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The inguinal or 'high' approach to femoral hernia repair is advantageous for repair of simultaneous inguinal and femoral hernias. Sometimes, it is used when a femoral hernia has been mistaken for an inguinal hernia. Its disadvantages are that it is technically more difficult and slower than the low approach. Also, it can weaken an otherwise normal inguinal canal and its access is not ideal for a large femoral hernia.
The initial stages of the approach are exactly the same as for an open inguinal herniorrhaphy - see submenu. Once the inguinal canal has been entered, the cord or round ligament is displaced superiorly. Then, the transversalis fascia along the medial section of the posterior wall is divided. This should reveal the neck of the femoral hernial sac. The sac is delivered above the inguinal ligament into the wound. After careful dissection of the fat from the sac, it is incised on its lateral aspect. The contents are examined - any non-viable viscus is dealt with as described in the submenu under 'strangulation found during repair'. Viable tissue is returned to the peritoneal cavity.
Having emptied the sac, it is rotated around the neck, transfixed with a stitch and excised. The femoral canal is reinforced from above - pelvic aspect - by suturing the inguinal ligament to the pectineal ligament. A figure-of-eight stitch can be used in the same manner as a crural or low approach.
Finally, the inguinal canal is repaired and the skin closed in the same manner as an inguinal herniorrhaphy. The Shouldice repair provides a particularly strong reconstruction.