EP 110 Concurrent Ipsilateral Direct, Indirect, and Femoral Hernias Identified During TAPP Repair: A Rare Case Highlighting Essential Steps to Avoid Missing Femoral Defects
Jianling Zhang, Fanghong Wang, Xinglong Lu, Wenzhen YuanAbstract
Background
The transabdominal preperitoneal (TAPP) approach offers a panoramic view of the myopectineal orifice and is particularly valuable for detecting occult femoral hernias, which are easily missed during open or limited laparoscopic repairs.
Case Presentation
We report a rare case of a middle-aged male patient with simultaneous ipsilateral indirect, direct, and femoral hernias. During TAPP repair for a symptomatic right groin hernia, diagnostic laparoscopy revealed an indirect hernia lateral to the inferior epigastric vessels, a direct hernia medial to the vessels, and an unexpected femoral hernia located beneath the inguinal ligament at the femoral ring. The femoral defect was not suspected preoperatively and was identified only through systematic intraoperative exploration. Representative intraoperative images were documented.
Surgical Technique and Key Points
A wide peritoneal incision was created to allow full exposure of the preperitoneal space. Dissection was deliberately extended inferiorly to expose Cooper’s ligament and the femoral canal. Routine, stepwise inspection of the entire myopectineal orifice—particularly the area below the inguinal ligament—was essential for identifying the femoral hernia. A single appropriately sized mesh was placed to comprehensively cover all three defects.
Conclusion
The coexistence of ipsilateral direct, indirect, and femoral hernias in male patients is exceptionally rare. This case underscores the importance of systematic inspection of the femoral region during TAPP repair. Consistent exposure of Cooper’s ligament and the femoral canal is crucial to preventing missed femoral hernias, especially in patients with multiple concurrent groin hernias.