Non-Mesh Repair of Femoral Hernia
Lloyd M. Nyhus, MD,* and Jose E Patifio, MD?
The evolution of operative approaches for the repair of
groin hernias has been rapid during the past several
decades. Undoubtedly, many of these proposed changes
have been salutary, but not necessarily all. The tendency
today is to espouse the use of prosthetic mesh, whether
onlay, inlay, or plug, indiscriminately, for all groin hernia
repairs; this is known as the "knee jerk" phenomenon.
The development of a hernia classification, when
properly applied to the patient population under discus-
sion, allows for a sensible choice of operative technical
approaches. The "haberdashery mentality," of one suit fits
all, can be discarded.
THE CLASSIFICATION OF GROIN HERNIA
The classification of groin hernia includes primary ingui-
nal and femoral hernias (types 1, 2, and 3), as well as
recurrent groin hernias (type 4). Primary inguinal her-
nias are classified according to the severity of damage to
the underlying internal abdominal ring or the defect in
the Hesselbach triangle. Small to massive (eg, scrotal or
sliding) indirect hernias may be viewed as a continuum
of disease. Initially, they are confined to the internal
abdominal ring (type 1), then they enlarge medially
(type 2). In the final stages, they alter the posterior
inguinal wall (type 3). All direct hernias (small and large
without involvement of the internal abdominal ring) are
in the transversalis fascia layer and are, therefore, consid-
ered type 3.1
The classification of groin hernias is based on anatomi-
cal criteria. The challenge in devising a classification of
this nature lies in formulating descriptions that are clear
and specific.
Type One
Type 1 hernias are indirect inguinal hernias (usually in
infants, children, or young adults) in which the internal
From the Living Institute for Surgical Studies, Department of Surgery,
University of Illinois College of Medicine, Chicago, IL; and the Department of
Surgery, Fundacion Santa Fe de Bogota, Bogota, Columbia.
*Professor of Surgery Emeritus, University of Illinois, Chicago, IL.
"~ChairmanEmeritus, Department of Surgery, Fundacion Santa Fe de Bogota,
Bogota, Columbia.
Address reprint requests to Lloyd M. Nyhus, MD, Department of Surgery (mc
958), University of Illinois, College of Medicine, 840 South Wood St, Chicago, IL
60612.
Copyright 9 1999 byW.B. Saunders Company
1524-153X/99/0102-0003510.00/0
132 Operative Techniques i n General Surgery, Vol 1, No 2 (December), 1999: pp 132-141
abdominal ring is of normal size, configuration, and
structure. The boundaries are well delineated and the
Hesselbach triangle is normal. The indirect hernial sac
extends variably, from just distal to the internal abdomi-
nal ring, to the midinguinal canal.
Type Two
Type 2 hernias are indirect inguinal hernias in patients in
whom the internal ring is enlarged and distorted without
impinging on the floor of the inguinal canal. The
Hesselbach triangle (floor of the canal) is normal as
palpated through the opened peritoneal sac. The hernial
sac is not scrotal but may occupy the entire inguinal
canal.
Type Three
Type 3 classifies defects in the posterior inguinal wall
(floor) into three subtypes: direct, indirect, and femoral.
In direct inguinal hernias (type 3A), the protrusion
does not herniate through the internal abdominal (ingui-
nal) ring. The weakened transversalis fascia (posterior
inguinal wall medial to the inferior epigastric vessels)
bulges outward in front of the hernial mass. As previ-
ously stated, all direct hernias, small or large, are type 3A.
Type 3B hernias are indirect inguinal hernias with a
large dilated ring that has expanded medially and en-
croaches on the posterior inguinal wall (floor) to a
greater or lesser degree. Type 3B hernias frequently have
a scrotal position. Occasionally, the cecum on the right or
the sigmoid colon on the left makes up a portion of the
sac wall. These sliding hernias always destroy a portion
of the inguinal floor (type 3B). The internal abdominal
ring may be dilated without displacement of the inferior
epigastric vessels. Direct and indirect components of the
hernial sac may straddle those vessels to form a panta-
loon hernia (type 3B).
Type 3 C hernias are femoral hernias, a specialized form
of posterior wall defect.
Type Four
Type 4 hernias are recurrent hernias. They can be direct
(type 4A), indirect (type 4B), femoral (type 4C), or a
combination of these types (type 4D). They cause intri-
cate management problems and carry a higher morbidity
than do other hernias.
Non-Mesh Repair of Femoral Hernia
Following the precepts of our hernia classification, it
seems clear that the type 1, 2, and 3C hernias may be
handled successfully without the use of prosthetic mesh. 2,3
Parenthetically, one of us (J.ER) does use mesh to
buttress a seemingly intact Hesselbach triangle in middle-
aged or older men, as a prophylactic measure for type 2
hernias.
Femoral hernia repair from the open posterior preperi-
toneal approach has proven ideal with a less than 1%
recurrence rate? Why should a foreign body of any type
other than two or three sutures of monofilament polypro-
pylene be used in the repair of uncomplicated femoral
hernias? W h y should an intact posterior inguinal wall be
Iliopubic tract
Spe
C
llic
with po
Intern~
iliac
1 The important anatomical structures of the posterior inguinal wall as seen from the preperitoneal
approach. Areas susceptible to herniation: F, femoral; D, direct; I, indirect.
133
incised to approach the repair of a femoral hernia from
the open anterior approach such as in the Bassini, McVay,
Shouldice, and innumerable other publicized tech-
niques? The open posterior approach bypasses the poste-
rior inguinal wall, preserving its integrity. Further, this
technique must be mastered so that in the presence of
strangulated intestine within the femoral hernia sac, an
adequate repair can be performed in a setting where the
use of prosthetic mesh clearly is contraindicated.
The anatomical structures contained within the poste-
rior inguinal wall (wherein lies the femoral hernia
orifice) are given for orientation (see Fig 1).
tbdominis
arch
ubic
tract
ligament
134 Nyhus and Pati~o

