patient positioned in a steep Trendelenburg position. This allowed us to
perform a diagnostic laparoscopy and assess bowel viability. Consequently, further unnecessary procedures were avoided together with their
associated short- and long-term morbidity. Hernioscopy is a safe, feasible, and valuable technique that is potentially underutilized. We feel that
this is a cornerstone in the application of minimal access surgery for a common general surgical emergency, and hence further research with
application of this technique is required in this field.
Keywords: Femoral hernia, Hernioscopy, Laparoscopy, Laparotomy.
World Journal of Laparoscopic Surgery (2019): 10.5005/jp-journals-10033-1378

cAse Description 1–3 Department of General Surgery, Russells Hall Hospital, Dudley, West
A 79-year-old lady was referred from primary care with an England, UK
increasingly painful left groin swelling over several months. Her past Corresponding Author: Shafquat Zaman, Department of General
surgical history included a left-sided total hip replacement. Clinical Surgery, Russells Hall Hospital, Dudley, England, UK, Phone: +91
examination revealed a 3 × 3 cm hard, fixed swelling below and 7944657005, e-mail: shafquatzaman@nhs.net
lateral to the pubic tubercle. This was extremely tender on palpation. How to cite this article: Zaman S, Kamal M, Waterland P. Femoral
An ultrasound of the left groin showed a 2.6 cm thick-walled Hernioscopy: A Minimally Invasive Procedure to Evaluate Bowel
cystic structure with no changes noted on the Valsalva maneuver. Viability. World J Lap Surg 2019;12(3):133–134.
There was no free fluid or discrete collections seen on imaging. The Source of support: Nil

patient was subsequently taken to the theatre for groin exploration. Conflict of interest: None
surgicAl technique

A left-sided groin crease incision was made, and a femoral hernia Femoral hernioscopy is a particularly useful technique in the
identified. The hernia sac contained hemoserous fluid only. In order emergency setting as it can potentially avoid a further explorative
to further inspect the retracted bowel, a blunt 12 mm balloon laparotomy. It allows the contents of a spontaneously reduced
port was introduced via the hernial sac into the abdominal cavity hernia to be fully inspected.
(Fig. 1). Standard insufflation with carbon dioxide was performed, It is relatively quick to perform (approximately 10 minutes),
maintaining an intra-abdominal pressure of 14 mm Hg. The and the technique can be adapted depending on the clinical
patient was repositioned in a steep Trendelenburg position, and context such as inguinal sac hernioscopy. In our case, a single
pneumoperitoneum was established. port, in combination with the Trendelenburg position, provided
Laparoscopy showed a mildly congested but viable small excellent views of the reduced hernial sac contents. A single incision
bowel loop. Constriction markings were seen on this segment laparoscopic port (SILS) can also be used to allow the introduction
of the bowel and were consistent with entrapment within the of further instruments to obtain better views.
hernia sac (Fig. 2). As the loop of bowel was completely viable, no There are limited reports in the literature especially, on femoral
resection was required. The laparoscope was withdrawn, the port hernioscopy as a technique for evaluating incarcerated hernias
was removed, and a standard mesh repair of femoral hernia was that retract under anesthesia. One study involving five patients
performed. Postoperatively the patient made an excellent recovery with inguinal and femoral hernias showed that the technique was
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and was discharged home the following day. simple and may prevent unnecessary laparotomies. Kneessy and
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Weinbaum described a similar approach undertaken to examine
Discussion a loop of incarcerated bowel, which had spontaneously retracted
back into the abdomen. It appears that their patient positioning
Femoral hernia is the protrusion of a peritoneal sac through the was not modified, and so an additional 5 mm port was required to
femoral ring into the femoral canal. Less common than inguinal manipulate and handle bowel.
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hernias, it is seen most frequently in older females. It is associated Valderrama et al. used a smaller single 5 mm port for
with higher rates of acute complications such as incarceration and the insertion of a 0° laparoscope in the management of an
strangulation. incarcerated right femoral hernia causing small bowel obstruction.
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