Extra-peritoneal approach

The extra-peritoneal approach to femoral hernia repair was popularised by Henry and McEvedy. It is a good approach for hernias which are:

• large
• long-standing
• in the obese
• bilateral
• found to be strangulated and with poor access by a different approach

However, technically it is demanding.

A pararectal or oblique incision is made on the side of the hernia above the inguinal ligament. An incision is made through the external oblique aponeurosis and conjoint tendon. The transversalis fascia is opened and a plane developed by blunt dissection between the muscular aponeurosis and the peritoneum. It may be necessary to retract rectus abdominis medially to permit better access.

Progressing inferiorly, the femoral canal is identified. The neck of the sac is found medial to the femoral vessels and posterior to the inguinal canal. The femoral sac is delivered into the wound by manipulating it from above and below. It may be necessary to divide the lacunar ligament to liberate the sac.

The sac is cleaned, opened and its contents inspected. Viable contents are returned to the abdominal cavity. Non-viable bowel may be resected and anastomosed through the same approach. Rarely, if further access is required, the peritoneum can be incised to enter the abdominal cavity. The empty sac is transfixed, ligated and excised.

The femoral canal is repaired by apposing inguinal and pectineal ligaments in the same manner as a 'high' approach. The abdominal wall is closed in layers.