Robotic-Assisted Transabdominal Preperitoneal (rTAPP) Femoral Hernia Repair

Abstract

Femoral hernias are an uncommon cause of groin pain but occur more frequently in women than in men and are often overlooked during clinical evaluation and imaging review. Failure to recognize these "hidden" hernias may lead to persistent symptoms despite previous inguinal hernia repair.

A 43-year-old woman presented with chronic left groin pain despite prior open left inguinal hernia repair with mesh plug placement. Her medical history included cesarean section and abdominoplasty, with pain initially attributed to postoperative nerve injury. A computed tomography (CT) scan obtained in 2023 was interpreted as negative for recurrent hernia; however, retrospective review demonstrated an obvious left femoral hernia adjacent to the previously placed mesh plug. She subsequently underwent treatment for May-Thurner syndrome with left common iliac vein stenting without improvement in symptoms. Clinical examination, office ultrasound, and re-evaluation of prior imaging confirmed the diagnosis of a symptomatic femoral hernia.

A robotic transabdominal preperitoneal (rTAPP) repair was performed. After establishing abdominal access and creating a generous preperitoneal flap, the myopectineal orifice was completely exposed. The previously placed mesh plug was identified medial to the inferior epigastric vessels and largely left undisturbed with only a small portion excised to facilitate flat placement of new mesh. The femoral hernia sac and incarcerated preperitoneal fat were reduced, the round ligament was divided, a large preperitoneal mesh was positioned to cover the femoral canal and all potential groin defects, and the peritoneal flap was closed.

This case demonstrates the importance of maintaining a high index of suspicion for occult femoral hernias in women with persistent groin pain, particularly following previous anterior inguinal hernia repair. Robotic TAPP repair provides excellent visualization of the entire myopectineal orifice and enables definitive treatment while preserving previously implanted mesh when appropriate.

Keywords

Femoral hernia; robotic TAPP; rTAPP; groin pain; hidden hernia; female hernia; recurrent groin pain; minimally invasive hernia surgery.

Case Overview

Background

Femoral hernias account for a relatively small proportion of groin hernias but occur disproportionately in women. Because they lie inferior to the inguinal ligament and are often not readily appreciated on physical examination or routine imaging interpretation, they are considered "hidden hernias" and may be overlooked during initial evaluation. Consequently, female patients with persistent groin pain may undergo anterior inguinal hernia repair without treatment of the true pathology.

Robotic transabdominal preperitoneal (rTAPP) repair provides comprehensive visualization of the entire myopectineal orifice, allowing identification and treatment of femoral, indirect, direct, and obturator defects during the same operation. This case highlights the value of minimally invasive posterior exploration in a woman with persistent groin pain following prior open inguinal hernia repair, ultimately revealing an occult femoral hernia responsible for her ongoing symptoms.

Focused History of the Patient

A 43-year-old woman presented with chronic left-sided groin pain that persisted despite previous surgical intervention. Her medical history was significant for cesarean section and cosmetic abdominoplasty.

Because of her prior abdominal operations, her symptoms were initially attributed to postoperative neuropathic pain. She subsequently underwent an open left inguinal hernia repair using a mesh plug placed within the direct space based on the clinical exam and the patient’s symptoms. After surgery, her symptoms failed to improve and progressively worsened.

A CT scan obtained in 2023 was interpreted as demonstrating no significant pathology. During further evaluation for persistent symptoms, she was diagnosed with May-Thurner syndrome and underwent placement of a left common iliac vein stent. Despite technically successful venous intervention, her groin pain remained unchanged.

Upon referral for further hernia evaluation, careful review of her clinical examination, office ultrasound, and retrospective assessment of the prior CT scan demonstrated a left femoral hernia that had not been identified on the original radiology report. Given her persistent symptoms and imaging findings, rTAPP repair was recommended.

Physical Exam

Physical examination demonstrated focal tenderness within the left groin. Although no large palpable inguinal recurrence was appreciated, findings were suspicious for an occult groin hernia. Office ultrasound demonstrated a left femoral hernia corresponding to the patient's symptoms. The prior anterior mesh repair appeared intact without evidence of recurrence.

Imaging

Preoperative CT imaging from 2023 demonstrated the previously placed anterior mesh plug within the direct space (Figure 1). Careful retrospective review also revealed a left femoral hernia that had not been described in the original radiology interpretation (Figures 2 and 3). The previously implanted mesh remained appropriately positioned and was not believed to be the source of her symptoms.

