Many technical procedure has been developed to repair femoral hernia. Since 1989 the Lichtenstein Plug technique has diminished the post operative complication and recurrence. The advantages present,in term of pain and post operative discomfort, recovery of physicaland labor activity are very good. This technique can be indicated in complicated hernia^[1,2]. The aim of this article is to describe the surgical technique and to analyze the preliminary results of our series of 46 patients.

Methods

We perfomed a descriptive and observational study with a retrospective Character in our surgical group at “Dr. Enrique Cabrera”Teaching and General Hospital, between the years 2009-2018 to the patients who under went surgical repair of femoral hernia through the Lichtenstein Plug technique and their post operative behaviour. The following variable were analyzed: age, type of hernia, tolerance to local anesthesia, surgical technique, operating time, post operative pain,wound sepsis and recurrence of hernia; return to activity. All these ítems were collected in Microsoft Excel base and later were processed in the SPSS statistics program.

Results

Table 1 shows the most relevant results of this series. We can seethat the largest number of patients was women, 36 in total, 78% andthere were only 10 men, 22%; which is in accordance with what hasbeen reported with other authors. The most frequent location was the right one in 31 patients, 67.5% and the average age of the patients was 58.7 years, with a range between 19 and 92 years zx^[3]. 47 surgical interventions were performed in 46 patients, since there was a relapse 2.2%. It was a patient who had undergone surgery for a recurrent incarcerated femoral hernia and who had a wound infection in thepostoperative period^[4]. The most used anesthesia was the local one which was applied to 29 patients. 63%, followed by the regional one in 12 patients, 26.2% of the cases, Table 2 It is also observed in this table that the average duration of surgical interventions was 25 minutes and the hospital stay was 8 hours, like other authors^[5-7].

Table 1: Sex, Location, Recurrence, Varity, Middle Ages

Source: Data collection form

Table 2: Type of Anesthesia, Average Duration, Hospital media stay.

Source: Data collection form

The only recurrences observed in our series were in a patient who was operated on because of a relapsed, incarcerated hernia. In the surgical act a wide femoral orifice was observed that was occluded with a cylinder of polypropylene mesh like all the other patients. In the post operative period he presented wound infection and recurrence at four months. In the reoperation, it was found that the cylindrical prosthesis was of insufficient size to occlude the femoral orifice. This patient underwent a pre-peritoneal repair with a wide patch of polypropylenemesh.

Discussion

The great advantage of this technique is the absence of tension,and for this the mesh must completely occlude the hernial orifice. Therefore the prosthesis will be adapted to the size of the hole and not the reverse, avoiding the partial closure of the hole when it is large, since this would give rise to tension zones with the consequent risks of recurrence. In the primary femoral hernia figure 1, the hernialorificeis small figure 2 and can be satisfactorily occluded with the polypropylene cylindrical prosthesis figure 3. The low rate ofcomplications and its simple and rapid execution means that we considerit as a technique of choice in cases of primary femoral hernia.In recurrent femoral hernia, the ring is generally larger, and in cases of urgent surgery due to a stuck or strangulated femoral hernia, it is often necessary to expand the hernia ring to adequately manage the affected bowel. In no case should try to reduce the size of the hole bysuture, even large, because of the danger of recurrence. In these cases,it may be useful to replace the Lichtenstein cylindrical prosthesis witha cone-shaped mesh as it has been used by other authors. The prosthetic material used in the cases has been a monofilament polypropylene mesh, as it is considered the most appropriate, since it is strong, resistant to infection and the cases of intolerance are practically non-existent since the yellow a rapid interstitial fibroblastic proliferation that fixes it intimately to the tissues, which fixes it intimately to the tissues, according to reports Mansilla Molina D^[8]. In our series, we did not have any deaths and the highest morbidity occurred in the group of older patients. For this reason, to get her with the high probability of strangulation of the femoral hernia^[9] we believe that all patients diagnosed with femoral hernia, regardless of age and surgical risk, should undergo a programmed procedure after adequate preparation, thus avoiding situations adverse events that increase morbidity and mortality, according to what was expressed by Porrero JL in 1993 and Chamary V.L. also in 1993^[10-12]. Local anesthesia was the most used in our series, 63%, due to the great benefits they bring to the patients with high surgical risk, however, atpresent the most frequently used is the regional one^[13,14]. Finally, we can affirm that the series we present is not very extensive, but it is supported by good results, both in the immediate post-operative periodand in there incorporation of the patients to his habitual activity, as well as, in the absence of recurrences or complications delayed, when applying the Lichtenstein Plug technique in the repair of the femoral hernia. We can conclude affirming like other authors^[14-16]. Which are equally significant, the convenience of repair when performed under local anesthesia, which is ideal if it is scheduled surgery, since the reduction of tissues trauma and post-operative discomfort and a lower incidence of sepsis and tissues tension, reduce potential recurrence and favour early Ambulation^[17-19].

