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Year : 2018  |  Volume : 6  |  Issue : 4  |  Page : 151-155

Synchronous laparoscopic cholecystectomy and mesh repair of incarcerated femoral hernia: Is it feasible?

Department of Surgery, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia

Date of Web Publication13-Dec-2018

Correspondence Address:
Dr. M Ezzedien Rabie
Department of Surgery, Armed Forces Hospital Southern Region, P. O. Box 101, Khamis Mushait
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ssj.ssj_77_17

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Cholecystectomy and hernia repair are common surgical procedures. While laparoscopic cholecystectomy is the gold standard for managing gallstone disease, the situation is not similar for laparoscopic hernia repair, as the debate between the laparoscopic and open approaches continues. However, laparoscopic femoral hernia repair has been recommended by some, especially in females. In this report, we describe the clinical course of a 53-year-old female with chronic calcular cholecystitis, who presented with incarcerated femoral hernia. The patient underwent laparoscopic cholecystectomy and mesh repair of her femoral hernia. The challenge, in this case, was the application of a mesh after cholecystectomy and in the presence of hernia incarceration, with both posing a potential risk of mesh infection. However, with proper precautions to avoid bile spillage and suction irrigation to clean the hernia operative site, together with the administration of an antibiotic coverage, a successful outcome was obtained. To our knowledge, this is the first report on simultaneous laparoscopic cholecystectomy and incarcerated femoral hernia repair.

Keywords: Cholecystectomy, femoral hernia, incarceration, laparoscopic repair

How to cite this article:
Rabie M E, Hummadi A, Osama M. Synchronous laparoscopic cholecystectomy and mesh repair of incarcerated femoral hernia: Is it feasible?. Saudi Surg J 2018;6:151-5

How to cite this URL:
Rabie M E, Hummadi A, Osama M. Synchronous laparoscopic cholecystectomy and mesh repair of incarcerated femoral hernia: Is it feasible?. Saudi Surg J [serial online] 2018 [cited 2019 Jun 25];6:151-5. Available from: http://www.saudisurgj.org/text.asp?2018/6/4/151/247419

  Introduction Top

Femoral hernia is a relatively rare encounter, representing 4.8% of all groin hernias.[1] It is more common in females with a female-to-male ratio of 2:1,[2],[3] compared to 1:12 for inguinal hernia.[3] In addition, an emergency presentation is more frequent in females, and generally, an emergency surgery is more frequently needed for femoral than inguinal hernia. During surgery, bowel resection is also more likely.[4]

Cholecystectomy and hernia repair, two of the most common surgical procedures, could both be done by the open or laparoscopic means. While laparoscopic cholecystectomy gained wide acceptance as the standard of care soon after its inception, the situation is not so for laparoscopic hernia repair. The adoption of laparoscopic cholecystectomy was based on certain proved advantages over the open procedure. Less postoperative pain, less wound complication rate, shorter hospital stay, and earlier return to work have all been attained.[5],[6],[7],[8] As for hernia repair, the situation is controversial.

  Case Report Top

A 53-year-old female, with a history of Helicobacter pylori (HP) infection and varicose veins of the lower limb, for which she was on aspirin, presented to the clinic with right upper quadrant and epigastric pain, radiating to the back and right scapula, associated with fatty dyspepsia.

Abdominal examination was unremarkable, apart from an asymptomatic right groin swelling. Ultrasonography showed gallstones, for which the patient was listed for elective cholecystectomy.

In the waiting period, the patient presented to the emergency room with epigastric pain. Owing to the history of HP infection, she was referred to the gastroenterologist who performed upper gastroduodenoscopy, with antral and gastric biopsies. The patient was then discharged on anti HP medications for follow-up.

Few days later, she presented again to the emergency room as her groin swelling became painful 5 days previously, but there were no other associated symptoms.

