Femoral hernia pathophysiology: Difference between revisions
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===Anatomy=== | ===Anatomy=== | ||
*The boundaries of the femoral ring are: | *The boundaries of the [[femoral ring]] are: | ||
**Femoral vein laterally | **[[Femoral vein]] laterally | ||
**Inguinal ligament anteriorly | **[[Inguinal ligament]] anteriorly | ||
**Lacunar ligament medially | **[[Lacunar ligament]] medially | ||
**Pectineal ligament posteriorly | **[[Pectineal ligament]] posteriorly | ||
*Pelvicrural interval, an opening from the abdomen to the thigh is divided in to two spaces:<ref name="pmid17103962">{{cite journal |vauthors=Panton JA |title=Factors bearing upon the Etiology of Femoral Hernia |journal=J. Anat. |volume=57 |issue=Pt 2 |pages=106–46 |year=1923 |pmid=17103962 |pmc=1262989 |doi= |url=}}</ref> | *Pelvicrural interval, an opening from the [[abdomen]] to the [[thigh]] is divided in to two spaces:<ref name="pmid17103962">{{cite journal |vauthors=Panton JA |title=Factors bearing upon the Etiology of Femoral Hernia |journal=J. Anat. |volume=57 |issue=Pt 2 |pages=106–46 |year=1923 |pmid=17103962 |pmc=1262989 |doi= |url=}}</ref> | ||
**Lacuna musculosa (lateral space), as the name suggests the iliopsoas muscles pass through this space. | **Lacuna musculosa ([[lateral]] space), as the name suggests the [[iliopsoas]] muscles pass through this space. | ||
**Lacuna vasculosa (medial space), as the name suggests this is the passage for the femoral vessels. | **Lacuna vasculosa (medial space), as the name suggests this is the passage for the [[femoral]] [[vessels]]. | ||
*In the pelvis along the anterior surface of the iliopsoas muscle run the external iliac vessels.<ref name="Lichtenstein">{{cite book | last = Lichtenstein | first = Irving | title = 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 | publisher = Ishiyaku EuroAmerica | location = St. Louis | year = 1986 | isbn = 0912791306 }}</ref> | *In the [[pelvis]] along the [[anterior surface]] of the [[iliopsoas]] [[muscle]] run the [[external iliac]] [[vessels]].<ref name="Lichtenstein">{{cite book | last = Lichtenstein | first = Irving | title = 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 | publisher = Ishiyaku EuroAmerica | location = St. Louis | year = 1986 | isbn = 0912791306 }}</ref> | ||
*The external iliac vessels pass between the iliopubic tract and Cooper's ligament and then under the inguinal ligament to become the femoral vessels.<ref name="Lichtenstein" /> | *The [[external iliac]] [[vessels]] pass between the [[iliopubic tract]] and [[Cooper's ligaments|Cooper's ligament]] and then under the [[inguinal ligament]] to become the [[femoral]] [[vessels]].<ref name="Lichtenstein" /> | ||
*As the external iliac vessels pass along the lacuna vasculosa they are covered by the transversalis fascia forming the femoral sheath.<ref name="Lichtenstein" /> | *As the [[external iliac]] [[vessels]] pass along the lacuna vasculosa they are covered by the [[transversalis fascia]] forming the [[femoral sheath]].<ref name="Lichtenstein" /> | ||
*The femoral sheath extends 4cm caudally to become the adventitia of the femoral vessels.<ref name="Lichtenstein" /> | *The [[femoral sheath]] extends 4cm caudally to become the [[adventitia]] of the [[femoral]] [[vessels]].<ref name="Lichtenstein" /> | ||
*The femoral sheath has a medial compartment that is known as the femoral canal.<ref name="Lichtenstein" /> | *The [[femoral sheath]] has a medial compartment that is known as the [[femoral canal]].<ref name="Lichtenstein" /> | ||
*The femoral canal is less than 2 cm in diameter and it contains lymphatics and glands.<ref name="Lichtenstein" /> | *The [[femoral canal]] is less than 2 cm in diameter and it contains [[lymphatics]] and [[glands]].<ref name="Lichtenstein" /> | ||
