Operative Surgery and Topographic Anatomy - 2016

Content Module No. 3. Topographic Anatomy and Operative Surgery of the Abdominal Wall and Organs

Topic 12. Femoral canal. Surgical management of femoral hernias. Surgical treatment of incarcerated femoral hernias. Potential complications. Hernias of the linea alba and umbilical hernias

1. Relevance of the topic: The Mechanism of femoral hernia formation requires a thorough Study of the Anatomical Features of the proximal thigh, muscular and vascular lacunae, and the femoral canal. This is essential for selecting the appropriate Surgical Treatment method for femoral hernias.

2. Specific objectives:

1. Analyze the Anatomy of the femoral canal formed during femoral hernia development, including its femoral ring, saphenous opening, and the walls of the femoral canal.

2. Explain the Surgical anatomy of hernias of the linea alba and the umbilical ring.

3. Explain how to perform the most common surgical techniques for femoral hernias.

4. Explain how to perform surgical interventions for hernias of the linea alba and the umbilical ring.

3. Guidelines for independent student preparation for the Class.

3.1. List of key terms, parameters, and characteristics to be mastered by the student in preparation for the class:

3.2. Theoretical questions for the class:

1. How are the muscular and vascular lacunae formed?

2. What anatomical structures bound the internal opening of the femoral canal?

3. Name the walls of the femoral canal in the presence of a hernia.

4. How can a femoral hernia be differentiated from an inguinal hernia? What are the types of femoral hernias?

5. What surgical approaches can be used for hernioplasty in femoral hernias?

6. How is hernioplasty performed using the Cooper-Bassini technique?

7. How is hernioplasty performed using the Ruge-Parlavecchio technique?

8. What are the causes of hernias of the linea alba?

9. Describe the surgical Procedures for umbilical hernias (Sapezhko, Lexer, and Mayo techniques).

3.3. Practical skills to be acquired during the class:

1. Dissection of the subinguinal space.

2. Repair of the femoral canal using femoral and inguinal approaches (Cooper, Bassini, Ruge, Parlavecchio).

3. Surgical repair of umbilical hernia (Sapozhkov, Mayo, and Lexer techniques).

4. Topic Content

Using charts, a skeletal model, and a cadaver, students examine the external landmarks of the femoral canal. Next, they proceed to cadaver dissection. First, a 10–12 cm longitudinal Skin incision is made on the anterior surface of the thigh, followed by a horizontal incision parallel to and just below the inguinal ligament. Dissection is carried medially to expose the subcutaneous tissue containing the great saphenous vein and its tributaries, tracing the course of this vein to where it pierces the cribriform fascia—the Superficial layer of the fascia lata. This fascial layer is found to be loose and perforated by small Blood and Lymphatic vessels, forming the cribriform fascia. Incising this fascia exposes the saphenous opening (fossa ovalis), where the great saphenous vein joins the femoral vein. Lateral to the femoral vein lies the femoral artery; both vessels reside within the lateral compartment of the vascular lacuna. The space within the vascular lacuna located medial to these vessels, specifically medial to the vein, represents the femoral ring (which serves as the internal ring of the femoral canal when a hernia develops).

The femoral ring is bounded superiorly and anteriorly by the inguinal ligament, medially by the lacunar ligament, and laterally by the femoral vein. When a hernia descends, the walls of the femoral canal are formed by: the femoral vein laterally, the superficial layer of the fascia lata anteriorly, and the Deep Layer of the fascia lata posteriorly. The external opening of the femoral canal roughly corresponds to the saphenous hiatus, which features a falciform margin and two horns (superior and inferior) formed by the fascia lata. As noted above, the great saphenous vein empties into the femoral vein at this Location, covered by the cribriform fascia. Two surgical approaches are used to repair a femoral hernia. The first is the femoral approach, where the hernial sac is managed and the hernia defect is closed via the anterior thigh; the second is the inguinal approach, where these surgical steps are performed through the Inguinal Canal, which is subsequently reinforced at the end of the procedure.

When using the femoral approach, special care must be taken to protect the great saphenous vein, Lymph Nodes, and femoral vessels (artery and vein) to prevent iatrogenic injury. The technique for managing the hernial sac is identical to that used in inguinal hernia repairs. The hernial defect is closed by suturing the inguinal ligament to the pectineal ligament (Cooper's ligament). This requires retracting the femoral vein laterally and placing 2–3 silk sutures using strongly curved needles. The superficial layer of the fascia lata bounding the saphenous opening (falciform margin) is then sutured to the Fascia of the pectineus Muscle using several interrupted sutures (Bassini's method).

In the inguinal approach (Ruge-Parlavecchio procedure), an incision is made just above the inguinal ligament, the inguinal canal is opened, and the Spermatic Cord is isolated and retracted aside. The posterior wall of the inguinal canal (transversalis fascia) is incised longitudinally, and its upper edge is retracted superiorly to enter the properitoneal space, where the neck of the hernial sac is identified. The hernial sac is delivered into the inguinal canal and managed in the standard fashion: it is opened between two forceps near the fundus, and the incision is extended along the body of the sac. The Contents of the sac are inspected and, if viable, reduced into the peritoneal cavity. The empty hernial sac is pulled up, transfixed at its neck, ligated on both sides, and excised. Next, the hernia defect is repaired. For this, the inguinal and pectineal ligaments are cleared of surrounding adipose tissue, and the inguinal ligament is sutured to the pectineal ligament with two to three silk sutures (Ruge's method); if the lower edges of the internal oblique and transversus abdominis Muscles are also included in the sutures to the pectineal ligament (Parlavecchio's method), the inguinal canal is simultaneously reinforced along with the closure of the femoral ring.