On examination, her vital signs were normal and her chest and heart examinations were unremarkable. Abdominal examination showed soft, nontender abdomen, and there was an irreducible tender globular swelling in the right inguinal region, with no cough impulse. The condition was initially diagnosed as incarcerated inguinal hernia, but due to the lateral location of the hernia in the groin, an alternative diagnosis of incarcerated femoral hernia was raised.

Laboratory investigations showed normal blood picture as well as the liver and renal values.

Computerized axial tomography scan (CT) showed the swelling to be a femoral hernia, lying just medial to and compressing the femoral vein [Figure 1]. There was fat stranding in the hernia contents, signifying incarceration, but there were no bowel loops.
Figure 1: Right femoral hernia (white arrow) appears just medial to the femoral vein (white arrowhead), which appears flattened, compared to the left side, by the compressing hernia

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Based on the presence of dual pathology, an incarcerated right femoral hernia and chronic cholecystitis, simultaneous laparoscopic cholecystectomy and hernia repair were planned and prophylactic antibiotics, amoxicillin/clavulanic acid 1.2 G bd, were started.

At the start of the procedure, a Foley's catheter was inserted to decompress the urinary bladder, and pneumoperitoneum was created by the closed technique through the umbilicus, using Veress needle. On entering the abdomen, laparoscopic exploration confirmed the presence of right femoral hernia with incarcerated omentum.

Cholecystectomy was performed first by the standard technique, avoiding leaking of bile. Following gallbladder extraction, hernia repair was then started and another 5 mm port was inserted to the left of the umbilicus. At that point, the patient was repositioned in the head-down, left-tilt position. Adherent omentum was seen attached to the anterior abdominal wall near the midline and was sharply released. The hernia was identified [Figure 2] and the incarcerated omentum was reduced with some difficulty into the abdomen. On reduction, a reddish fluid escaped from the hernia sac into the abdomen, but the omentum appeared grossly viable, though with congested vessels. Thorough suction of the escaped fluid with irrigation of the operative field was done, and a standard transabdominal preperitoneal (TAPP) repair was then performed. After general inspection of the peritoneal cavity, the ports were withdrawn under direct vision and the process was concluded.
Figure 2: Right femoral hernia containing incarcerated omentum.IEV: Inferior epigastric vessels. DH: site of direct inguinal hernia.IH: site of indirect inguinal hernia. FH: femoral hernia with incarcerated omentum

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The antibiotic was continued for 7 days and the postoperative recovery was uneventful. In the 3rd postoperative day, the patient was discharged for follow-up. Two weeks later, she appeared in the clinic in good health.

  Discussion Top

Femoral hernia is notorious for its illusive local signs, even in the presence of complications. This is especially so in elderly females, who may present with abdominal signs with no or little signs in the groin.[9] In addition, the surgeon might be faced with a groin hernia, the type of which may not be readily apparent. This confusion could be settled by ultrasound or preferably CT scan. In our patient, it was clear that the hernia lied above the medial part of the inguinal ligament, qualifying it as an inguinal hernia. However, a subtle sign, pathognomonic for femoral hernia, namely the more lateral location of the swelling in the groin (Hamilton Bailey)[10] [Figure 3] and [Figure 4], led us to suspect the correct diagnosis, which was confirmed by CT scan.
Figure 3: Femoral hernia lying above the medial end of the inguinal ligament, occupying a more lateral position than inguinal hernia would do (first author's archive)

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Figure 4: The usual location of femoral hernia below the medial end of the inguinal ligament, clearly distinguishing it from inguinal hernia (first author's archive)

