OBJECTIVE: Incarcerated femoral hernia patients had high risk of hernia contents necrosis. We provide our experience of management ischemia and necrosis of hernia contents in emergency incarcerated femoral hernia patients, and to investigate its risk factors.
METHODS: This is a case-control study. Eighty-nine incarcerated femoral patients who underwent emergency surgery from January 2015 to December 2021 were included, and divided into normal group (60 cases) and ischemia/necrosis group (29 cases) according to the intraoperative condition of hernia contents. The surgical methods, intraoperative and postoperative conditions were compared between the two groups. Multivariate logistic regression was used to analyze the risk factors of ischemia and necrosis of hernia contents.
RESULTS: Open preperitoneal tension-free repair was the most commonly used surgical methods (68.5%) for incarcerated femoral patients. The utilization rate of laparoscopic repair in the ischemia/necrosis group was lower than that in the normal group (13.8% vs. 20.0%, P = 0.475). The proportion of mesh placement in the normal group was significantly higher than that in the ischemia/necrosis group (98.3% vs 65.5%, P < 0.001). The hernia contents resection rate (55.2% vs 1.7%), operation time (90 vs 40 min), intraoperative bleeding (5 vs 2 ml), ICU admission rate (31.0% vs 1.7%), and hospital stay (7 vs 4 d) were significantly higher in the ischemia/necrosis group than those in normal group. Results of multivariate logistic regression showed that incarceration time more than 9 h (aOR = 19.3, 95%CI: 1.9-192.9) was an independent risk factor for ischemia and necrosis of hernia contents in emergency incarcerated femoral hernia patients.
CONCLUSIONS: Open tension-free repair was the most commonly used surgical methods for emergency incarcerated femoral hernia patients. Ischemia and necrosis of hernia contents will increase bowel resection rate and prolong operation and hospital stay. Long incarceration time is an independent risk factor for ischemia and necrosis of hernia contents.

BACKGROUND: Groin hernia is one of the most commonly managed surgical diseases around the world. The typical question asked by patients is \"Does my hernia require urgent surgery?\". The currently available classifications are insufficient to stratify patients into different groups. We propose a new classification that incorporates diverse clinical elements together with anatomical and other vital information, which allows us to stratify patients into different groups.
METHODS: A task force was formed by the Hong Kong Hernia Society, working with international expert hernia surgeons. The framework of the classification system was formulated. Clinical elements that are important in groin disease stratification were identified. A comprehensive literature review was conducted using PubMed. Those which dictate the severity of the disease were selected and compiled to form the new proposed classification. Application of this classification model to a single hernia surgeon\'s registry in The Hong Kong Adventist Hospital Hernia Centre was done for initial evaluation.
RESULTS: This new classification incorporates important clinical characteristics forming a total of nine grades of differentiation, together with the anatomical details and special information. This comprehensive system allows the stratification of patients into different groups based on disease severity. It also enables more accurate data collection for future audits, comparisons of disease progression over time, and the effect of different management strategies for different-stage patients.
CONCLUSIONS: This is the first classification system which incorporates essential clinical parameters, which allows the stratification of groin hernia into different stages. Further studies and validation should be performed to evaluate the usefulness and value of this classification in groin hernia management.

Femoral hernia (FH) is traditionally treated by open surgery (OS). Laparoscopic treatment has also shown good results in treating FH. However, there have been few comparative studies of these two techniques. Therefore, our aim was to compare the outcomes of open and laparoscopic surgical FH treatment.
Adult patients with primary unilateral FH undergoing OS or transabdominal preperitoneal (TAPP) hernia repair at our hospital from January 2013 to June 2018 were included in this study. Patients with history of abdominal surgery, contraindications to general anesthesia and those not wishing to receive general anesthesia received OS. Demographics, operation details and complications were compared retrospectively between the two groups.
A total of 132 patients were recruited to the study, 62 and 70 of whom underwent OS and TAPP, respectively. Compared to OS group, the TAPP group had a significantly shorter hospital stay (3.0 vs. 2.0 days, respectively, P < 0.05) and a lower postoperative pain score (3.0 vs. 1.0, P < 0.05), and took less time to return to normal activities (13.0 vs. 6.0 days, respectively, P < 0.05). The overall complication rates were equivalent between the groups (10 vs. 9.7%, OR = 1.037, 95% CI 0.329-3.270).
Both laparoscopic and open surgery appear to be safe and effective in a cohort of patients with femoral hernia and laparoscopic surgery might offer some advantages in reducing length of hospital stay, lower postoperative pain score and quicker return to activities.

