Page 60 - International guidelines for groin hernia management

Hernia

Discussion is, therefore, advised to avoid division of the round liga-
There are several case reports and case series, but only one ment in open (anterior) hernia repair. If the ligament is
small prospective cohort study describing the onset of a divided nonetheless, care should be taken to properly
groin lump in pregnancy associated with varicose veins of address any incidentally ligated nerves.
the round ligament rather than a groin hernia. All conclude Division of the round ligament in laparoscopic hernia
that a watchful waiting strategy is safe and preferred. It repair is optional and might facilitate optimal mesh
seems prudent to confirm the diagnosis with color Doppler placement. The round ligament is enveloped by the peri-
sonography. The true prevalence of groin hernia formation toneum and may lead to lower folding of the mesh or
during pregnancy is unknown, difficult to determine, and peritoneum sliding beneath. For this reason, many surgeons
only mentioned—but not investigated—in two small choose to divide it in laparoscopic repair. There are fewer
cohort studies. The level of evidence supporting the implications of division in the preperitoneal space as the
statements in this section is low because of limited medical nerves are not adherent to the ligament until it enters the
literature on the subject. internal ring. Division of the round ligament should,
therefore, be performed proximal to the genital branch
Key question meeting, which is typically best performed at the fusion
with the peritoneum where division has no functional
KQ16.e What is the best management of the round liga- implication.
ment in women who undergo groin hernia repair?

Evidence in literature Discussion
One unaddressed issue in the management of groin hernia There is no literature that addresses the sparing or division
repair in women is whether the round ligament should be of the round ligament in groin hernia repair in women. The
divided or spared during surgery. Although there is no statements are based on anatomical considerations and
evidence in the literature to support either, there are some thorough discussion with experts in anterior and
anatomy-based considerations to take into account, mainly retroperitoneal neurectomy.
based on extrapolation from extended experience with
anterior and retroperitoneal neurectomy.
The round ligament is attached to the uterus through the
broad ligament of the uterus, enters the inguinal canal, and Chapter 17
finally terminates in the digital process of fat of the labia
majora. The genital branch of the genitofemoral nerve
mostly meets the round ligament at the internal ring, but Femoral hernias
sometimes it may join earlier. Division of the round liga-
ment in open repair inherently implies simultaneous divi- H. Eker, N. Schouten, K. Bury, and F. Muysoms
sion of the genital nerve and likely division of the
ilioinguinal nerve. Sacrifice typically has minimal mor- Introduction
bidity or consequence but carries a small risk of deaf- Elective and emergent femoral hernia repairs constitute
ferentation hypersensitivity and ipsilateral labial numbness roughly 2–4% of all groin hernia repairs. However, the true
that may contribute to complaints of sexual dysfunction. It femoral hernia incidence is likely lower than 2–4%, since

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