Novel 3-Layer Femoral Herniorrhaphy: Combining the Best of McVay and Shouldice

Abstract

Femoral hernias occur less frequently than inguinal hernias, but are often more challenging to repair surgically. Femoral hernias constitute between 2% and 8% of groin hernias, with the majority afflicting women. Because of the narrow neck and unyielding surrounding structures, femoral hernias are more likely to incarcerate or strangulate than their inguinal counterparts. They commonly present with incarceration of fat or intra-peritoneal contents. There has been extensive controversy in the last several decades concerning optimal approaches to femoral hernia repair, beginning with inguinal vs femoral approaches initially, to current debates about open vs laparoscopic and mesh vs tissue. Annandale is credited with the first inguinal approach to femoral hernia repair. Many other techniques have been described, but the contributions of Chester McVay established the fundamental basis for understanding femoral hernia repair. The McVay repair requires a relaxing incision to obtain a tension-free repair. Since Lichtenstein and colleagues described the use of prosthetic mesh for tension-free herniorrhaphy, many have turned to mesh to address the difficulties of femoral hernia repair, obviating the need for a relaxing incision. The use of prosthetic mesh is not universally applicable to femoral or inguinal hernia repair due to the incidence of strangulation and necrosis causing a potentially contaminated field. In addition, mesh can lead to other complications, such as chronic pain, infection, migration, and erosion. An effective primary tissue repair for femoral hernia is a useful procedure in the armamentarium of the general surgeon. During two recent humanitarian missions to Guatemala, surgeons from the George Washington University Department of Surgery encountered an unusually large incidence of femoral hernias. A technique developed at George Washington University, which combines a classic McVay (Cooper’s ligament [CL]) repair with a