BACKGROUND: An incarcerated hernia is a common cause of acute abdominal pain. There are various types of incarcerated hernias, including incarcerated hernias of the appendix. These hernias are often complicated by appendiceal inflammation, necrosis, and suppuration, which affect the outcome of surgical repair. A De Garengeot hernia is a femoral hernia that contains the appendix. This type of hernia has a low incidence. When a De Garengeot hernia is clinically suspected, emergency surgical treatment should be performed as soon as possible.
METHODS: A 59-year-old man was admitted to the hospital with a painful right inguinal mass that had suddenly developed 6 hours earlier. Physical examination revealed a 4 cm × 2 cm palpable mass in the right groin. The mass was hard and could not be reduced due to tenderness. It did not descend into the scrotum. B-ultrasound revealed an incarcerated hernia. During surgery, the hernia was found to contain the appendix, which exhibited distal avascular necrosis. A De Garengeot hernia was diagnosed according to the classification criteria of this type of inguinal hernia. Laparoscopic reduction of the incarcerated hernia, appendectomy, and small-incision femoral hernia repair were performed in the emergency department, and cefuroxime was administered as anti-infection therapy for 2 d postoperatively. After treatment, the patient had no abdominal pain or infection and was discharged on postoperative day 4. He had no recurrence of the inguinal hernia after 16 months of follow-up.
CONCLUSIONS: De Garengeot hernias have a low incidence and are difficult to diagnose. Laparoscopy is useful for their diagnosis and treatment.

A De Garengeot hernia is a rare type of femoral hernia that involves a vermiform appendix within a femoral hernia sac. Because of the rarity of this disease, a standard surgical procedure has not been established, and most cases are diagnosed intraoperatively. Preoperative diagnosis of a De Garengeot hernia is quite difficult. Computed tomography is the most sensitive and specific technique among the available imaging tests for preoperative diagnosis of a De Garengeot hernia. Although a standard surgical procedure is lacking, prompt surgery has become the consensus. The most common procedure is the open anterior approach; this allows exploration of the hernia sac and rapid treatment of its contents, routine appendectomy through a single incision, and preperitoneal repair of the femoral hernia.

BACKGROUND: A modified Kugel patch is more expensive than ordinary mesh and demands a wide dissection of the preperitoneal space in femoral hernia repair. We therefore adopted a novel method using mini-mesh and a Lichtenstein repair. This study compared mini-mesh and Lichtenstein repair with a modified Kugel technique in patients with a primary unilateral femoral hernia.
METHODS: Patients with unilateral femoral hernia were assigned randomly to undergo mini-mesh and Lichtenstein repair (M group) or modified Kugel repair (K group), followed-up at one week, three months, one year and two years. Demographics, hernia characteristics and operative outcomes of two groups were analysed.
RESULTS: A total of 48 patients in the K group and 49 participants in the M group completed follow-up. The operation time for the M group (68.6 ± 13.4 minutes) was significantly shorter than that of the K group (80.6 ± 10.1 minutes; p=0.030). There was no significant difference between the two groups for chronic pain, foreign body feeling and quality of life, and no recurrence occurred.
CONCLUSIONS: Mini-mesh and Lichtenstein repairs have reasonable results in the patients with femoral hernia in this study, with a reduced operation time compared with a modified Kugel repair. The trial was registered with the Chinese Clinical Trials Registry: ChiCTR1900022264.

Hernias are one of the most common diseases. The frequency of multiple hernias is much higher than the frequency reported during herniorrhaphy. Multiple hernias may account for some of the so-called recurrences, in which the small hernia may be veiled by the bigger one and omitted. In this study, we present a case of an 83-year-old female who suffered from multiple hernias namely a left-sided indirect inguinal hernia, a right-sided femoral hernia, and a right-sided incarcerated obturator hernia. Additionally, the characteristics and treatment of obturator hernia were discussed. Ultrasound and computed tomography (CT) are capable of accurately diagnosing groin hernia. Preoperative bilateral ultrasound of examinations or abdominopelvic CT should be recommended to perform routinely for patients with suspected hernias to avoid ignoring the concurrent hernias. A careful exploration of the operative field in the operation is mandatory. The CT is also helpful for early diagnosis of obturator hernia. In addition, the intra-abdominal approach through a low midline incision might be a preference for the treatment of obturator hernia.