*The true opening of the femoral canal is a musculoaponeurotic ring that consists of:<ref name="pmid4278445">{{cite journal |vauthors=McVay CB |title=The anatomic basis for inguinal and femoral hernioplasty |journal=Surg Gynecol Obstet |volume=139 |issue=6 |pages=931–45 |year=1974 |pmid=4278445 |doi= |url=}}</ref> | *The true opening of the [[femoral canal]] is a musculoaponeurotic ring that consists of:<ref name="pmid4278445">{{cite journal |vauthors=McVay CB |title=The anatomic basis for inguinal and femoral hernioplasty |journal=Surg Gynecol Obstet |volume=139 |issue=6 |pages=931–45 |year=1974 |pmid=4278445 |doi= |url=}}</ref> | ||
**Cooper's ligament inferiorly | **[[Cooper's ligaments|Cooper's ligament]] inferiorly | ||
**Femoral vein laterally | **[[Femoral vein]] laterally | ||
**Iliopubic tract superiorly and medially | **[[Iliopubic tract]] superiorly and medially | ||
*The medial boundary of the femoral ring is made up of the lateral edge of the aponeurosis of the insertion of the transversus | *The [[medial]] boundary of the [[femoral ring]] is made up of the lateral edge of the [[aponeurosis]] of the insertion of the [[transversus abdominis muscle]] with the [[transversalis fascia]] onto the [[pubis]].<ref name="pmid4278445">{{cite journal |vauthors=McVay CB |title=The anatomic basis for inguinal and femoral hernioplasty |journal=Surg Gynecol Obstet |volume=139 |issue=6 |pages=931–45 |year=1974 |pmid=4278445 |doi= |url=}}</ref> | ||
*The true inner ring of the femoral canal is bounded:<ref name="pmid14275790">{{cite journal |vauthors=MCVAY CB |title=INGUINAL AND FEMORAL HERNIOPLASTY |journal=Surgery |volume=57 |issue= |pages=615–25 |year=1965 |pmid=14275790 |doi= |url=}}</ref> | *The true inner ring of the [[femoral canal]] is bounded:<ref name="pmid14275790">{{cite journal |vauthors=MCVAY CB |title=INGUINAL AND FEMORAL HERNIOPLASTY |journal=Surgery |volume=57 |issue= |pages=615–25 |year=1965 |pmid=14275790 |doi= |url=}}</ref> | ||
**Anteriorly and medially by the iliopubic tract. | **Anteriorly and medially by the [[iliopubic tract]]. | ||
**Posteriorly by the Cooper's ligament. | **Posteriorly by the [[Cooper's ligaments|Cooper's ligament]]. | ||
*The distal orifice (neck of the femoral canal) of the femoral canal has a rigid boundary which is usually less than 1cm in diameter and is surrounded by:<ref name="pmid4280996">{{cite journal |vauthors=Lytle WJ |title=The inguinal and lacunar ligaments |journal=J. Anat. |volume=118 |issue=Pt 2 |pages=241–51 |year=1974 |pmid=4280996 |pmc=1231505 |doi= |url=}}</ref><ref name="pmid18634743">{{cite journal |vauthors=Papanikitas J, Sutcliffe RP, Rohatgi A, Atkinson S |title=Bilateral retrovascular femoral hernia |journal=Ann R Coll Surg Engl |volume=90 |issue=5 |pages=423–4 |year=2008 |pmid=18634743 |pmc=2645754 |doi=10.1308/003588408X301235 |url=}}</ref> | *The distal [[orifice]] (neck of the [[femoral canal]]) of the [[femoral canal]] has a rigid boundary which is usually less than 1cm in diameter and is surrounded by:<ref name="pmid4280996">{{cite journal |vauthors=Lytle WJ |title=The inguinal and lacunar ligaments |journal=J. Anat. |volume=118 |issue=Pt 2 |pages=241–51 |year=1974 |pmid=4280996 |pmc=1231505 |doi= |url=}}</ref><ref name="pmid18634743">{{cite journal |vauthors=Papanikitas J, Sutcliffe RP, Rohatgi A, Atkinson S |title=Bilateral retrovascular femoral hernia |journal=Ann R Coll Surg Engl |volume=90 |issue=5 |pages=423–4 |year=2008 |pmid=18634743 |pmc=2645754 |doi=10.1308/003588408X301235 |url=}}</ref> | ||