SURGICAL TECHNIQUE
General Approach to the Preperitoneal Space

Incision
site

2 The preperitoneal space is entered through a transverse

lower abdominal incision placed 3 cm above the inguinal
ligament. The incision, then, is about 2 fingerbreadths above
the symphysis pubis and slightly above the usual inguinal
incision used in conventional anterior hernial repairs.
Non-Mesh Repair of Femoral Hernia 135

3 The left-sided dissection is carried successively through the skin, subcutaneous tissue, and
anterior rectus sheath. Before incision of the rectus sheath, estimation of the external inguinal
ring position as a basic landmark allows a more accurate "minds eye" visualization of the internal
abdominal ring. The incision through the anterior abdominal wall must be placed so that it is
above (cephalad to) the internal abdominal ring.
136 Nyhus and Patifio

4 The initial incision is placed over the rectus muscle.

Non-Mesh Repair of Femoral Hernia 137

Rectus
abdominis

5 The rectus muscle is retracted slightly toward the midline, and the transverse incision is extended
laterally a few centimeters through the full thickness of the musculoaponeurotic layers that are formed
by the external oblique aponeurosis and the internal oblique and transversus abdominis muscles. The
transversalis fascia is now exposed. It is opened transversely, with special care being taken not to enter
the underlying peritoneum. The preperitoneal space is entered. Slight retraction of the lower margin of
the incision exposes the posterior inguinal wall and the area of herniation. The general pelvic
peritoneum and the preperitoneal fat are reflected by blunt dissection, and any peritoneal projections
through the posterior inguinal wall are readily visualized.
138 Nyhus and Patifio

ates
~ction
ial

nial
mt

6 (A-B) The left femoral hernial sac is reduced by traction. If the hernia is incarcerated, one releases the sac by carefully incising
the insertion of the iliopubic tract into the Cooper's ligament at the medial margin of the femoral ring.
Non-Mesh Repair of Femoral Hernia 139

i, i~ !:
9 : i84~9

Excision
i: !!' of hernial
i sac
J
i :i; ?;) :;~

ii
r

7 The sac should

then be opened for in- iilii; :

spection of its contents.

Closure
of peritoneum

8 The repair of the hernia

is begun with high ligation
of the sac. The anterior mar-
gin of the hernial defect is
formed by the fliopubic tract
and the posterior margin by
the Cooper's ligament.
140 Nyhus and Patifto

:i~i~~i784~:~
: ii i

5i!ii!~!

Iliopubic
tract

Cooper's ligament
A

9 (A-B) The hernioplasty is completed by suturing these two structures together (0 or no. 1
monofilament polypropylene suture with a sweged-on Mayo needle), thereby obliterating the femoral
canal medial to the femoral vein. In the preperitoneal approach, there is no problem in regard to
visualization of the external iliofemoral vein; it is easily seen and protected, and the correct degree of
closure of the canal medial to it without compressing it is more readily obtained. The aberrant
obturator artery (corona mortis) crossing the Cooper's ligament is seen and protected when present.
Non-Mesh Repair of Femoral Hernia 141

ff defect
I suture

9 (continued)

If the restraining fascia is distal at the femoral canal RESULTS

orifice (Gimbernat ligament), release can be attained
Our recurrence rate remains at 1% or less. We have never
from above. We can envision, however, the rare possibil-
repaired a femoral hernia that has recurred after our
ity of performing a counterincision in the upper thigh
recommended approach and repair. These exceptional
over the femoral hernial mass for release of this restrict-
results have been confirmed. 4 Thus, we continue to
ing fascia. We have, however, never found this necessary.
espouse the preperitoneal approach and iliopubic tract
Use of relaxing incisions or of polypropylene mesh has
repair as the method of choice for the treatment of
not been necessary for the iliopubic tract repair of
femoral hernia. The use of the foreign bodies (prosthetic
femoral hernias.
mesh) currently promoted for the repair of femoral
hernias is unnecessary in our opinion.
Incarcerated or Strangulated Femoral Hernia
Incarceration or strangulation is managed with relative REFERENCES
ease. Transperitoneal control of the unaffected intestine
1. Nyhus LM: Individualization of hemia repair: A new era. Surgery
at the hernial ring allows full control of the necrotic
114:1-2, 1993
intestine and its lethal contents. After proximal control of 2. Krahenbfihl L, Frei E: Laparoscopic inguinal hernia repair: An
the intestine is achieved through the posterior approach individualized approach? Dig Surg 14:82-87, 1997
(and, in this instance, preperitoneal and transperitoneal 3. Patifio JF, Garcia-Herreros LG, Zundel N: Inguinal hernia repair:
exposure), release of the constricting insertion of the The Nyhus posterior preperitoneal operation. Surg Clin North Am
posterior inguinal wall into the Cooper's ligament at the 78:1063-1074, 1998
4. Ljungdahl I: Inguinal and femoral hernia: Personal experience
femoral ring, of the Gimbernat ligament at the distal with 502 operations. Acta Chir Scand 439:7-81, 1973 (suppl)
femoral orifice, or of both, allows for easy intestinal
resection and anastomosis. The classic iliopubic tract
repair follows.