Femoral hernia repair has various surgical methods. However, controversy still exists regarding the best method for management. This study aimed to compare the infrainguinal with the inguinal approach in the treatment of femoral hernias.
Eighty patients with primary unilateral femoral hernias were prospectively randomized to either the infrainguinal (n = 40) or inguinal approach groups (n = 40). Patient demographics, operative time, duration of hospital stay, postoperative complications, and recurrence rate were recorded.
There were no statistically significant differences between both study groups with respect to the patients\' demographics and associated comorbidities. Regarding inpatient outcomes, there were no differences between the infrainguinal and inguinal approach groups concerning the postoperative duration of stay (P = 0.248), urinary retention (P = 0.494), superficial wound infection (P = 0.494), seroma (P = 0.615), foreign body sensation (P = 0.615), and chronic pain (P = 0.359). However, total complications were encountered in 3 patients (7.5%) in the infrainguinal approach group compared to 11 patients (27.5 %) in the inguinal approach group (P = 0.037). Also, the mean operative time was significantly shorter in the infrainguinal approach group compared to that in the inguinal group (P < 0.001). Throughout the 15 mo median follow-up duration, there was no recurrence in the inguinal approach group and one (2.5%) recurrence in the infrainguinal approach group (P = 1.000).
In patients undergoing elective primary femoral hernia repair, the infrainguinal approach has a similar clinical curative effect to that of the inguinal approach. However, the former has the advantages of simple operation, short operation time, and fewer complications.

Femoral hernias constantly present as incarceration or strangulation and require emergency surgery. Incarcerated and strangulated femoral hernia repair remains challenging and controversial. The aim of our study was to analyze the efficacy of preperitoneal tension-free hernioplasty via lower abdominal midline incision for incarcerated and strangulated femoral hernia.
Data of 47 patients who underwent emergency surgery for incarcerated or strangulated femoral hernias from January 2009 to December 2017 were retrospectively analyzed. According to the surgical incisions, they were divided into two groups: the observation group (21 cases) had a lower abdominal midline incision, and the control group (26 cases) had a traditional inguinal incision. General data of patients, intraoperative findings, operative time and postoperative complications were compared.
Patient characteristics showed that the two groups were comparable.15 cases (31.9%) underwent intestinal resection, and 32 cases (68.1%) underwent first-stage tension-free repair in total. The rate of first-stage tension-free hernioplasty was significantly higher in the observation group (18/21, 85.7% vs 14/26 53.8%, P = 0.020). No additional incision was required in the observation group, while six cases of the control group (23.1%) had an additional incision for intestinal resection and anastomosis (P = 0.026). Mean operative time (53.6 ± 24.7 min vs 77.9 ± 36.5 min, P = 0.012) and the length of hospital stay (6.3 ± 4.2 days vs 10.3 ± 6.9 days, P = 0.020) were significantly shorter in the observation group. The time of return to normal physical activity resulted significantly reduced compared to the control group (9.2 ± 4.1 days vs 13.3 ± 6.6 days, P = 0.017). The total incidence of postoperative complication (including chronic pain, foreign body sensation, hernia recurrence, wound infection and seroma/hematomas) in the observation group was lower (14.3% vs 42.3% P = 0.037). There were two recurrences in the control group. No mesh-related infection and no mortalities in two groups.
Midline preperitoneal approach for incarcerated and strangulated femoral hernia is a convenient and effective technique. It can improve the rate of first-stage tension-free repair of incarcerated femoral hernia and allow intestinal resection through the same incision, and with lower rate of postoperative complications.

Laparoscopic repair of inguinal hernia is mini-invasive and has confirmed effects. Femoral hernia could be repaired through the laparoscopic procedures for inguinal hernia. These procedures have clear anatomic view in the operation and preoperatively undiagnosed femoral hernia could be confirmed and treated. Lower recurrence ratio was reported in laparoscopic procedures compared with open procedures for repair of femoral hernia. The technical details of laparoscopic repair of femoral hernia, especially the differences to laparoscopic repair of inguinal hernia are discussed in this article.