Figure 1. Previously placed mesh plug within the direct space, medial to the epigastric vessels. 

Figure 2. Fat-containing hernia within the femoral space.

Figure 3. Femoral defect with fat-containing hernia medial to the nerve, artery, and vein. 

Figures 1–3 demonstrate:

• Previously placed mesh plug in the direct space.
• Left femoral hernia inferior to the inguinal ligament, consistent with a hidden femoral hernia.
  

Natural History

Untreated femoral hernias frequently enlarge over time and carry a substantially greater risk of incarceration and strangulation than inguinal hernias. Because symptoms may initially consist only of chronic groin pain without an obvious groin bulge, diagnosis is frequently delayed. This is particularly true in women, in whom femoral hernias represent a greater proportion of groin hernias in women than in men.

Options for Treatment

Treatment options included continued observation, repeat anterior groin exploration, or minimally invasive posterior repair.

Observation was considered inappropriate because of the patient's persistent symptoms and the known risk of future incarceration associated with femoral hernias.

Repeat anterior exploration would have required dissection through scar tissue from the prior repair while providing limited visualization of the femoral canal.

An rTAPP repair was selected because it permits complete visualization of the myopectineal orifice, confirmation of all potential groin defects, preservation of previously implanted mesh when appropriate, and placement of a large preperitoneal prosthesis covering the femoral, direct, indirect, and obturator spaces.

Rationale for Treatment

The goals of surgery were to identify and repair the occult femoral hernia responsible for the patient's persistent symptoms while avoiding unnecessary removal of previously implanted mesh that was not contributing to her pain. Additional objectives included complete coverage of the myopectineal orifice to reduce the risk of future groin hernias.

Special Considerations

Women presenting with chronic groin pain warrant careful evaluation for femoral hernias, particularly when prior anterior inguinal hernia repair has failed to relieve symptoms. These patients may benefit from a posterior minimally invasive approach, which allows visualization of hernias not accessible through standard anterior repair.

Previous mesh implantation does not necessarily require complete mesh explantation if it is well incorporated and not contributing to symptoms. Limited excision may be sufficient when needed to facilitate proper placement of new mesh.

Prior lower abdominal operations, including cesarean section and abdominoplasty, should be considered during trocar placement and abdominal entry because of anticipated adhesions and altered anatomy.

Discussion

Abdominal access was established through the periumbilical region. Given the patient's history of abdominoplasty, entry was performed through a small pre-existing umbilical fascial defect that was planned for closure at the completion of the operation. Following insufflation, two additional robotic trocars were inserted and the robotic platform was docked.

A large peritoneal flap was developed while maintaining a high plane to maximize space for prosthetic mesh placement. Medial dissection into the retropubic (Retzius) space was performed to the extent necessary to expose Cooper's ligament, achieve adequate medial mesh overlap, and evaluate for occult direct or obturator defects. Care was taken to avoid unnecessary dissection inferior to Cooper's ligament because of the potential risk of injury to the corona mortis and aberrant obturator vessels. The entire myopectineal orifice was then systematically exposed. As anticipated, the previously implanted mesh plug was identified medial to the inferior epigastric vessels within the direct space. The mesh appeared well incorporated without evidence of infection or migration and was therefore preserved.

Attention was then directed to the femoral canal, where the femoral hernia sac and incarcerated preperitoneal fat were identified. Careful traction and countertraction facilitated complete reduction of the hernia contents. Within the femoral canal, normal lymphatic tissue was intentionally preserved while all incarcerated fat was reduced away from the anticipated mesh position.

The round ligament was identified and carefully dissected. While preservation of the round ligament is an acceptable and commonly employed strategy during minimally invasive inguinal hernia repair, division may be necessary when it facilitates optimal prosthetic mesh positioning without compromising critical structures. In this case, the ligament was isolated, clipped, and divided proximally before its entry into the internal or deep inguinal ring to optimize mesh placement while minimizing the risk of injury to the genital branch of the genitofemoral nerve.

A small portion of the previously implanted mesh plug was excised to permit flat placement of the new prosthetic mesh. Complete mesh explantation was unnecessary because the existing prosthesis was not contributing to the patient's symptoms and remained well incorporated.