**The lacunar ligament medially | **The [[lacunar ligament]] medially | ||
**The inguinal ligament anteriorly | **The [[inguinal ligament]] anteriorly | ||
**Fascia of the pectineal muscle posteriorly | **[[Fascia]] of the pectineal muscle posteriorly | ||
**The rigidity of these structures is the reason for strangulation in femoral hernias. | **The rigidity of these structures is the reason for [[strangulation]] in [[Femoral hernia|femoral hernias]]. | ||
===Pathogenesis=== | ===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.<ref name="Doherty">{{cite book | last = Doherty | first = Gerard | title = Current diagnosis & treatment : surgery | publisher = Lange Medical Books/McGraw-Hill | location = New York | year = 2010 | isbn = 978-0071635158 }}</ref> | *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]].<ref name="Doherty">{{cite book | last = Doherty | first = Gerard | title = Current diagnosis & treatment : surgery | publisher = Lange Medical Books/McGraw-Hill | location = New York | year = 2010 | isbn = 978-0071635158 }}</ref> | ||
*The hernia sac can contain preperitoneal fat, omentum or small bowel.<ref name="Doherty" /> | *The [[hernia]] sac can contain preperitoneal [[fat]], [[omentum]] or [[small bowel]].<ref name="Doherty" /> | ||
*Femoral hernias typically have a narrow neck, which predisposes them to incarceration and the need for emergent surgery.<ref name="Doherty" /> | *[[Femoral hernia|Femoral hernias]] typically have a narrow [[neck]], which predisposes them to incarceration and the need for emergent surgery.<ref name="Doherty" /> | ||
*De Garengeot hernia is a type of femoral hernia that contains the appendix.<ref name="pmid21442431">{{cite journal |vauthors=Phillips AW, Aspinall SR |title=Appendicitis and Meckel's diverticulum in a femoral hernia: simultaneous De Garengeot and Littre's hernia |journal=Hernia |volume=16 |issue=6 |pages=727–9 |year=2012 |pmid=21442431 |doi=10.1007/s10029-011-0812-2 |url=}}</ref> | *De Garengeot [[hernia]] is a type of [[femoral hernia]] that contains the [[appendix]].<ref name="pmid21442431">{{cite journal |vauthors=Phillips AW, Aspinall SR |title=Appendicitis and Meckel's diverticulum in a femoral hernia: simultaneous De Garengeot and Littre's hernia |journal=Hernia |volume=16 |issue=6 |pages=727–9 |year=2012 |pmid=21442431 |doi=10.1007/s10029-011-0812-2 |url=}}</ref> | ||
*Littre hernia is an uncommon type of femoral hernia that contain a Meckel's diverticulum.<ref name="pmid21442431">{{cite journal |vauthors=Phillips AW, Aspinall SR |title=Appendicitis and Meckel's diverticulum in a femoral hernia: simultaneous De Garengeot and Littre's hernia |journal=Hernia |volume=16 |issue=6 |pages=727–9 |year=2012 |pmid=21442431 |doi=10.1007/s10029-011-0812-2 |url=}}</ref> | *Littre [[hernia]] is an uncommon type of [[femoral hernia]] that contain a [[Meckel's diverticulum]].<ref name="pmid21442431">{{cite journal |vauthors=Phillips AW, Aspinall SR |title=Appendicitis and Meckel's diverticulum in a femoral hernia: simultaneous De Garengeot and Littre's hernia |journal=Hernia |volume=16 |issue=6 |pages=727–9 |year=2012 |pmid=21442431 |doi=10.1007/s10029-011-0812-2 |url=}}</ref> | ||
==Genetics== | ==Genetics== | ||