In strangulated femoral hernias, the lacunar ligament is typically incised. It is crucial to remember the potential for an aberrant obturator artery. Normally, the obturator artery originates from the internal iliac artery; however, in 28–30% of cases, it may arise from the inferior epigastric artery or the external iliac artery, coursing directly behind the lacunar ligament. The femoral ring is surrounded by major vessels: the inferior epigastric artery superiorly near the inguinal ligament, the femoral vein laterally, and the obturator artery behind the lacunar ligament. This vascular arrangement is known as the "crown of death" (corona mortis), as dividing the strangulating ring (lacunar ligament) can lead to catastrophic, life-threatening Hemorrhage.

Surgical repair of umbilical hernias involves either a midline incision along the linea alba or a transverse incision curving beneath the hernial protrusion.

The skin is meticulously dissected away from the hernial sac to expose the hernia defect formed by the margin of the umbilicus. The hernial sac is then fully mobilized and managed. Next, the umbilical ring is incised either vertically along the linea alba (Sapozhkov technique) or transversely (Mayo technique). Interrupted sutures are placed on the aponeurotic flaps, overlapping them in a double-breasted (duplication) manner. In children with small umbilical hernias, the umbilical ring is closed using a purse-string suture (Lexer technique). Additional interrupted sutures are placed over the tied purse-string suture.

5. Self-Assessment Materials

A. Self-Assessment Tasks

Test No. 1

A patient presents with a herniation protruding from the lateral margin of the left rectus abdominis muscle, located 4 cm below the umbilicus level. In which “weak spot” did the hernia form in this case?

a. Umbilical ring

b. Linea alba

c. Linea semilunaris

d. Arcuate line

e. Inguinal triangle (Hesselbach's interval)

Test No. 2

A surgeon performed umbilical ring plasty using the Mayo-Diakonov technique. What type of suture did the surgeon use in this case to reinforce the umbilical ring?

a. Purse-string suture

b. Multanovsky suture

c. Simple continuous suture

d. Simple interrupted suture

e. Mattress suture

Test No. 3

A surgeon performed umbilical ring plasty using the Sapezhko technique. The patient has concomitant diastasis of the rectus abdominis muscles. In which direction should the umbilical ring be incised in this case?

a. Longitudinal

b. Transverse

c. Obliquely from left to right

d. Obliquely from right to left

e. Radially

Test No. 4

A surgeon is closing the Linea Alba of the abdomen following an upper midline laparotomy. Which suture is rational to use in this case to prevent The formation of an incisional hernia?

a. Simple interrupted

b. Mattress (U-stitch)

c. Multanovsky

d. Simple continuous

e. Purse-string

B. Self-Assessment Tasks

Task 1. When operating on a patient with an incarcerated femoral hernia, the surgeon dissected the internal ring of the femoral canal upward. Did the surgeon act correctly?

Task 2. When operating on a patient with an incarcerated hernia, the surgeon dissected the internal ring of the femoral canal medially. Severe bleeding occurred. What mistake did the surgeon make? Further management strategy.

Task 3. During surgery for a femoral hernia, at the moment of suturing the inguinal ligament to the pectineal ligament, severe bleeding occurred in the lateral part of the internal ring of the femoral canal. Where is the bleeding from? What is the surgeon's error?

Task 4. What is the surgeon's strategy if the "corona mortis" is identified during surgery for an incarcerated femoral hernia?

Task 5. What is the Water/144.html">Origin of the vascular ring that surrounds the internal opening of the femoral canal and is referred to as the "corona mortis"?

References

Main

1. Operative Surgery and Topographic Anatomy; edited. by M.S. Skrypnikov. — K.: Vyshcha Shkola, 2000. — P. 290-294.

2. Operative Surgery and Topographic Anatomy; edited. by M.P. Kovalsky. — K.: Medytsyna, 2010. — P. 222-234.

Supplementary

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2. Operativnaya khirurgiya i topograficheskaya анатомия [Operative Surgery and Topographic Anatomy]; ed. by G.E. Ostroverkhov. — Rostov-on-Don, 1998. — P. 574-587.

3. Operativnaya khirurgiya i topograficheskaya anatomiya [Operative Surgery and Topographic Anatomy]; ed. by K.I. Kulchitsky. — Kyiv, 1994. — P. 196-206.

4. Elizarovsky, S.I. Operativnaya khirurgiya i topograficheskaya anatomiya [Operative Surgery and Topographic Anatomy] / S.I. Elizarovsky, R.N. Kalashnikov. — Moscow, 1979.

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6. Tomashuk, I.P. Rukovodstvo po operativnoy tekhnike dlya nachinayushchikh khirurgov [Manual of Operative Technique for Beginner Surgeons] / I.P. Tomashuk, I.I. Tomashuk. — Kyiv: European University Publishing House, 2001. — 860 p.

7. Frauhi, V.Kh. Kurs topograficheskoy anatomii i operativnoy khirurgii [Course of Topographic Anatomy and Operative Surgery] / V.Kh. Frauhi. — Moscow, 1976.