How to effectively and rationally perform tension-free repair of femoral hernia is still controversial, and the “Surgical treatment plan for adult inguinal hernia and femoral hernia (revised)” formulated by the Hernia and Abdominal Wall Surgery Group of the Chinese Medical Association in 2004 did not give a more detailed description [1]. Tension-free repair of femoral hernia with open femoral ring and reinforcement of pubic ramus orifice above the femoral ring was carried out in our department from October 1999 to February 2010, and the follow-up results were satisfactory. The surgical approach and principles are discussed. Materials and methods I. General information Among the 50 patients in this group, 48 were female and 2 were male, aged 41 to 81 years old, with an average age of 59.6 years old, including 2 cases of incarcerated femoral hernia without strangulation. II.MATERIALS AND METHODS 1. Anesthesia 12 cases were applied continuous epidural anesthesia and 38 cases were operated under local anesthesia. Epidural anesthesia was implemented by anesthesiology department and local anesthesia was implemented by the surgeon, using 20ml of 2% lidocaine hydrochloride plus 10ml of 0.75% bupivacaine hydrochloride diluted with 10ml of saline, and anesthesia was carried out by layered blocking method. 2.Materials for repair Flat piece and mesh plug produced by Bard Company of the United States were used. 3, the surgical procedure ① take the conventional inguinal incision, from the inguinal ligament 1.5cm above the midpoint to the pubic symphysis to make an incision of 4cm ~ 5cm, layer by layer incision, cut the abdominal obliquity tendon membrane, free uterine round ligament or spermatic cord, hanging with a catheter; ② in the abdominal wall of the lower artery medial incision of the transversal abdominal fascia, a little downward inward to do a little free can be revealed femoral hernia hernia sac neck, which is medial for the traps ligament, the inguinal ligament or ilio-pubic fascia in the front. Ligament or iliopubic bundle, lateral to the femoral vein, the hernia capsule from the femoral canal sharp plus blunt freeing; the hernia capsule lifting, at this time you can see the posterior edge of the femoral ring mouth, that is, the ligament of the pubic comb; ③ sufficiently free the anterior peritoneal space that is pubic ramus, to make a diameter of about 6 cm space, the hernia capsule back into the abdominal cavity, will be polypropylene mesh plugs fully flattened umbrella-shaped, placed in this anterior peritoneal space, the mesh plugs of the inner flap with the ligament of pubic bone comb The inner flap of the mesh plug is fixed with the pubic comb ligament, the inner side of the transversus abdominis fascia and the ligament of Henle with 6~8 stitches, so that the mesh plug can reliably cover the pubic foramen, and the polypropylene mesh plug will not be protruded outward by increasing the abdominal pressure. Put the round uterine ligament or spermatic cord back to its original position, intermittently suture the tendon membrane of the external abdominal oblique muscle, and suture it layer by layer to the skin, and then finish the operation (Figure 1). Postoperative compression with 500g sandbag local 6h ~ 8h. Results Unilateral femoral hernia requires about 30min, the shortest 20min, hernia sac is larger, difficult to drag out from the femoral canal, the need to incise the inguinal ligament to expand the femoral ring is a little longer, generally need 40min ~ 50min; most patients 3h ~ 6h that is, get out of bed to relieve themselves of urination, 7d removal of stitches. All the patients in this group were Ⅰ/A healing; all the patients were followed up for 6~60 months, all the patients had no recurrence, 11 patients complained that they felt the local hardness in 3~5 months, and it gradually softened and disappeared after half a year. Discussion Myopectineal orifice [2] (myopectineal orifice) is an ovoid fissure located in the anterior wall of the lower abdomen and connected to the pelvis, divided into upper and lower zones by the inguinal ligament located in the front and the ilio-pubic bundle in the back, with the spermatic cord (or uterine round ligament), the internal ring, and the hesselbach’s triangle in the upper zone and the femoral blood vessels, nerves, and the fossa of the ovary in the lower zone, on which is protected by the trapdoor ligament. Protection. This area is covered only by the thin transversal abdominal fascia, where structural defects or the presence of increased intra-abdominal pressure can lead to the development of hiatal hernias, rectus hernias and femoral hernias. Therefore, hiatal hernias, rectal hernias and femoral hernias should have the same anatomical basis, and therefore femoral hernias should also be categorized as inguinal hernias. The repair of femoral hernia has been controversial in operation. Some scholars believe that the mesh plug can be placed in the femoral ring [3], and some people suggest that it may be more reasonable to place the mesh plug above the femoral ring [4]. 