*First degree relatives of patients with inguinal hernia are more susceptible to developing femoral hernia.<ref name="pmid9225924">{{cite journal |vauthors=Liem MS, van der Graaf Y, Beemer FA, van Vroonhoven TJ |title=Increased risk for inguinal hernia in patients with Ehlers-Danlos syndrome |journal=Surgery |volume=122 |issue=1 |pages=114–5 |year=1997 |pmid=9225924 |doi= |url=}}</ref><ref name="pmid26686553">{{cite journal |vauthors=Jorgenson E, Makki N, Shen L, Chen DC, Tian C, Eckalbar WL, Hinds D, Ahituv N, Avins A |title=A genome-wide association study identifies four novel susceptibility loci underlying inguinal hernia |journal=Nat Commun |volume=6 |issue= |pages=10130 |year=2015 |pmid=26686553 |pmc=4703831 |doi=10.1038/ncomms10130 |url=}}</ref> | *First degree relatives of patients with [[inguinal hernia]] are more susceptible to developing femoral hernia.<ref name="pmid9225924">{{cite journal |vauthors=Liem MS, van der Graaf Y, Beemer FA, van Vroonhoven TJ |title=Increased risk for inguinal hernia in patients with Ehlers-Danlos syndrome |journal=Surgery |volume=122 |issue=1 |pages=114–5 |year=1997 |pmid=9225924 |doi= |url=}}</ref><ref name="pmid26686553">{{cite journal |vauthors=Jorgenson E, Makki N, Shen L, Chen DC, Tian C, Eckalbar WL, Hinds D, Ahituv N, Avins A |title=A genome-wide association study identifies four novel susceptibility loci underlying inguinal hernia |journal=Nat Commun |volume=6 |issue= |pages=10130 |year=2015 |pmid=26686553 |pmc=4703831 |doi=10.1038/ncomms10130 |url=}}</ref> | ||
==Associated Conditions== | ==Associated Conditions== | ||
*Ehlers-Danlos syndrome<ref name="pmid9225924">{{cite journal |vauthors=Liem MS, van der Graaf Y, Beemer FA, van Vroonhoven TJ |title=Increased risk for inguinal hernia in patients with Ehlers-Danlos syndrome |journal=Surgery |volume=122 |issue=1 |pages=114–5 |year=1997 |pmid=9225924 |doi= |url=}}</ref><ref name="pmid27826465">{{cite journal |vauthors=Harrison B, Sanniec K, Janis JE |title=Collagenopathies-Implications for Abdominal Wall Reconstruction: A Systematic Review |journal=Plast Reconstr Surg Glob Open |volume=4 |issue=10 |pages=e1036 |year=2016 |pmid=27826465 |pmc=5096520 |doi=10.1097/GOX.0000000000001036 |url=}}</ref><ref name="pmid22630060">{{cite journal |vauthors=Lei W, Huang J, Luoshang C |title=New minimally invasive technique for repairing femoral hernias: 3-D patch device through a femoris approach |journal=Can J Surg |volume=55 |issue=3 |pages=177–80 |year=2012 |pmid=22630060 |pmc=3364305 |doi=10.1503/cjs.030710 |url=}}</ref> | *[[Ehlers-Danlos syndrome]]<ref name="pmid9225924">{{cite journal |vauthors=Liem MS, van der Graaf Y, Beemer FA, van Vroonhoven TJ |title=Increased risk for inguinal hernia in patients with Ehlers-Danlos syndrome |journal=Surgery |volume=122 |issue=1 |pages=114–5 |year=1997 |pmid=9225924 |doi= |url=}}</ref><ref name="pmid27826465">{{cite journal |vauthors=Harrison B, Sanniec K, Janis JE |title=Collagenopathies-Implications for Abdominal Wall Reconstruction: A Systematic Review |journal=Plast Reconstr Surg Glob Open |volume=4 |issue=10 |pages=e1036 |year=2016 |pmid=27826465 |pmc=5096520 |doi=10.1097/GOX.0000000000001036 |url=}}</ref><ref name="pmid22630060">{{cite journal |vauthors=Lei W, Huang J, Luoshang C |title=New minimally invasive technique for repairing femoral hernias: 3-D patch device through a femoris approach |journal=Can J Surg |volume=55 |issue=3 |pages=177–80 |year=2012 |pmid=22630060 |pmc=3364305 |doi=10.1503/cjs.030710 |url=}}</ref> | ||
*Appendicitis<ref name="pmid21442431">{{cite journal |vauthors=Phillips AW, Aspinall SR |title=Appendicitis and Meckel's diverticulum in a femoral hernia: simultaneous De Garengeot and Littre's hernia |journal=Hernia |volume=16 |issue=6 |pages=727–9 |year=2012 |pmid=21442431 |doi=10.1007/s10029-011-0812-2 |url=}}</ref><ref name="pmid22983696">{{cite journal |vauthors=Kalles V, Mekras A, Mekras D, Papapanagiotou I, Al-Harethee W, Sotiropoulos G, Liakou P, Kastania A, Piperos T, Mariolis-Sapsakos T |title=De Garengeot's hernia: a comprehensive review |journal=Hernia |volume=17 |issue=2 |pages=177–82 |year=2013 |pmid=22983696 |doi=10.1007/s10029-012-0993-3 |url=}}</ref><ref name="pmid25073217">{{cite journal |vauthors=Snoekx R, Geyskens P |title=De Garengeot's hernia: acute appendicitis in a femoral hernia. Case report and literature overview |journal=Acta Chir. Belg. |volume=114 |issue=2 |pages=149–51 |year=2014 |pmid=25073217 |doi= |url=}}</ref><ref name="pmid28050438">{{cite journal |vauthors=Sinraj AP, Anekal N, Rathnakar SK |title=De Garengeot's Hernia - A Diagnostic and Therapeutic Challenge |journal=J Clin Diagn Res |volume=10 |issue=11 |pages=PD19–PD20 |year=2016 |pmid=28050438 |pmc=5198391 |doi=10.7860/JCDR/2016/21522.8871 |url=}}</ref> | *[[Appendicitis]]<ref name="pmid21442431">{{cite journal |vauthors=Phillips AW, Aspinall SR |title=Appendicitis and Meckel's diverticulum in a femoral hernia: simultaneous De Garengeot and Littre's hernia |journal=Hernia |volume=16 |issue=6 |pages=727–9 |year=2012 |pmid=21442431 |doi=10.1007/s10029-011-0812-2 |url=}}</ref><ref name="pmid22983696">{{cite journal |vauthors=Kalles V, Mekras A, Mekras D, Papapanagiotou I, Al-Harethee W, Sotiropoulos G, Liakou P, Kastania A, Piperos T, Mariolis-Sapsakos T |title=De Garengeot's hernia: a comprehensive review |journal=Hernia |volume=17 |issue=2 |pages=177–82 |year=2013 |pmid=22983696 |doi=10.1007/s10029-012-0993-3 |url=}}</ref><ref name="pmid25073217">{{cite journal |vauthors=Snoekx R, Geyskens P |title=De Garengeot's hernia: acute appendicitis in a femoral hernia. Case report and literature overview |journal=Acta Chir. Belg. |volume=114 |issue=2 |pages=149–51 |year=2014 |pmid=25073217 |doi= |url=}}</ref><ref name="pmid28050438">{{cite journal |vauthors=Sinraj AP, Anekal N, Rathnakar SK |title=De Garengeot's Hernia - A Diagnostic and Therapeutic Challenge |journal=J Clin Diagn Res |volume=10 |issue=11 |pages=PD19–PD20 |year=2016 |pmid=28050438 |pmc=5198391 |doi=10.7860/JCDR/2016/21522.8871 |url=}}</ref> | ||
*Meckel's diverticulum<ref name="pmid18176301">{{cite journal |vauthors=Zacharakis E, Papadopoulos V, Athanasiou T, Ziprin P, Zacharakis E |title=An unusual presentation of Meckel diverticulum as strangulated femoral hernia |journal=South. Med. J. |volume=101 |issue=1 |pages=96–8 |year=2008 |pmid=18176301 |doi=10.1097/SMJ.0b013e31815d3c83 |url=}}</ref><ref name="pmid21442431">{{cite journal |vauthors=Phillips AW, Aspinall SR |title=Appendicitis and Meckel's diverticulum in a femoral hernia: simultaneous De Garengeot and Littre's hernia |journal=Hernia |volume=16 |issue=6 |pages=727–9 |year=2012 |pmid=21442431 |doi=10.1007/s10029-011-0812-2 |url=}}</ref><ref name="pmid25309093">{{cite journal |vauthors=Wu SY, Ho MH, Hsu SD |title=Meckel's diverticulum incarcerated in a transmesocolic internal hernia |journal=World J. Gastroenterol. |volume=20 |issue=37 |pages=13615–9 |year=2014 |pmid=25309093 |pmc=4188914 |doi=10.3748/wjg.v20.i37.13615 |url=}}</ref> | *[[Meckel's diverticulum]]<ref name="pmid18176301">{{cite journal |vauthors=Zacharakis E, Papadopoulos V, Athanasiou T, Ziprin P, Zacharakis E |title=An unusual presentation of Meckel diverticulum as strangulated femoral hernia |journal=South. Med. J. |volume=101 |issue=1 |pages=96–8 |year=2008 |pmid=18176301 |doi=10.1097/SMJ.0b013e31815d3c83 |url=}}</ref><ref name="pmid21442431">{{cite journal |vauthors=Phillips AW, Aspinall SR |title=Appendicitis and Meckel's diverticulum in a femoral hernia: simultaneous De Garengeot and Littre's hernia |journal=Hernia |volume=16 |issue=6 |pages=727–9 |year=2012 |pmid=21442431 |doi=10.1007/s10029-011-0812-2 |url=}}</ref><ref name="pmid25309093">{{cite journal |vauthors=Wu SY, Ho MH, Hsu SD |title=Meckel's diverticulum incarcerated in a transmesocolic internal hernia |journal=World J. Gastroenterol. |volume=20 |issue=37 |pages=13615–9 |year=2014 |pmid=25309093 |pmc=4188914 |doi=10.3748/wjg.v20.i37.13615 |url=}}</ref> | ||