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For groin hernia repair, the advantages of the laparoscopic over the open approaches are inconsistent and clearly conflicting. While some reports failed to show the superiority of the laparoscopic repair,[11],[12],[13],[14],[15] other studies showed its clear advantages. In one study, the laparoscopic repair of femoral hernia was associated with less recurrences compared to open repair. Moreover, the incidence of subsequent appearance of inguinal hernia on the same side was less.[16] In addition, laparoscopic repair was associated with less acute and chronic pain and faster recovery.[17] Furthermore, shorter hospital stay, earlier return to work, ability to operate on bilateral cases through the same incisions, easier dissection in recurrent open cases, the ability to diagnose early and occult cases, and the ability to perform other intra-abdominal operations have all been attained with the laparoscopic repair (Bátorfi).[18]

Parallel to this and based on a nationwide analysis in Denmark, published in JAMA in 2014, laparoscopic repair has been recommended for femoral hernia,[16] and the utilization of TAPP has also been favored by some.[2] In this context, some authorities have recommended laparoscopic repair for all primary groin hernias in females. As for males, the decision between open and laparoscopic repair was left to the local expertise, financial considerations, and the patient's preference.[17]

Simultaneous laparoscopic cholecystectomy and groin hernia repair have been previously reported. The dual procedure was first reported in 1994, by Tsimoyiannis in six patients, five with inguinal and one with femoral hernia.[19] Others explored this potential, where Simon et al. performed simultaneous laparoscopic cholecystectomy and inguinal hernioplasty in two patients,[20] while Al-Dowais went further by performing a single-port laparoscopic cholecystectomy and inguinal hernia repair in one patient.[21] More importantly, Sarli et al. performed a randomized trial including sixty-four patients, where laparoscopic cholecystectomy was followed by laparoscopic hernia repair in one limb and open tension-free repair in the other. However, it appeared that the totally laparoscopic procedures took much longer and did not result in much benefit, apart from improved early postoperative comfort.[22] All these procedures were performed electively with no incarceration or strangulation present.

Although not the standard, laparoscopic repair of strangulated groin hernia has been proved to be feasible with certain advantages over the open repair. In their study, Yang et al. reported their experience with 188 patients, 57 underwent laparoscopic repair and 131 underwent open repair. The laparoscopic repair had a shorter hospital stay and less wound infection rates with no mesh infection encountered in both groups.[23] In another report, Deeba et al. performed an extensive data search of the English language publications on laparoscopic repair of incarcerated/strangulated inguinal hernia, where the laparoscopic approach was exclusively used. They recognized 7 case series, the smallest included 6 patients and the largest 194, with a total number of 328 patients.[24] At the end of their analysis, the authors concluded that the laparoscopic approach is feasible with acceptable results. However, they recommended larger multicenter randomized trials to get a definite answer.

In the patient presented here, there were few available options. The first was to operate in two sessions, starting with the more urgent one, the incarcerated hernia. The second was to perform laparoscopic cholecystectomy and open hernia repair in one session. The third was to conduct two simultaneous laparoscopic procedures. Our pursuit of the third option was based on supportive evidence from the literature as the laparoscopic repair of femoral hernia was recommended in females. Furthermore, we believed that our patient will benefit from the advantages of laparoscopy as perceived in other types of surgery.

Laparoscopic management of incarcerated/strangulated femoral hernia, as a single pathology, has been previously reported. Our PubMed database search, using the terms (laparoscopic, femoral, hernia, incarcerated/strangulated) in the title and abstract, yielded several reports.[23],[25],[26],[27],[28],[29],[30],[31],[32],[33] Adding the term (cholecystectomy) to the previous search terms yielded no pertinent results, signifying that simultaneous laparoscopic cholecystectomy and incarcerated/strangulated femoral hernia repair have not been previously reported, making our report the first of its kind.

  Conclusion Top

Simultaneous laparoscopic cholecystectomy and repair of incarcerated femoral hernia are feasible and safe. Although there are several reports on simultaneous groin hernia repair along with cholecystectomy in the same laparoscopic session, there are no such reports in the presence of incarceration. To our knowledge, this is the first report on laparoscopic repair of incarcerated femoral hernia, concomitant with laparoscopic cholecystectomy, which was performed successfully in our patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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