Cloquet's hernia is a hernial sac protruding underneath the fascia of the pectineus muscle, it is also highly liable to strangulate.

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Femoral Vs inguinal hernia

◼️The NECK of an inguinal hernia always emerge from the external inguinal ring whether it is direct or indirect, therefore the neck will be above and medial to the most medial end of the inguinal ligament at its attachment to the pubic tubercle.

◼️The neck of a femoral hernia always pass through the femoral canal, which will be below and slightly lateral to the pubic tubercle.

◼️Applying pressure on the external inguinal ring and asking the patient to cough is another way to differentiate, in femoral hernia a cough impulse is exerted when the pressure is applied and vice versa.

◼️The fundus of a femoral hernia may pass in the path of least resistance and may overlie the inguinal ligament.

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Femoral hernia and the gender

The female to male ratio is 2:1, it is interesting that female patients are usually elderly, whereas male patients are usually between 35-40 years, so it useful to remember the quote (your grandmother and your father have femoral hernia)

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Surgical anatomy of the femoral ring

◼️Anteriorly it is bound by the inguinal ligament.

◼️Medially it is bound by the Lacunar ligament (Gimbernant's ligament).

◼️Posteriorly it is bound by the ileopectineal ligament (Astley cooper's ligament) and the pubic bone and fascia over the pectineus muscle.

◼️Laterally it is bound by a thin membrane seperating it from the femoral vein.

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Reduction en masse


Reduction-en-masse means reduction all together, it refer to a complication of manual reduction of a hernia in which the entire hernial mass including the contents and the sac and the neck are reduced back to the abdomen, so practically the strangulation is not relieved.

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Femoral sheath and femoral canal

◼️The femoral sheath lies in the femoral triangle and it is a sleeve of fascia that is continuous superiorly with the transversalis fascia.

◼️It is divided by septa into compartments.

◼️The most medial compartment is called the femoral canal.

◼️The femoral canal is 1.25cm long and 1.25 cm width at its base which is directed upwards.

◼️The femoral canal contains lymphatic vessels and lymph nodes of Cloquet.

◼️It starts from the femoral ring and ends at the saphenous openings.

◼️From above it is closed by a septum called septum crurale and from below it is closed by the cribriform fascia.

◼️The septum crurale is pierced by lymphatics and is a potential point of weakness making the femoral canal the site of femoral hernias

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The word VAN helps to remind you the order of structures within femoral triangle from medial to lateral they are

V= femoral Vein
A= femoral Artery
N= femoral Nerve

Dont forget the the most medial one is the femoral canal containing lymphatics and lymph nodes of Cloquet

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#Femoral_Triangle

◼️It is a wedge shaped depression formed by the muscles of the upper thigh at the junction between the anterior abdominal wall and lower limb.
◼️The base of the triangle is the inguinal ligament.
◼️Medial border is the medial margin of adductor longus.
◼️Lateral border is the medial margin of sartorius muscle.
◼️Floor of the triangle is formed medially by the pectineus muscle and adductor longus,, laterally it is formed by the iliopsoas muscle descending from the abdomen.
◼️The apex is continuous with a fascial canal called Adductor canal which pass posteromedially down the thigh and ends in a hole in adductor magnus muscle to open on the popliteal fossa.

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Recurrence of Hernia after operation:

◼️Reports suggest that recurrence rate vary between 0.2% up to 15% depending on the technique used.

◼️Only by using meticulous technique principally concentrating on reinforcement of the posterior wall of inguinal canal with the shouldice technique or mesh hernioplasty can a recurrence rate of less than 2% be achieved.

◼️Only 50% of recurrences will become apparent within two years.

◼️In a few cases "false" recurrence occur, i.e another type of hernia occur - direct after indirect, femoral after inguinal. How ever to the patient it is recurrence!!

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Direct inguinal hernia

◼️Figure above is a direct inguinal hernia descended into scrotum (unusual) with gangrene and sloughing of skin.
◼️They are always acquired and result from passage of the hernial sac through a point of weakness or a defect of transversalis fascia in posterior inguinal wall usually medial to the inferior epigastric vessels.
◼️Risk factors include male gender, smoking (thought to cause acquired collage defeciency), old age, straining or heavy lifting, and injury of the Ilioinguinal nerve (previous appendicectomy/more with Gridiron incision).
◼️Patients often have elongated buldings in the abdominal wall resulting from poor lower abdominal musculature (Malgaigne's buldgings).
◼️The sac is often smaller than the observed mass indicate because of thick coverings mainly made of extraperitoneal fat.
◼️The neck is wide thus strangulation is less often.
◼️If presented unilaterally, there is a fourfold higher risk of contralateral involvement in the future.

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Examination sequence for hernia

◼️Examine the groin while the patient is standing up.
◼️Examine the inguinal and femoral canals and scrotum for any buldges.
◼️Identify the anatomical relationship between the buldge and pubic tubercle and the inguinal ligament to distinguish femoral from an inguinal hernia.
◼️Palpate the external inguinal ring and along the inguinal canal for any defects. Ask the patient to cough and feel for cough impulse.
◼️Instruct the patient to lie down and see whether the hernia reduce spontaneously or not.
◼️If so, press two fingers over the internal inguinal ring (midpoint between anterior superior iliac spine and pubic symphesis about 1.25cm above inguinal ligament) and ask the patient to cough if the hernia reappears it is DIRECT and if pressure prevent it from reappearing it is INDIRECT.
◼️Examine the opposite side for possibility of asymptomatic hernia (inguinal hernia is bilateral in 12% of cases).