*Intestinal obstruction<ref name="pmid25309093">{{cite journal |vauthors=Wu SY, Ho MH, Hsu SD |title=Meckel's diverticulum incarcerated in a transmesocolic internal hernia |journal=World J. Gastroenterol. |volume=20 |issue=37 |pages=13615–9 |year=2014 |pmid=25309093 |pmc=4188914 |doi=10.3748/wjg.v20.i37.13615 |url=}}</ref> | *[[Intestinal obstruction]]<ref name="pmid25309093">{{cite journal |vauthors=Wu SY, Ho MH, Hsu SD |title=Meckel's diverticulum incarcerated in a transmesocolic internal hernia |journal=World J. Gastroenterol. |volume=20 |issue=37 |pages=13615–9 |year=2014 |pmid=25309093 |pmc=4188914 |doi=10.3748/wjg.v20.i37.13615 |url=}}</ref> | ||
*Intestinal volvulus<ref name="pmid25309093">{{cite journal |vauthors=Wu SY, Ho MH, Hsu SD |title=Meckel's diverticulum incarcerated in a transmesocolic internal hernia |journal=World J. Gastroenterol. |volume=20 |issue=37 |pages=13615–9 |year=2014 |pmid=25309093 |pmc=4188914 |doi=10.3748/wjg.v20.i37.13615 |url=}}</ref> | *[[Intestinal volvulus]]<ref name="pmid25309093">{{cite journal |vauthors=Wu SY, Ho MH, Hsu SD |title=Meckel's diverticulum incarcerated in a transmesocolic internal hernia |journal=World J. Gastroenterol. |volume=20 |issue=37 |pages=13615–9 |year=2014 |pmid=25309093 |pmc=4188914 |doi=10.3748/wjg.v20.i37.13615 |url=}}</ref> | ||
*Intussusception<ref name="pmid25309093">{{cite journal |vauthors=Wu SY, Ho MH, Hsu SD |title=Meckel's diverticulum incarcerated in a transmesocolic internal hernia |journal=World J. Gastroenterol. |volume=20 |issue=37 |pages=13615–9 |year=2014 |pmid=25309093 |pmc=4188914 |doi=10.3748/wjg.v20.i37.13615 |url=}}</ref> | *[[Intussusception]]<ref name="pmid25309093">{{cite journal |vauthors=Wu SY, Ho MH, Hsu SD |title=Meckel's diverticulum incarcerated in a transmesocolic internal hernia |journal=World J. Gastroenterol. |volume=20 |issue=37 |pages=13615–9 |year=2014 |pmid=25309093 |pmc=4188914 |doi=10.3748/wjg.v20.i37.13615 |url=}}</ref> | ||
==Gross Pathology== | ==Gross Pathology== | ||
*On gross pathology, incarcerated bowel is a characteristic finding of femoral hernia.<ref name="pmid23794497">{{cite journal |vauthors=Wang T, Vajpeyi R |title=Hernia sacs: is histological examination necessary? |journal=J. Clin. Pathol. |volume=66 |issue=12 |pages=1084–6 |year=2013 |pmid=23794497 |doi=10.1136/jclinpath-2013-201734 |url=}}</ref> | *On gross pathology, incarcerated [[bowel]] is a characteristic finding of [[femoral hernia]].<ref name="pmid23794497">{{cite journal |vauthors=Wang T, Vajpeyi R |title=Hernia sacs: is histological examination necessary? |journal=J. Clin. Pathol. |volume=66 |issue=12 |pages=1084–6 |year=2013 |pmid=23794497 |doi=10.1136/jclinpath-2013-201734 |url=}}</ref> | ||
==Microscopic 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.<ref name="pmid23794497">{{cite journal |vauthors=Wang T, Vajpeyi R |title=Hernia sacs: is histological examination necessary? |journal=J. Clin. Pathol. |volume=66 |issue=12 |pages=1084–6 |year=2013 |pmid=23794497 |doi=10.1136/jclinpath-2013-201734 |url=}}</ref> | *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.<ref name="pmid23794497">{{cite journal |vauthors=Wang T, Vajpeyi R |title=Hernia sacs: is histological examination necessary? |journal=J. Clin. Pathol. |volume=66 |issue=12 |pages=1084–6 |year=2013 |pmid=23794497 |doi=10.1136/jclinpath-2013-201734 |url=}}</ref> | ||
==References== | ==References== | ||
Revision as of 20:45, 23 January 2018
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Femoral hernia Microchapters |
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Femoral hernia pathophysiology On the Web |
