Editing Femoral hernia (section)

=== '''Modified McEvedy''' approach ===

* 10cm transverse incision - Langer's lines - midpoint overlying lateral edge of the rectus sheath, 4cm above the pubic tubercle (previously done through a vertical incision)
** Original McEvedy was vertical skin incision
* Look out for superficial epigastric veins
* Open anterior rectus sheath vertically - just medial to linea semilunaris (can also open transverse if you want)
* Pass at lateral border of rectus muscle into pre-peritoneal plane - retract muscle medially, to get into TEP plane
* Expose underlying transversalis fascia and peritoneum (no posterior sheath as below arcuate line)
* Identify and ligate the inferior epigastric vessels
* Try to enter pre-peritoneal space and blunt dissect down to neck of hernia
** Alternatively, enter peritoneum and reduce incarcerated viscera from within (combination internal and external force)
* Identify sac - reduce. If unable to reduce:
** Gently dilate the neck of the hernia with a finger alongside the sac
** Apply pressure externally and gentle traction from within
** Consider dissecting the sac
** '''Maybe''' divide lacunar ligament (medial), first checking that there is no corona mortis (common variant aberrant vascular anastomosis between external iliac artery (OR deep inferior epigastric artery) and the obturator artery. It runs along the deep border of the lacunar and pectineal ligaments, and is present in up to 30%. 
*** Can divide inguinal ligament if necessary
*** Can also divide pectineal ligament posteriorly, but unlikely to get much more space as you are right on bone posteriorly anyway
* Open hernial sac and review bowel (can also open peritoneum posteriorly)
* Close orifice with vertical nylon or Prolene sutures between inguinalligament/iliopubic tract anteriorly and pectineal ligament (can also use polypropylene mesh plug)
* Re-approximate peritoneum and rectus sheath