2004 China’s Hernia and Abdominal Wall Surgery Group issued a guideline program described in this way: it is preferable to use the hernia ring filling type of tension-free hernia repair surgery, the hernia sac after the hernia is retracted with a mesh plug placed in the femoral ring, and be careful not to injure the medial femoral vein when fixing the mesh plug. A molded patch placed on the superficial side of the mesh plug is no longer used [1]. The overly concise description creates some confusion in standardizing the surgical treatment of femoral hernia. In our opinion, femoral hernia repair styles must be designed with the aim of restoring the normal structure of the groin and femoral ring area. Anatomically, the femoral ring and the femoral canal are only the channels for descending femoral hernia, and the optimal position for repair should be above the femoral ring, i.e., the area composed of the upper conjugate tendon arch, the lower pubic symphysis ligament, the medial Henle ligament, and the lateral inferior epigastric artery, where abdominal contents together with the peritoneum break through the posterior layer of transversus abdominis fascia, and then go downward through the femoral ring and enter into the femoral canal, which is the formation of femoral hernia; if all of transversus abdominis fascia breaks through into the inguinal canal, then femoral hernia is formed. If the transversal abdominal fascia is completely broken through into the inguinal canal, then a direct hernia is formed. Repairing here is most consistent with the principle of high level repair. From this understanding, whether it is through the inguinal or femoral part of the femoral ring for mesh plug filling is inappropriate, because this repair can not achieve the purpose of repairing the abdominal wall, but also may be on the femoral vein in the femoral canal caused by compression, resulting in the formation of deep vein thrombosis of the lower extremities. Figure 1. Schematic diagram of tension-free repair of femoral hernia (the arrow shows the open femoral ring, with the mesh plug on the left, the femoral vessels on the right, and the fat hernia on the top) Figure 2. Position of the mesh plug in the peritoneal space after flattening (shown by the circle) The femoral canal, i.e., the medial compartment of the femoral sheath, is only possessed by human beings, and its existence allows the femoral vein to have room for expansion, and prevents the femoral vein from coming into contact with the sharp lateral edge of the trapezoid ligament in the upright position [5]. Therefore, filling the femoral ring with a mesh plug will limit the physiologic dilation of the femoral vein and create compression of the femoral vein. Moreover, it has been reported that the repair material can cause obstruction of femoral venous return [6]. Therefore, it is reasonable to think that the operation of filling the femoral ring with mesh plugs for the treatment of femoral hernia is not reasonable and should be avoided as much as possible. Instead, the mesh plug is fully spread out like an umbrella and placed in the preperitoneal space behind the transversus abdominis fascia to close the pubococcygeal foramen, which can treat femoral hernia, and then attaching a flat sheet to the superficial surface of the transversus abdominis fascia strengthens the weak area of the abdominal wall in the inguinal area that is not covered by the muscles, and eliminates the root cause of the inguinal hernia’s occurrence and recurrence (Fig. 2). Therefore, we believe that the use of a flat piece in the repair of femoral hernia is of equal importance to the repair of hiatal and rectal hernias. Happily, more discussion of tension-free femoral hernia repair styles has begun to appear in the literature [7,8], and there has been a gradual increase in the awareness of the importance of the pubic foramen. The advantage of this procedure is that there is no need to fill the femoral ring, which reduces the risk of surgery and the possibility of complications. At the same time, the strengthening of the weak area of the pubococcygeal foramen makes the possibility of recurrent hernia in the whole inguinal region less likely. In addition, in the early days we took epidural anesthesia, and with surgical proficiency and cognitive improvement, we found that local anesthesia gave good results in most cases. The addition of an appropriate amount of bupivacaine to lidocaine significantly prolonged analgesia. In terms of indications, we have begun to try a one-time repair of femoral hernia with incarceration but without strangulation, with good results, and we need to expand the cases in the future to verify its safety.