Through an inguinal incision, 1 cm above the medial half of the inguinal ligament (Figure 1) the femoral hernia sac can be explored from below (Lockwood approach) (Figure 2 – (a)). A simple femoral hernia repair can then be performed if this is found without compromised sac content. Figure 1 Surface anatomy and skin incision. Figure 2 Approaches to the hernial sac: (a) Infrainguinal approach. (b) Transinguinal approach. (c) High approach. If no femoral hernia is discovered but an inguinal hernia is present, then the inguinal canal can be explored by dividing the external oblique aponeurosis (Figure 2 – (b)) and

completing a classical open inguinal hernia repair of the surgeon’s choice. More importantly Nutlin 3a however, with this technique, if the femoral hernia contains click here compromised bowel requiring resection, this can be achieved by creating a plane superficial to the external oblique aponeurosis (Figure 2 – (c)). The rectus sheath is then divided along the linea semilunaris 4 cm above the inguinal ligament (Figure 2), thus preserving the inguinal canal, but exposing the lateral border of the rectus abdominis muscle which is retracted

medially. Then the fascia transversalis and peritoneum are divided giving access to the peritoneal cavity and compromised bowel. Discussion We do not presume to be the first to have performed this technique, but we are not aware that it has been formally reported in the literature. More importantly surgical teaching is still centred around the three classical approaches to femoral hernia repair, and, although we do not deny the historical value of these, we feel that awareness of this approach is of value for the surgical trainee.

Although rare, we estimate that we perform approximately 3-4 emergency femoral hernia repairs per year using this technique, and to date collaboratively have performed 78 cases. There have been no complications associated with this technique although we do not suggest that complications associated with any groin hernia operation such as seroma formation and wound infection are significantly decreased with this approach. We are not aware of any hernia recurrences using this technique although the age group and co-morbidities of the patients involved often preclude long Ergoloid term follow up, as do restrictions on clinic space in the current NHS. In terms of post-operative recovery, particularly where strangulated bowel is encountered, the lack of conversion to laparotomy or further skin incisions can only, we believe, contribute to quicker recovery times. Most importantly however, this simple technique minimises the preoperative debate as to which incision will allow the best approach to the femoral sac, allow for alteration to a simple inguinal hernia repair if necessary, and more importantly obviate the need for further skin incisions if compromised bowel is encountered that requires resection. References 1.