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Risk calculators and risk factors for Femoral hernia pathophysiology |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: M. Khurram Afzal, MD [2]
Overview
Pathophysiology
Anatomy
- The boundaries of the femoral ring are:
- Femoral vein laterally
- Inguinal ligament anteriorly
- Lacunar ligament medially
- Pectineal ligament posteriorly
- Pelvicrural interval, an opening from the abdomen to the thigh is divided in to two spaces:[1]
- In the pelvis along the anterior surface of the iliopsoas muscle run the external iliac vessels.[2]
- The external iliac vessels pass between the iliopubic tract and Cooper's ligament and then under the inguinal ligament to become the femoral vessels.[2]
- As the external iliac vessels pass along the lacuna vasculosa they are covered by the transversalis fascia forming the femoral sheath.[2]
- The femoral sheath extends 4cm caudally to become the adventitia of the femoral vessels.[2]
- The femoral sheath has a medial compartment that is known as the femoral canal.[2]
- The femoral canal is less than 2 cm in diameter and it contains lymphatics and glands.[2]
- The true opening of the femoral canal is a musculoaponeurotic ring that consists of:[3]
- Cooper's ligament inferiorly
- Femoral vein laterally
- Iliopubic tract superiorly and medially
- The medial boundary of the femoral ring is made up of the lateral edge of the aponeurosis of the insertion of the transversus abdominis muscle with the transversalis fascia onto the pubis.[3]
- The true inner ring of the femoral canal is bounded:[4]
- Anteriorly and medially by the iliopubic tract.
- Posteriorly by the Cooper's ligament.
- The distal orifice (neck of the femoral canal) of the femoral canal has a rigid boundary which is usually less than 1cm in diameter and is surrounded by:[5][6]
- The lacunar ligament medially
- The inguinal ligament anteriorly
- Fascia of the pectineal muscle posteriorly
- The rigidity of these structures is the reason for strangulation in femoral hernias.
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.[7]
- The hernia sac can contain preperitoneal fat, omentum or small bowel.[7]
- Femoral hernias typically have a narrow neck, which predisposes them to incarceration and the need for emergent surgery.[7]
- De Garengeot hernia is a type of femoral hernia that contains the appendix.[8]
- Littre hernia is an uncommon type of femoral hernia that contain a Meckel's diverticulum.[8]
Genetics
- First degree relatives of patients with inguinal hernia are more susceptible to developing femoral hernia.[9][10]
Associated Conditions
- Ehlers-Danlos syndrome[9][11][12]
- Appendicitis[8][13][14][15]
- Meckel's diverticulum[16][8][17]
- Intestinal obstruction[17]
- Intestinal volvulus[17]
- Intussusception[17]
Gross Pathology
- On gross pathology, incarcerated bowel is a characteristic finding of femoral hernia.[18]
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.[18]
References
- ↑ Panton JA (1923). "Factors bearing upon the Etiology of Femoral Hernia". J. Anat. 57 (Pt 2): 106–46. PMC 1262989. PMID 17103962.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 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.
- ↑ 3.0 3.1 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.
- ↑ 7.0 7.1 7.2 Doherty, Gerard (2010). Current diagnosis & treatment : surgery. New York: Lange Medical Books/McGraw-Hill. ISBN 978-0071635158.
- ↑ 8.0 8.1 8.2 8.3 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.
- ↑ 9.0 9.1 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.
- ↑ 17.0 17.1 17.2 17.3 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.
- ↑ 18.0 18.1 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.