Figure 1: Patients with right femoral hernia

Figure 2: Hernia sac dissected through the dilated femoral orifice.

Figure 3: Occlusion of the femoral ring with a polypropylene cylindrical prosthesis.

Conclusion

For all of the above, we believe that the Lichtenstein Plug techniqueshould be of choice in the surgical treatment of femoral hernia.

Conflicts of Interest

The authors do not declare having conflicts of interest

References

1. 1. Lichtenstein, I.L., Shore, J.M. Simplified repair of femoral and recurrent inguinal hernias by a “plug” technic. (1974) Am J Surg 128(3): 439-444.

   PubMed│CrossRef│Others

2. 2. Nicholson, S, Keane, T.E., Devlin, H.B. Femoral hernia: an avoidable source of surgical mortality. (1990) Br J Surg 77(3): 307-308.

   PubMed│CrossRef│Others

3. 3. Bendavid, R. New techniques in hernia repair. (1989) World J Surg 13(5): 522-531.

   PubMed│CrossRef│Others

4. 4. Lichtenstein, I.L. Herniorrhaphy. A personal experience with 6,321 cases. (1987) Am J Surg 153(6): 553-559.

   PubMed│CrossRef│Others

5. 5. Gilbert, A.I. Sutureless repair of inguinal hernia. (1992) Am J Surg 163(3): 331-334.

   PubMed│CrossRef│Others

6. 6. Robbins, A.W., Rutkow, I.M. Mesh plug repair and groin hernia surgery. (1998) Surg Clin North Am 78(6): 1007-1023.

   PubMed│CrossRef│Others

7. 7. Lichtenstein, I.L., Shulman, A.G., Amid, P.K. Use of mesh to prevent recurrence of hernias. (1990) Postgrad Med 87(1): 155-158.

   PubMed│CrossRef│Others

8. 8. Mansilla Molina, D., Perez Folques, J.E., Civera Muñoz, J., et al. Hernioplasty without tension in crural hernias. (1999) Cir Esp 65: 176-178.

   PubMed│CrossRef│Others

9. 9. Cobaleda, F.S.B., Muñoz-Najar, A.G., Trujillo, B.M., et al. Recurrent inguinal hernia: treatment using a preperitoneal approach and a wide polypropylene mesh prosthesis. (2000) Cir Esp 67: 354-357.

   PubMed│CrossRef│Others

10. 10. Porrero, J.L., Ten, M., Martín, D., et al. Experience with the LUG tenstein PLUG technique in the treatment of Crural Hernia. (1993) Cir Esp 53: 97-99.

    PubMed│CrossRef│Others

11. 11. Chamary, V.L. Femoral hernia: intestinal obstruction is an unrecognized source of morbidity and mortality. (1993) Br J Sur 80(2): 230-232.

    PubMed│CrossRef│Others

12. 12. Porrero, J.L., Sánchez-Cabezudo, C., Bonachía, O., et al. [Inguinofemoral hernia: multicenter study of surgical techniques]. (2005) Cir Esp 78(1): 45-49.

    PubMed│CrossRef│Others

13. 13. Rafael, R.F., Fernandez, E.I.M., Rabassa, P.P.C., et al. Use of Bioprosthesis in complicated inguinocrural hernias. (2003) Rev Cubana Cir 42(2): 1-7.

    PubMed│CrossRef│Others

14. 14. de Juan, A., Mena, A., Die, J., et al. Is the Lichtenstein Plug technique suitable for the treatment of complicated crural hernia? (2003) Spanish Surgery 74: 104-107.

    PubMed│CrossRef│Others

15. 15. Acevedo, A., Reyes, E., Herrera, J.C. Femoral hernia: study of the posterior wall of the Inguinal Canal. (2005) Reuchi Cir 57: 495-499.

    PubMed│CrossRef│Others

16. 16. Townsend, C.M., Beauchamp, R.D., Evers, B.M., et al. Sabiston text Book of Surgery. The Biological Basis of Modern Surgical Practice, 18th ed. (2007) Saunders Elservier, USA.

    PubMed│CrossRef│Others

17. 17. Lòpez Rodriguez, P.R., Leòn Gonzàlez, O.C., Satorre Rocha, J., et al. Femoral Hernia. Ten years of experience in using the Lichtenstein Plug Technique. (2012) Rev Cuban Cir 51(3): 211-216.

    PubMed│CrossRef│Others

18. 18. Townsend, C.M., Beanchamp, R.D., Evers, B.M., et al. Sabiston Texbook of Surgery. 20th ed. The Biological Basis of Modern Surgical Practice . (2017) Elsevier Saunders, USA.

    PubMed│CrossRef│Others

19. 19. Lockhart, K., Dunn, D., Teo, S., et al. Mesh versus non-mesh for inguinal and femoral hernia repair. (2018) Cochrane Database Syst Rev 9: CD 011517.

    PubMed│CrossRef│Others