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#Inguinal_Triangle
◼️ Synonym=Hasselbach's triangle.
◼️Medial border is the lateral margin of rectus abdominis muscle.
◼️ Superolateral border is the inferior epigastric vessels.
◼️ Inferior border is the inguinal ligament.
◼️ It is a potential point of weakness, direct inguinal hernias occur medial to the inferior epigastric vessels in the inguinal triangle,, what is the exception to this rule?

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Types of indirect inguinal hernia

◼️Bubonocele "Bubon is greek for groin", here the hernia is limited to the inguinal canal.

◼️Funicular "funiculus latin for small cord" Here the processus vaginalis is closed just above the epididymis, the contents of the sac can be felt seperately from the testis.

◼️ Complete (synonym = scrotal), it is rarely present at birth but commonly encountered thereafter during infancy, it can also occur in adolescents and adults, the testis appear to lie within the lower part of the hernia.

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Anatomy of inguinal canal
◼️In infants the internal and external rings almost oppose each other and the obliquity of the canal is slight.
◼️In adults the canal is about 3.75cm long extending from the internal to the external ring downwards and medially.
◼️In males the canal transmit the spermatic cord, ilioinguinal nerve and genital branch of genitofemoral nerve, in females the round ligament replaces the spermatic cord.
◼️The posterior wall is formed of the transversalis fascia (black arrow) and the conjoined tendon of internal oblique and transversus abdominis muscles (yellow arrow).
◼️The anterior wall is mainly formed of external oblique aponeurosis.
◼️The inferior boundery is the inguinal ligament.
◼️The superior boundery is formed by the conjoined muscles (internal oblique and transversus abdominis).

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Surgical anatomy

◼️The deep inguinal ring is a U shaped condensation of the transversalis fascia, which is the fascial envelope of the abdomen it lies between the parietal peritoneum and the muscles of the abdominal wall(see figure above).
◼️The deep inguinal ring is about 1.25 cm above the inguinal ligament midway between the symphesis pubis and the anterior superior iliac spine.
◼️The competency of the deep inguinal ring greatly depends upon the integrity of the transversalis fascia.

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Surgical anatomy

◼️ The superficial inguinal ring is a triangular aperture in the aponeurosis of the external oblique.
◼️ It is bounded superomedially by the medial crus (black arrow) which is thinner and attached to the anterior aspect of the pubic symphesis AND bounded inferolaterally by a thicker crus, called the lateral or inferolateral crus (yellow arrow) , both are interconnected by the intercrural fibers (blue arrow) .
◼️The ring is bounded below by the pubic crest.
◼️The external inguinal ring lies about 1.25 cm above the pubic tubercle.
◼️Normally the external inguinal ring do not admit the tip of the little finger.

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Clinical features of strangulated hernia:

◼️Sudden pain starting at the hernial site followed by generalized abdominal pain, this pain is colicky in nature and mainly around the umbilicus.
◼️Nausea and vomitting.
◼️ Recent increase in the size of the hernia.
◼️Extreme tenderness over the hernia.
◼️Tense hernial sac.
◼️Irreducible hernia.
◼️Absence of expansile cough impulse.

N.B sudden spontaneous cessation of pain must be viewed with caution as this may be a sign of perforation

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Pathology Of Strangulated Hernia

◼️Constriction ring develops and impairs blood supply (thin black arrow)

◼️Venous return from the involved segment is affected first.

◼️Congestion develops with transudation of serous fluid into the hernial sac.

◼️Distension of the involved loop and edema results in furthur narrowing of the ring and compromising blood supply even more.

◼️Arterial supply then becomes more and more compromised.

◼️The viability of the bowel becomes affected resulting in translocation of bacteria through the wall leading to infection of the sac.

◼️If left unrelieved, gangrene develops (usually within 6 hours) first at the seat of constriction ring (thick black arrow) then at the antemesentric border(yellow arrow) perforation is expected in these sites.

◼️Because of these pathological events peritonitis spreads from the sac to the general peritoneal cavity.

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Types of Hernias

◼️ Reducible.. Where the hernia can be reduced when the patient lies down or by the patient himself or by the surgeon, if the contents are intestine, then there is often a gurgling sound at time of reduction, and also the first part is usually more difficult to reduce than the last part, if the contents are omentum, then it will feel as a doughy mass, the last portion is more difficult to reduce than the first one.
◼️ Irreducible.. Refer to a hernia which do not return to the abdomen in absence of any other related symptoms it may occur because of adhesions between the sac and the contents or may occur due to overcrowdening of the sac with contents, such a hernia that doesnt reduce and doesnt produce any symptoms is highly suggestive of omentocele. Note that any degree of irreducibility predispose to strangulation.
◼️Obstructed.
◼️Strangulated.. Can proceed to gangrene within only 6 hours.
◼️Inflamed

What does incarcerated hernia mean?
-See below, I have quoted it.🌚

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