Femoral hernia pathophysiology: Difference between revisions
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==Overview== | ==Overview== | ||
A | A femoral hernia is the protrusion of the [[hernia]] sac through the [[femoral ring]] in to the [[femoral canal]]. The [[anatomy]] of the [[femoral canal]] is such that the neck is made up of rigid structures that predispose herniated [[bowel]] to [[strangulation]] and incarceration. The [[hernia]] sac contains [[small bowel]] which can predispose to [[intestinal obstruction]]. Some [[connective tissue diseases]] predispose the patient to developing [[femoral hernia]]. [[Malignancy]] is very rarely associated with [[Femoral hernia|femoral hernias]], thus [[histopathological]] analysis is done routinely following a repair but shows [[Incarcerated hernia|incarcerated]] [[bowel]] on most occasions. | ||
==Pathophysiology== | ==Pathophysiology== | ||
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*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" /> | ||
*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> | ||
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==Microscopic Pathology== | ==Microscopic Pathology== | ||
*It is recommended that | *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== | ||
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[[Category:Medicine]] | [[Category:Medicine]] | ||
[[Category:Gastroenterology]] | [[Category:Gastroenterology]] | ||
[[Category:Up-To-Date]] | [[Category:Up-To-Date]] | ||
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[[Category:Primary care]] | [[Category:Primary care]] | ||
{{WS}} | {{WS}} | ||
{{WH}} | {{WH}} | ||
Revision as of 19:30, 24 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
A femoral hernia is the protrusion of the hernia sac through the femoral ring in to the femoral canal. The anatomy of the femoral canal is such that the neck is made up of rigid structures that predispose herniated bowel to strangulation and incarceration. The hernia sac contains small bowel which can predispose to intestinal obstruction. Some connective tissue diseases predispose the patient to developing femoral hernia. Malignancy is very rarely associated with femoral hernias, thus histopathological analysis is done routinely following a repair but shows incarcerated bowel on most occasions.
Pathophysiology
Anatomy
- 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.