A large preperitoneal mesh was positioned to provide broad coverage of the femoral, direct, indirect, and obturator spaces while extending across the midline into the retropubic space. Given the large femoral defect, the mesh was secured with limited medial suture fixation to Cooper's ligament to enhance stability, while surgical adhesive was used along the inferior border to reduce the extent of penetrating fixation. Although atraumatic fixation alone is a well-established option in minimally invasive groin hernia repair, selective suture fixation was considered appropriate in this case to maintain mesh position. Particular attention was paid to avoiding fixation within zone 1, more specifically the triangle of pain, which contains the lateral femoral cutaneous nerve, anterior femoral cutaneous nerve, femoral branch of the genitofemoral nerve, femoral nerve, and, variably, the genital branch of the genitofemoral nerve. Following confirmation of appropriate mesh position and complete coverage of all potential defects, the peritoneal flap was closed.

This case illustrates several important principles in the evaluation of women with chronic groin pain. First, femoral hernias remain an underrecognized source of symptoms and are commonly overlooked during both imaging interpretation and anterior groin exploration. Women are particularly susceptible to delayed diagnosis because occult femoral and inguinal hernias frequently present without a visible bulge and may instead manifest solely as chronic groin pain. Wong et al. emphasized that these "hidden hernias" often result in prolonged patient suffering when symptoms are attributed to musculoskeletal or neuropathic causes rather than prompting further evaluation for an occult groin hernia.¹

Second, persistence of symptoms after open inguinal hernia repair should prompt reconsideration of the diagnosis rather than the assumption of neuropathic pain alone. In the present case, the previously implanted mesh plug was well incorporated and demonstrated no evidence of migration, infection, or recurrence, supporting preservation rather than explantation. Instead, the patient's symptoms originated from an occult femoral hernia that had remained untreated. This finding underscores the importance of reassessing the entire myopectineal orifice in patients with persistent postoperative groin pain rather than focusing exclusively on the prior repair site.¹

This case also highlights the limitations of routine radiologic interpretation. Although cross-sectional imaging had been obtained previously, the femoral defect was not initially recognized. Miller et al. demonstrated substantial variability in radiologic detection of occult groin hernias and showed that dedicated review by radiologists experienced in abdominal wall pathology significantly improves diagnostic accuracy. Their work emphasizes that close collaboration between surgeons and radiologists, combined with careful correlation of imaging findings and physical examination, is often necessary for accurate diagnosis of occult groin hernias.² In our patient, retrospective review of imaging, together with office ultrasonography and clinical examination, ultimately established the correct diagnosis.

The rTAPP approach provided excellent exposure of the entire myopectineal orifice, allowing identification of the occult femoral hernia while avoiding unnecessary dissection through scarred anterior tissues. The operation adhered to the principles described by Daes and Felix, which advocate complete exposure of all potential groin hernia sites—including the direct, indirect, femoral, and obturator spaces—before mesh placement. Achieving this critical view minimizes the risk of overlooking concurrent or occult defects and contributes to a more durable repair.³

The patient's operative findings further demonstrated a well-developed femoral hernia sac containing incarcerated preperitoneal fat, suggesting an ongoing risk of future incarceration had the defect remained untreated. Broad preperitoneal mesh coverage of the direct, indirect, femoral, and obturator spaces, with extension into the retropubic space, addressed both the symptomatic hernia and any occult defects in accordance with modern posterior groin hernia repair principles.³

This case represents a classic example of a female patient with persistent groin pain whose symptomatic femoral hernia was initially missed despite prior imaging and previous open inguinal hernia repair. Careful review of cross-sectional imaging, combined with clinical examination and office ultrasound, led to the correct diagnosis and definitive treatment using rTAPP repair. The case reinforces growing evidence that persistent groin pain after hernia repair should prompt evaluation for occult groin hernias and that meticulous posterior inspection of the entire myopectineal orifice is critical for avoiding missed diagnoses and achieving durable symptom resolution.^1–3

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Disclosures

Katie Marrero, MD:

• Nothing to disclose.

Eric M. Pauli, MD, FACS, FASGE, FEBSAWS (Hon.):

• Speaking/Teaching Honoraria:
  • Becton-Dickinson, Medtronic.
• Consultant:
  • Boston Scientific, Actuated Medical, Cook, Allergan, Mesh Suture Inc, Provation, Telabio.
• Royalties:
  • UpToDate (Wolters Kluwer), Springer.
• Lead Section Editor for General Surgery:
  • JOMI (no involvement in the editorial processing of this article in any capacity other than as an author).